Identifying and Eliminating 

Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating 

Comprehensive Tobacco Control Programs 

OFFICE ON SMOKING AND HEALTH 

Centers for Disease 

Control and Prevention 

National Center for Chronic 

Disease Prevention and 

Health Promotion 2022 

Disclaimer 

The findings and conclusions in this report are those of the authors and do not necessarily 

represent the views of the Centers for Disease Control and Prevention. 

Suggested Citation 

Centers for Disease Control and Prevention. Identifying and Eliminating Tobacco-Related 

Disparities: Key Outcome Indicators for Evaluating Comprehensive Tobacco Control 

Programs—2022. Atlanta, GA: Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2021. 
 

Acknowledgments 

This publication was prepared under the direction of the Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office 

on Smoking and Health. 

Brian Armour, PhD 

Associate Director for Science 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Natasha Buchanan-Lunsford, PhD 

Associate Director for Health Equity 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Frank Chaloupka, PhD 

Distinguished Professor 

Institute for Health Research and Policy 

University of Illinois at Chicago 

Kevin Collins, PhD 

Deputy Branch Chief, Epidemiology Branch 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Elizabeth Courtney-Long, MA, MSPH 

Deputy Associate Director for Science 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Tana Feiner 

Training and Technical Assistance Coordinator 

Tobacco Prevention and Control Program 

Wisconsin Department of Health Services 

ACKNOWLEDGMENTS iii 
Jean Forster, PhD 

Professor Emerita 

Division of Epidemiology and Community Health 

School of Public Health 

University of Minnesota 

Erika Fulmer, PhD* 

Health Scientist 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Bridgette Garrett, PhD* 

Associate Director for Health Equity 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Corinne Graffunder, DrPH* 

Division Director 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Yessica Gomez, MPH* 

Health Scientist 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Nikki Hawkins, PhD 

Evaluation Team Lead 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs iv 
Patricia Nez Henderson, MD 

Vice President 

Senior Scientist 

Black Hills Center for American Indian Health 

Sally Herndon, MPH 

Branch Head 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and Human Services 

David Homa, PhD 

Senior Science Officer, Epidemiology Branch 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Delmonte Jefferson 

Executive Director 

National African American Tobacco Prevention Network 

The Center for Black Health and Equity 

Charlotte D. Kaboré, MPH 

Public Health Analyst 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Brian King, PhD 

Deputy Director for Research Translation 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Nicole Kuiper, MPH* 

Health Scientist 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

ACKNOWLEDGMENTS v 
Rene Lavinghouze, MA* 

Evaluation Team Lead 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Joseph G. L. Lee, PhD 

Associate Professor 

Department of Health Education and Promotion 

College of Health and Human Performance 

East Carolina University 

Rod Lew, MPH 

Founder and Executive Director 

Asian Pacific Partners for Empowerment, Advocacy, and Leadership (APPEAL) 

Chad Morris, PhD 

Professor of Psychiatry 

Director of Behavioral Health & Wellness Program 

Department of Psychiatry 

Anschutz Medical Campus 

University of Colorado 

Rebecca Murphy, PhD 

Health Communications Specialist 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Linda Neff, PhD 

Branch Chief, Epidemiology Branch 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Briana Oliver, MPH 

ORISE Fellow 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs vi 
Elizabeth Reimels, JD* 

Associate Director for Policy 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Megan E. Roberts, PhD 

Assistant Professor 

College of Public Health 

The Ohio State University 

April Roeseler, MSPH 

Branch Chief 

California Tobacco Control Program 

California Department of Health 

Yolanda Savage-Narva, MSEd. 

Executive Director 

Operation Understanding DC 

Scout, PhD 

Deputy Director 

National LGBT Cancer Network 

Karla Sneegas, MPH 

Branch Chief, Program Services Branch 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Sonia Tetlow, MPH* 

Health Scientist 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Dennis R. Trinidad, PhD 

Associate Professor of Family Medicine and Public Health 

Department of Family Medicine and Public Health 

School of Medicine 

University of California San Diego 

ACKNOWLEDGMENTS vii 
Donna Vallone, PhD 

Chief Research Officer 

Truth Initiative 

Teresa Wang, PhD* 

Health Scientist 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Monica Webb-Hooper, PhD 

Professor of Oncology, Family Medicine & Community Health and Psychological Sciences 

Associate Director for Cancer Disparities Research 

Director of the Office of Cancer Disparities Research 

Principal Investigator of the Tobacco Obesity and Oncology Laboratory 

Case Comprehensive Cancer Center 

Case Western Reserve University 

* Affiliation at the time contributions were made may differ from current affiliation 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs viii 
 

 

 

 

 

 

PREFACE 

The Centers for Disease Control and Prevention’s (CDC’s) Office on Smoking and Health 

(OSH) developed this publication to assist state and territorial commercial tobacco control 

programs evaluate efforts to reduce tobacco-related health disparities. The primary audiences 

for this publication consist of planners, managers, and evaluators of tobacco control programs. 

This publication is the fourth in a series of key outcome indicator guides released by OSH and 

the first to specifically focus on tobacco-related disparities. This guide can be used in 

combination with outcome indicators from the three other guides: Preventing Initiation of 

Tobacco Use: Outcome Indicators for Comprehensive Tobacco Control Programs—2014, 

Promoting Quitting Among Adults and Young People: Outcome Indicators for Comprehensive 

Tobacco Control Programs—2015, and Eliminating Exposure to Secondhand Smoke: Outcome 

Indicators for Comprehensive Tobacco Control Programs–2017.

1-3 Many indicators in the 

present guide align closely with those in previously published guides with the addition of 

information specific to tobacco-related disparities. This indicator guide supports evaluation of 

the National Tobacco Control Program (NTCP), which aims to reduce tobacco-related disease, 

disability, and death. The NTCP seeks to achieve these goals by working in four areas: 

1. Preventing initiation among youth and young adults. 

2. Eliminating exposure to secondhand smoke. 

3. Promoting quitting among adults and youth. 

4. Identifying and eliminating tobacco-related disparities. 

A logic model with corresponding indicators for Goal Area 4 of the NTCP (Identifying and 

Eliminating Tobacco-Related Disparities) is included in the present guide, which contains indepth information on indicators that can be used to measure progress toward various outcomes. 

Consumer Reports®–type ratings are included to allow for tailored selection of indicators by 

state and territorial tobacco control programs. Moreover, this guidance document highlights how 

to use indicators to integrate program and evaluation planning. 

This guide supports and complements broader monitoring and evaluation efforts to identify and 

eliminate tobacco-related disparities. It supports application of CDC’s Framework for Program

Evaluation in Public Health Practice4 and may be used in coordination with CDC’s workbook,

Developing an Effective Evaluation Plan: Setting the Course for Effective Program Evaluation,

5 

and other OSH surveillance and evaluation resources. Tobacco prevention and control program 

managers and evaluators can use the indicators in this document to focus their evaluations, 

inform the selection of indicators, link these to intended outcomes, and assist in gathering 

credible evidence. 

PREFACE ix 
References 

1. Centers for Disease Control and Prevention. Preventing initiation of tobacco use: outcome 

indicators for comprehensive tobacco control programs–2014. Atlanta, Georgia: Centers for 

Disease Control and Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2014. 

2. Centers for Disease Control and Prevention. Eliminating exposure to secondhand smoke: 

outcome indicators for comprehensive tobacco control programs–2017. Atlanta, GA: 

Centers for Disease Control and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 2017. 

3. Centers for Disease Control and Prevention. Promoting quitting among adults and young 

people: outcome indicators for comprehensive tobacco control programs—2015. Atlanta, 

GA: Centers for Disease Control and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 2015. 

4. Centers for Disease Control and Prevention. Framework for program evaluation in public 

health. MMWR 1999;48(No. RR-11). 

5. Centers for Disease Control and Prevention. Developing an effective evaluation plan: setting 

the course for effective program evaluation. Atlanta, Georgia: 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 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 

x 
TABLE OF CONTENTS 

Acknowledgments...................................................................................................................... iii 

Preface ......................................................................................................................................ix 

Chapter 1 INTRODUCTION........................................................................................................1 

Chapter 2 LOGIC MODEL ........................................................................................................17 

Goal Area 4 Logic Model .......................................................................................................18 

Chapter 3 PROCESS INDICATORS .........................................................................................23 

Increased capacity to develop and implement interventions to identify and eliminate tobaccorelated disparities ..................................................................................................................24 

Chapter 4 OUTCOME INDICATORS ........................................................................................50 

Outcome 1: Increased knowledge of the harms of tobacco use among populations 

experiencing tobacco-related disparities and support for evidence-based tobacco control 

interventions..........................................................................................................................51 

Outcome 2: Increase equitable adoption, implementation, and enforcement of tobacco 

prevention and control policies ..............................................................................................70 

Outcome 3: Increased health systems changes and coverage that promote and support 

cessation in populations experiencing tobacco-related disparities .......................................117 

Outcome 4: Decreased tobacco industry and environmental influences that contribute to 

tobacco-related disparities...................................................................................................146 

Outcome 5: Increased quit attempts, quit attempts using evidence-based cessation services, 

and successful cessation among populations experiencing tobacco-related disparities.......172 

Outcome 6: Eliminate disparities in tobacco use initiation....................................................194 

Outcome 7: Eliminate disparities in tobacco use..................................................................209 

Outcome 8: Eliminate disparities in secondhand smoke exposure.......................................240 

Appendices ..................................................................................................................................I 

Appendix A: Instructions for Expert Panel Reviewers ............................................................. II 

Appendix B: Data Source Indicator Table ............................................................................ VIII 

Glossary and Acronyms....................................................................................................... XIII 

TABLE OF CONTENTS xi 

CHAPTER 1 

INTRODUCTION 
 

 

 

 

 

Introduction 

Background 

Commercial tobacco use is the leading cause of preventable illness and death in the United States.1 

Smoking-related diseases in the United States cost billions of dollars each year in direct medical care 

and lost productivity.1 Since the first landmark Surgeon General’s report in 1964, Smoking and Health,

2 

implementation of evidence-based strategies have led to reductions in commercial tobacco use, 

exposure to secondhand smoke (SHS), and commercial tobacco-related morbidity and mortality.1 In 

2018, 13.7 percent of U.S. adults reported current cigarette smoking, a two-thirds decline since 1965 and 

1,3 the lowest level ever recorded in the United States. 

Despite progress over the past few decades, reductions in commercial tobacco use and related declines 

in morbidity and mortality have not been realized across all population groups. The 2014 Surgeon 

General’s report, The Health Consequences of Smoking—50 Years of Progress, concluded that large 

disparities in tobacco use exist across groups defined by race, ethnicity, educational attainment, 

socioeconomic status, and geographic location.1 Disparities include significant differences in the 

prevalence of smoking, tobacco use initiation, exposure to secondhand smoke, and cessation behaviors 

across population groups.4 For example, current use of any commercial tobacco product in 2019 was 

highest among American Indian/Alaska Native persons (29.3%) and lowest among Asian persons 

(10.0%).3 

Tobacco-related health disparities are the result of and influenced by a complex mix of multi-level 

structural and social factors. Some of these influences were recognized in the 1998 Surgeon General’s

report, Tobacco Use Among U.S. Racial/Ethnic Minority Groups,

5 which stated, “No single factor

determines patterns of tobacco use among racial/ethnic groups; the patterns are a result of complex 

interactions of multiple factors such as socioeconomic status, cultural characteristics, acculturation, 

stress, biological elements, targeted advertising, price of products, and varying capacities of communities 

to mount effective tobacco control initiatives.” Structural and social determinants of health6 contribute to 

tobacco-related disparities and can include key factors, such as tobacco industry influence and target 

marketing, inequitable implementation and enforcement of tobacco control policies, social and 

environmental conditions that increase exposure to commercial tobacco products and risk of tobacco 

use, structural racism and discriminatory practices, economic inequities, and access to education and job 

opportunity.

1,7,8 Addressing many of these factors requires multisectoral public-private partnerships to 

execute multi-level approaches to tobacco prevention and control. 

The persistence of tobacco-related disparities underscores the importance of expanding efforts to 

implement evidence-based strategies that can reach and reduce tobacco use among populations 

experiencing tobacco-related disparities. As tobacco control programs implement strategies to address 

tobacco-related disparities, it is important that they monitor and evaluate whether their efforts are having 

the intended public health impact. Choosing appropriate outcome indicators is a key step in doing this. 

This guide is intended to help facilitate the selection of such indicators. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 2 
Focus of the Guide 

While tobacco-related health disparities can be addressed at multiple levels, this guide 

predominately focuses on outcome indicators linked to changes in commercial tobacco-related 

population-level policy, systems, environmental, and behavioral changes. Some of the 

indicators included in this guide can also be used to look at dimensions related to promoting 

health equity, however, this guide does not provide explicit guidance on advancing health equity 

in commercial tobacco control. Advancing health equity is a broader effort that would involve 

addressing multilevel structural and socioecological influences, historical and contemporary 

injustices and, therefore, extends beyond the scope of this guide. For example, indicators of 

equitable implementation and enforcement of comprehensive smokefree policies are important 

to understanding the impact of related actions for people from all socioeconomic, educational, 

and racial/ethnic backgrounds and thus can be a measure of progress toward health equity.

7 

Tobacco control programs can partner with multisectoral public health and non-public health 

partners to address and monitor broader socioecological issues that contribute to tobaccorelated disparities, such as structural and social determinants of health that drive and influence 

disparities. Indicators in this guide can help programs determine whether their efforts and 

multisectoral partnerships are leading to reductions in commercial tobacco-related disparities. 

While this guide predominantly focuses on outcome indicators to reduce tobacco-related health 

disparities, we also included a set of process indicators to acknowledge the importance of 

having capacity to effectively implement interventions that will reduce tobacco-related 

disparities. For example, tobacco control programs need access to disaggregated data for 

different population groups in order to identify disparities, in addition to informing the 

development, implementation, and evaluation of interventions to address them. Thus, 

addressing surveillance capacity is an important component in addressing disparities, even 

though it is not a direct outcome. Moreover, it is important for programs to meaningfully engage 

multisectoral public health and non-public health partners during all phases of related efforts 

and initiatives, to champion, stimulate, and facilitate socioecological changes, including policy 

interventions that can reduce tobacco-related disparities. 

Guide Preparation 

The indicators presented in this guide were developed using the same processes and 

procedures used to develop the outcome indicators for NTCP Goals 1-3: Preventing Initiation of 

Tobacco Use: Outcome Indicators for Comprehensive Tobacco Control Programs—2014; 

Promoting Quitting Among Adults and Young People: Outcome Indicators for Comprehensive 

Tobacco Control Programs—2015; Eliminating Exposure to Secondhand Smoke: Outcome 

Indicators for Comprehensive Tobacco Control Programs–2017. 

9-11 The sections below provide 

details on the development of the guide. 

CHAPTER 1 - Introduction 3 
 

Logic Model Development 

As explained in Introduction to Program Evaluation for Comprehensive Tobacco Control 

Programs, logic models depict the presumed causal pathways that connect program inputs, 

activities, and outputs with short-term, intermediate, and long-term outcomes.

12 

The logic model for NTCP Goal Area 4, Identifying and Eliminating Tobacco-Related Disparities, 

was developed to depict pathways to achieve population-level changes in policies, systems, 

environments, and behaviors that can reduce tobacco-related disparities. It was reviewed by 

OSH and external subject matter experts, and a literature review was conducted to inform 

refinements to the model and to identify indicators linked to each outcome in the logic model. 

Notably, many of the logic model outcomes and corresponding indicators identified for the 

NTCP Goal Area 4 logic model overlap with outcomes in the logic models for the NTCP Goals 

1, 2 and 3.9-11 This is not surprising, as the logic models included in previous indicator guides 

referenced decades of research and science to identify outcome indicators for preventing and 

reducing tobacco use and secondhand smoke exposure, including among population groups 

experiencing tobacco-related disparities. For example, there is extensive research on the 

environmental, social, and behavioral impacts of comprehensive smoke-free policies.1,7 

Comprehensive smoke-free policies protect people who do not smoke from exposure to 

secondhand smoke exposure, reduce the social acceptability of smoking, and promote and 

support cessation.1,7 When equitably implemented and enforced, these policies have the 

potential to reach and benefit everyone. However, there are disparities related to policy 

protections experienced by population groups.7,8 Inequitable implementation and enforcement of 

these policies can diminish their ability to benefit all population groups in fair and just ways. 

Thus, indicators related to smoke-free policies are also included in this guide within the context 

of eliminating tobacco-related disparities. 

To help tobacco prevention and control programs with planning and evaluation, the outcomes 

were numbered in each NTCP logic model to allow for easy reference in discussing the links 

between logic model components. 

Identification and Selection of Outcome Indicators 

Outcome indicators are specific, observable, and measurable characteristics or changes that 

represent achievement of an outcome.12-13 The logic model served as the framework for the 

development of the outcome indicators. For example, an indicator under outcome 2, “increase 

equitable adoption, implementation, and enforcement of tobacco prevention and control 

policies,” is the “proportion of jurisdictions that have comprehensive smokefree policies that 

prohibit smoking in all indoor areas of workplaces, including restaurants, and bars and the 

proportion of jurisdictions that are disproportionately burdened by secondhand smoke exposure 

that have comprehensive smokefree policies.” (Indicator 4.2.g). 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 4 
 

 

Figure 1. Rating Table 

Rating Overall Strength 

quality of 

Resources evaluation Face Accepted 

low+--+ high needed evidence Utility validity practice 

• • • • f- 0 a - ~ htt~:r 

Indicator Selection and Rating 

To start, CDC proposed a set of outcome indicators based on the results from the literature 

review. Next, a panel of 16 external subject matter experts in tobacco control practice, 

evaluation, and research to assess each indicator’s value on the basis of the following criteria: 

strength of evaluation evidence, resources needed, utility, face validity, uniqueness, conformity 

with accepted practice, and overall quality of the indicator. Each of these is defined in more 

detail in the Indicator Ratings Table section that follows and in Appendix A. In addition to rating 

the indicators that CDC proposed, the experts were invited to suggest other indicators and 

sources of data for those indicators. 

Upon completion of the external review, CDC convened an internal panel of nine OSH 

reviewers with different areas of expertise (e.g., evaluation, surveillance, policy, cessation, 

program, communications, disparities) to review the external subject matter experts’ responses,

comments, and suggestions. The internal panel then compiled the results across criteria for 

each indicator and subsequently refined, dropped (based on low ratings and/or insufficient 

evidence), and added new indicators (based on the input from the external and internal panels). 

New indicators have no ratings from the external panel because they were added after this step 

in the process. Thus, they have the symbol NR (i.e., “Not Rated,”) after their indicator numbers. 

Indicator Rating Table 

For each outcome component of the 

logic model, CDC developed an 

indicator rating table that lists the 

indicators associated with the outcome 

component and the external experts’

ratings for each indicator by criterion. Figure 1 presents an example of an indicator rating and 

detailed information on each of the criteria. For additional information on how the expert 

panelists rated each indicator and how the composite ratings were determined, see Appendix A. 

The ratings are based on the following criteria: 

➢

CHAPTER 1 - Introduction 5 

Overall quality: A summary rating that reflects the overall quality and general worth of 

the indicator as it relates to evaluating state tobacco prevention and control programs. 

➢ Resources needed: Quantity of resources needed to collect reliable and precise 

measures and to analyze primary or secondary data on the indicator. Considerations 

affecting cost include availability of existing data (e.g., archival records or other 

secondary data) versus need for primary data collection, and methodological and 

sampling issues. Dollar signs show the amount of resources (funds, time, and effort) 

needed to collect and analyze data on the indicator using the most commonly available 

data source: more dollar signs (maximum four) indicates more resources needed. The 

dollar signs do not represent specific amounts because the actual cost of measuring and 

analyzing an indicator varies according to the existing capacity of a state health 

department or organization to evaluate its programs. 
 

➢ Strength of evaluation evidence: The degree to which scientific evidence supports the 

assumption that implementing interventions to affect a given indicator will lead to a 

measurable change in the related outcome. This includes the extent to which the 

scientific literature supports use of the indicator for the evaluation of comprehensive, 

statewide tobacco prevention and control programs, and considers conflicting evidence 

and concerns regarding the methodology of supporting studies. Indicators with the 

highest ratings have a strong demonstrated relationship between the indicator and a 

downstream logic model outcome. Indicators with moderate ratings demonstrate an 

association between the indicator and an outcome in the logic model with moderately 

strong evidence. Indicators with low ratings may have conflicting evidence and/or be 

demonstrated by studies with weak methodology. 

➢ Utility: The extent to which the indicator would help to answer important comprehensive 

tobacco prevention and control program evaluation questions. 

➢ Face validity: The degree to which data on the indicator would appear valid to tobacco 

program stakeholders, such as decision makers who may be users of tobacco 

prevention and control program evaluation results. 

➢ Accepted practice: The degree to which use of the indicator is consistent with currently 

accepted, real-world tobacco control practice. 

Indicator Profiles 

Each indicator profile presents the following information: 

➢ Indicator number and name: Each indicator is uniquely identified by two numbers and 

a letter. The first number represents the goal area, the second number represents the 

outcome component (box) within the logic model, and the letter represents the indicator. 

For example, Indicator 4.1.a is first on the list of indicators (designated by the “a”)

associated with outcome component 1 in the logic model for NTCP Goal Area 4. 

➢ Outcome box: The title of the outcome component (i.e., logic model box) is provided in 

the logic model. 

➢ What to measure: A description of what to measure in order to gather data on the 

indicator. Population groups experiencing disparities for each indicator can be 

selected by the tobacco control program based on their state and/or local/community 

level data relevant for the indicator. Jurisdictions and/or communities 

disproportionately burdened by commercial tobacco use can be expanded to 

include other measures deemed appropriate by the tobacco control programs. For 

example, when selecting priority jurisdictions/communities for measurement of some of 

the indicators, a program may want to consider socioeconomic status, poverty rates, 

access to healthcare, or other factors in addition to tobacco use prevalence. 

➢ Similar existing indicator(s) from other goal areas: Indicates whether there is a 

similar indicator in the existing outcome indicator guides for the other NTCP goals areas 

and note the specific indicator. 

➢ Rationale: The rationale is provided for using the indicator as a measure of a specific 

outcome in the logic model. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 6 
 

 

 

 

➢ Applying health disparity framing: Information is provided on why this indicator can 

help measure progress in reducing tobacco-related disparities. Populations and/or 

common characteristics noted in the cited literature are provided for reference. However, 

this information is not intended to be comprehensive. Tobacco control programs can use 

their state and/or community level data to determine population groups experiencing 

tobacco-related disparities. 

➢ Example data source(s): Example past and current surveys and sources of data that 

measure the indicator as well as the population from which the data could be collected. 

In some cases, example data sources are shared to provide example survey questions 

that have been used in the past. For some indicators, programs may need to create data 

sources by adding questions to existing surveillance systems. Most listed data sources 

are well known and widely used national and state surveys or surveillance systems. 

Non-standardized, topic-specific data sources (e.g., policy tracking, environmental 

scans) that may not be as widely used but can be useful for evaluation are also included. 

➢ Example survey question(s): These are typically survey questions from state or 

national surveys or surveillance systems. Where appropriate, the range of possible 

responses to the survey questions is also given. If no state or national survey has an 

applicable question, an example question may have been created. Note, example 

survey questions focus on the indicator construct; example questions on demographic 

and other population characteristics are not noted but are needed to assess tobaccorelated disparities by population group characteristics. 

➢ Comments: Additional information on the indicator that may be useful for program 

planning and/or evaluation purposes. For example, suggestions on other uses for the 

indicator, the indicator’s limitations (if any) as a measure of a program’s progress,

potential elements of a model policy that may be used to guide measurement, or 

sources of information on data collection methods. Additionally, special considerations 

when measuring and/or analyzing the indicator are noted. 

➢ Reviewers’ ratings: The rating tables include the criterion ratings given to the indicator 

by the panel of experts. 

Additionally, indicators in this guide that are linked to Healthy People 2030 objectives are noted 

in the profile and have a symbol HP, which stands for “Healthy People.”

Organization of Indicators 

Similar to the outcome guides for NTCP Goals 1, 2, and 3, indicators in this guide are organized 

by the outcome component in the logic model: Short-term Outcomes (1-3), Intermediate 

Outcomes (4-5) and Long-term Outcomes (6-8). 

Because the capacity building indicators are meant to support implementation of interventions to 

achieve logic model outcomes, these indicators do not link to outcome components in the logic 

model. Consequently, they are presented in this guide before the outcome indicators. 

CHAPTER 1 - Introduction 7 
 

 

 

 

 

 

 

 

 

 

 

 

Using this Guide for Program Evaluation 

Planning Your Evaluation 

This guide supports evaluation efforts across the six steps of CDC’s Evaluation Framework for

Program Evaluation.14 The guide is especially helpful in implementing steps 2 (Describe the 

Program), 3 (Focus the Evaluation) and 4 (Planning for Gathering Credible Evidence) of CDC’s 

Evaluation Framework for Program Evaluation.14 

Describe the program. This guide assists in clarifying program efforts and expected outcomes 

related to identifying and eliminating tobacco-related disparities. Using this guide to help map a 

program’s causal pathway(s) provides an opportunity for stakeholders to work through concerns 

and challenges regarding the goals and objectives of the work and to set the stage for 

identifying key evaluation questions, focusing the evaluation, and connecting program planning 

and evaluation. It is unlikely that your program logic model will look exactly the same as the 

logic model in this guide. Some of your program’s activities, outputs, outcomes, and contextual 

factors may be different. It is critical for program staff and stakeholders to develop their logic 

model based on their program- and stakeholder-specific needs, taking into account program 

context. Moreover, your program may consider including organizational, structural, systemic, 

social, and economic factors that can influence tobacco-related disparities and/or 

acknowledging their influence and impact. 

Focus the evaluation. After identifying your program’s key evaluation questions, this guide can

be used to select indicators of progress related to short-term, intermediate, and long-term 

outcomes. Examine the indicator rating tables relevant to the short-term, intermediate, and longterm outcomes in your program logic model. The ratings pertaining to the indicators’ overall

quality, resources needed, strength of evaluation evidence, utility, face validity, and accepted 

practice can help you select the indicators that may be the most relevant, feasible, and 

appropriate to measure and monitor progress toward your short-term, intermediate, and longterm outcomes. 

Planning for gathering credible evidence. You can use the example data sources and survey 

questions included in the indicator profiles to help create a plan for gathering evidence for your 

program evaluation questions and related short-term, intermediate, and long-term outcomes. 

While monitoring a single indicator can serve as a helpful guidepost, it is important to include 

indicators from across short-term, intermediate, and long-term outcomes within a logic model to 

help ensure a robust evaluation. By assessing outcome indicators along the logic model, 

tobacco prevention and control programs can begin to see where efforts are making gains and 

where they are not. When a key indicator within the pathway fails to improve or begins 

declining, additional inquiry can determine whether the program itself is failing to achieve the 

intended effects and/or whether contextual factors along the causal pathway are responsible. In 

either case, understanding the roadblocks in achieving the intended public health goals provides 

important information to guide program improvement efforts. Moreover, programs can assess 

key contextual factors that influence disparities, such as structural, social, and economic issues, 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 8 
 

 

 

 

as well as factors related to implementation, such as community engagement efforts, and their 

influence on achieving outcomes along the logic model pathway. 

More information on using outcome indicators to develop an evaluation plan is provided in this 

section and in CDC’s workbook, Developing an Effective Evaluation Plan: Setting the Course for 

Effective Program Evaluation,

15 which can be accessed at 

https://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/surveillance_evalu 

ation/evaluation_plan/index.htm. 

Evaluation-Specific versus Core Indicators 

Evaluation-specific indicators are beneficial in supporting program evaluation of specific 

tobacco control interventions as they can help assess the extent to which intended outcomes of 

an implemented intervention were achieved. For example, a program whose efforts led to an 

increase in health systems change (e.g., protocols to screen and treat) in behavioral health 

treatment facilities may also want to assess whether these changes led to actual increased 

screening, advice to quit, treatment, and cessation among persons with behavioral health 

conditions. Having evaluation-specific indicators in place to address outcomes across the logic 

model pathway can be useful to see what is happening and how it is happening along the way, 

or conversely what is not happening to impede the impact of system-level changes. 

In addition to having evaluation-specific indicators, having core indicators that will be 

consistently measured over time can provide a broader and long-term view of a program’s 

impact. These core indicators can allow you to monitor progress across key outcomes (e.g., 

changes in priority policies, exposure to secondhand smoke, and prevalence of tobacco use), 

program goal areas, and/or for disproportionately impacted population groups. For example, a 

program’s strategic efforts may identify reducing commercial tobacco use among American 

Indian and Alaska Native (AI/AN) populations as a program goal. To assess progress over time 

towards achieving their goal, the program may identify core indicators related to smoke-free 

policies and health systems changes in AI/AN properties and healthcare facilities, as well as 

indicators to track changes in quit attempts and commercial tobacco product use prevalence 

among AI/AN populations. The program may also include distal indicators to track morbidity and 

mortality among AI/AN populations. 

Of note, evaluation-specific and core indicators are not necessarily mutually exclusive. Often, 

programs and their partners work on specific interventions that can contribute to the program’s 

overarching strategic priorities and similar indicators may be assessed as part of both 

intervention-specific evaluations and the program’s overarching priorities. However, core

indicators may be tracked over a longer period of time and may extend beyond specific program 

interventions and evaluations during the period established by the program. 

CHAPTER 1 - Introduction 9 
Measurement of Tobacco-Related Disparities 

Measurement Options and Considerations 

This section provides a brief overview of concepts and considerations when measuring tobaccorelated disparities. The concepts are further detailed in the resources provided under this 

section. This section is not meant to provide an exhaustive or detailed explanation of 

measurement options and issues. Rather, information in this section raises some measurement 

issues that programs can consider when measuring disparities. Because there are many 

methodological choices for measuring disparities, tobacco control programs may want to consult 

with their program statistician and other subject matter experts for additional guidance. 

Moreover, it is important for programs to provide the reasons and implications for methodologic 

approaches to justify and increase the credibility of their approach. In determining the best 

methodological approach for measuring disparities and progress toward elimination, two early 

decisions that must be made involve specifying the reference point and determining whether 

differences will be measured on an absolute versus relative scale. 

Reference Point: To measure changes in observed disparities, it is first necessary to identify a 

reference point from which differences will be measured. Common choices for reference points 

include the group with the lowest prevalence for a tobacco-related outcome or determinant, the 

largest social group, and the population average. There are advantages and disadvantages with 

each approach that should be considered when selecting a reference point that are detailed 

elsewhere.16,17 Each possible reference point has pros and cons. For example, while it may be 

convenient to use the group with the lowest prevalence of tobacco use as the reference point so 

that differences across groups are in the same direction, a disadvantage of this approach arises 

if the group with the lowest prevalence changes over time, and thus changes the scale upon 

which progress is measured. Programs can consider the pros and cons of each type of 

reference point and consider the implications of their selection to proactively identify strengths 

and weaknesses of the selection and to plan in advance for multiple possible scenarios. In 

some instances, programs may choose to instead use a program target established through 

their strategic planning process or by using Healthy People targets. 

Absolute versus Relative Scale: An absolute scale involves a numerical difference between a 

rate or prevalence and the reference point, while a relative scale expresses differences between 

prevalence in terms of the selected reference point and is often expressed as a ratio.

16-18 There 

is general consensus that differences should be measured on both an absolute and relative 

scale.16-20 Measuring both can provide a more complete understanding of the magnitude of the 

differences and disparities. 

In addition to making choices about the reference point and the use of an absolute versus 

relative scale, other important early considerations in methodology involve accounting for 

differences in group size, using differential weighting of certain groups (e.g., groups with low 

socioeconomic status), using a pairwise versus summary approach to compare differences 

across groups over time, and using population-weighted measures to account for changes in 

the distribution of the population over time. There are many available resources that provide 

more 16-20 guidance and details on each of these for measuring disparities. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 10 
Measuring Disaggregated Population Group Differences 

Research has shown that there can be substantial within-group differences in tobacco-related 

behaviors among population groups. For example, 2010-2013 data from the National Survey on 

Drug Use and Health showed that 10.9% of Asian American persons reported current tobacco 

product use, the lowest among racial/ethnic groups during those years.21 However, 

disaggregated data during those years showed that prevalence of tobacco use differed 

significantly among different Asian American populations, including Chinese (7.6%), Asian 

Indian (7.6%), Japanese (10.2%), Filipino (12.6%), Vietnamese (16.3%), and Korean (20.0%) 

persons.

21 These findings underscore the need to measure differences within population groups 

as much as possible. This may be particularly relevant for states and communities that have a 

large proportion of diverse population groups. Tobacco control programs may need to 

oversample for some population groups to collect, analyze, and report on disaggregated 

population group data. 

Measurement Plan 

Measurement plans, best developed in meaningful collaboration with multisectoral stakeholders, 

can be useful in highlighting key decision points, including selected indicators, the measurement 

approach, and the rationale for decisions. The collaborative development of a plan can help 

ensure consensus and transparency among all stakeholders, as well as consistency in 

measurement over time as staff and leadership changes occur. A plan to measure evaluationspecific indicators may be part of an evaluation plan, but a standalone plan may be beneficial 

for programs that select core indicators to track over time. A standalone measurement plan can 

include: 

Indicators: A set of actionable and priority indicators that will be consistently measured. These 

indicators may include key policy indicators and long-term indicators, as well as more distal 

tobacco-related morbidity and mortality indicators. Some programs may also choose to monitor 

social determinants of health indicators or other indicators that may be closely linked to tobaccorelated disparities. When identifying indicators, programs may want to determine whether the 

indicator will be measured at the individual and/or community level. 

Population Characteristics: Key population characteristics (e.g., race/ethnicity, income) that 

will be measured for selected indicators and over time. Examining state and community-specific 

data can help identify these population characteristics. Explicitly outlining these can also help 

inform potential changes in surveillance systems to capture these. 

Social Determinants of Health: Due to their impact, assessing changes in social determinants 

of health is important to understanding commercial tobacco control outcomes. Tobacco control 

programs can consider monitoring and assessing changes in social determinants of health and 

their effect on program efforts to reduce tobacco-related disparities as part of their evaluation 

and measurement plans. The five key social determinants of health assessed by Healthy 

CHAPTER 1 - Introduction 11 
People include: Economic Stability, Education, Social and Community Context, Health and 

Healthcare, and Neighborhood and Built Environment.6 

Definition of Progress: Description of how progress will be defined. For example, progress 

may be defined as closing the gap between and within population groups, achieving a particular 

target, and/or shifts towards intended outcomes (e.g., decrease in tobacco use) among 

individual and intersectional population groups experiencing disparities regardless of closing the 

gap. Programs may want to consider a combination of these approaches, for example, 

monitoring not only changes in differences, but also changes towards intended outcomes 

among population groups experiencing disparities. 

Measurement Approach: Description and rationale for how disparities will be measured and 

assessed over time. This is extremely important as it will influence the results and credibility of 

results. 

Data Sources: List of data sources for selected indicators. Explicitly listing these can help 

ensure consistency in data used over time and can help identify data gaps that need to be 

addressed. When selecting data sources, programs may want to ensure that data collection 

instruments are culturally appropriate and cognitively tested to adequately capture data on 

population groups experiencing tobacco-related disparities. 

Analysis: Proposed analysis for the indicators, including the type of analysis and planned 

disaggregation of data for individual and intersectional population groups. Programs can also 

consider specific geographic and spatial analyses that will be conducted for relevant indicators. 

Reporting: The frequency and method of reporting indicators to program decision-makers and 

other stakeholders to stimulate use of the findings to inform program efforts and decisions. 

Plan Updates: How often the measurement plan will be updated to reflect new information, 

lessons learned, and changes in program priorities. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 12 
 

 

 

 

Table 1. Population Characteristic 

Categories 

Age 

msability Sta11Js 

Educatior1 Attainment 

Geog1raphic loca~ion 

Income 

M:emtal health conditions 

Occupation 

Raoe and ethnicity 

Sex 

Sexual orientation and ,g:emder idemtity 

Substance use disorders 

Vetera III and mi itary s

Population Groups 

Table 1 provides a list of key population characteristics that 

are associated with tobacco-related disparities. This list is 

not exhaustive, and disparities may vary by community. 

There are additional related structural and social 

characteristics, which can be associated with tobaccorelated disparities (e.g., employment, home ownership). 

Programs should use their state and community-specific 

data to identify population characteristics most pertinent and 

relevant to tobacco-related disparities in their communities, 

including consideration of other characteristics (e.g., 

geographic locations with high poverty rates, high economic 

inequity, increased violence). 

It is important for programs to maintain and enhance their 

surveillance systems and other data collection mechanisms 

to measure population characteristics in ways that will help 

identify unique and intersectional populations experiencing 

tobacco-related disparities. Moreover, engaging unique and 

intersectional populations affected by disparities can help 

ensure that data collection instruments are culturally 

appropriate to adequately identify and monitor tobaccorelated disparities. 

Applying Health Disparity Framing 

Each outcome profile has a section titled “Applying Health Disparities Framing,” that highlights 

key population characteristics that emerged in the literature as being affected by tobaccorelated disparities related to the indicator. This section may not be exhaustive. Moreover, many 

of the studies cited in this section are national studies and may not be relevant for all state and 

community-specific disparities. The characteristics shared by populations experiencing tobaccorelated disparities may differ in different communities. Additionally, the populations that 

experience tobacco-related disparities in a community can change over time. Thus, this section 

may not have captured the entire range of population characteristics associated with these 

outcome indicators, but instead, reflect information derived from a point-in-time literature review. 

Additionally, because the capacity building indicators in this guide are not population-level 

indicators, the “Applying Health Disparities Framing” section are not framed around population 

characteristics. Rather, this section focuses more on why it is important and relevant to assess 

these indicators in efforts to identify and eliminate tobacco-related disparities. 

CHAPTER 1 - Introduction 13 
References 

1. 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, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 

2. U.S. Department of Health, Education, and Welfare. Smoking and health: report of the 

Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: 

U.S. Department of Health, Education, and Welfare, Public Health Service, Center for 

Disease Control; 1964. 

3. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among 

Adults — United States, 2019. MMWR Morb Mortal Wkly Rep 2020;69:1736–1742. 

4. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco 

control programs—2014. Atlanta, GA: 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. 

5. 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, 

Georgia: 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, 1998. 

6. Healthy People 2030. Washington, DC: U.S. Department of Health and Human Services, 

Office of Disease Prevention and Health Promotion. Accessed May 13, 2021. 

https://health.gov/healthypeople/objectives-and-data/social-determinants-health 

7. Centers for Disease Control and Prevention. Best practices user guide: health equity in 

tobacco 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, 2015. 

8. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

9. Centers for Disease Control and Prevention. Preventing initiation of tobacco use: outcome 

indicators for comprehensive tobacco control programs–2014. Atlanta, Georgia: Centers for 

Disease Control and Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2014. 

10. Centers for Disease Control and Prevention. Eliminating exposure to secondhand smoke: 

outcome indicators for comprehensive tobacco control programs–2017. Atlanta, GA: 

Centers for Disease Control and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 2017. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 14 
11. Centers for Disease Control and Prevention. Promoting quitting among adults and young 

people: outcome indicators for comprehensive tobacco control programs—2015. Atlanta, 

GA: Centers for Disease Control and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 2015. 

12. MacDonald G, Starr G, Schooley M, Yee SL, Klimowski K, Turner K. Introduction to program 

evaluation for comprehensive tobacco control programs. Atlanta, GA: 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; 2001. 

13. United Way of America. Measuring program outcomes: a practical approach. Alexandria, 

VA: United Way of America; 1996. 

14. Centers for Disease Control and Prevention. Framework for program evaluation in public 

health practice. MMWR Morb Mortal Wkly Rep. 1999;48(RR-11):1–40. 

15. Centers for Disease Control and Prevention. Developing an effective evaluation plan: setting 

the course for effective program evaluation. Atlanta, GA: 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. 

16. Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement 

of health disparities, health inequities, and social determinants of health to support the 

advancement of health equity. J Public Health Manag Pract. 2016 Jan-Feb;22 Suppl 

1(Suppl 1):S33-42.11. 

17. Keppel K, Pamuk E, Lynch J, et al. Methodological issues in measuring health disparities. 

Vital Health Stat 2. 2005 Jul;(141):1-16.12. 

18. Harper S, Lynch J. Methods for measuring cancer disparities: Using data relevant to Healthy 

People 2010 cancer-related objectives. NCI Cancer Surveillance Monograph Series, No 6. 

NIH Publication No. 05–5777. Bethesda, MD: U.S Department of Health and Human 

Services, National Institute of Health, National Cancer Institute; 2005. 

19. King NB, Harper S, Young ME. Use of relative and absolute effect measures in reporting 

health inequalities: structured review. Version 2. BMJ. 2012 Sep 3;345:e5774.13. 

20. Wagstaff A, Paci P, van Doorslaer E. On the measurement of inequalities in health. Soc Sci 

Med. 1991;33(5):545-57.14. 

21. Martell BN, Garrett BE, Caraballo RS. Disparities in adult cigarette smoking — United 

States, 2002–2005 and 2010–2013. MMWR Morb Mortal Wkly Rep. 2016;65:753–758. 

CHAPTER 1 - Introduction 15 

CHAPTER 2 

LOGIC MODEL 
Increased Capacity to Identify and Eliminate Tobacco-Related Disparities 

External Factors: Organizational, Political, Structural, Systemic, Social 

and Economic Factors that can influence Tobacco-Related Disparities.

Funding 

Leadership 

Political 

Commitment 

Culturally 

Competent 

Workforce 

Multi-Level 

and MultiDisciplinary 

Partnerships 

Cultural 

Humility 

Data 

Assessment and 

Action Planning 

State, Local, 

and Community 

Engagement 

Tailored, 

Culturally 

Appropriate 

Strategies 

Policy, 

Systems, and 

Environmental 

Changes to 

Prevent 

and Reduce 

Tobacco Use 

Inclusive 

and Diverse 

Partnerships that 

Promote Social, 

Economic, 

and Community 

Changes 

Surveillance 

and Evaluation 

Strategic/Action 

Plans in Place 

Community 

Engagement 

Activities in Place 

Completed 

Activities to 

Increase Tailored, 

Culturally 

Appropriate 

Strategies 

Completed 

Activities to 

Increase Policy, 

Systems, and 

Environmental 

Changes 

Inclusive 

and Diverse 

Partnerships 

are in Place 

Completed 

Activities 

to Identify, 

Monitor and 

Inform 

Disparities 

Inputs Activities Outputs

Short-term 

1. 

Increased 

knowledge of 

the harms of 

tobacco use 

among 

populations 

experiencing 

tobacco-related 

disparities and 

support for 

evidence-based 

tobacco control 

interventions 

2. 

Increased 

equitable 

adoption, 

implementation 

and 

enforcement of 

tobacco 

prevention and 

control policies, 

in population 

groups 

experiencing 

tobacco-related 

disparities 

3. 

Increased 

availability of 

coverage, and 

adoption of 

health care 

systems 

changes that 

promote and 

support 

cessation in 

populations 

experiencing 

tobacco-related 

disparities 

Outcomes 

Intermediate Long-term 

4. 

Decreased 

tobacco 

industry and 

environmental 

influences that 

contribute to 

tobacco-related 

disparities 

5. 

Increased quit 

attempts, quit 

attempts using 

evidence-based 

cessation 

services, and 

successful 

cessation 

among 

populations 

experiencing 

tobacco-related 

disparities 

Eliminate 

disparities in 

tobacco-related 

morbidity and 

mortality 

9. 

Eliminate 

disparities in 

tobacco use 

Eliminate 

disparities in 

SHS and 

e-cigarette 

aerosol 

exposure 

6. 

7. 

8. 

Eliminate 

disparities in 

tobacco use 

initiation 

 

GOAL AREA 4 

Goal Area 4 Logic Model 

Identifying and Eliminating Tobacco-Related Disparities 

Identifying and Eliminating Tobacco-Related Disparities:

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 18
GOAL AREA 4 

Goal Area 4: 

Identifying and Eliminating Tobacco-Related Disparities 

Process Indicators 

Increased capacity to develop and implement tobacco control interventions to identify 

and eliminate tobacco-related disparities 

1: Decision-maker support to address tobacco-related disparities 

2: Commitment to address tobacco-related disparities 

3: Resources to address tobacco-related disparities 

4: Culturally competent workforce to address tobacco-related disparities 

5: Data systems to identify, monitor, and evaluate tobacco-related disparities 

6: Multisectoral coalitions and partnerships to address tobacco-related disparities 

7: State-tribal-local collaborations to address tobacco-related disparities 

8: Community engagement in efforts to address tobacco-related disparities 

Outcome Indicators 

Outcome 1: Increased knowledge of the harms of tobacco use among populations 

experiencing tobacco-related disparities and support for evidence-based tobacco control 

interventions 

4.1.a: Disparities in the perceived harm of tobacco use 

4.1.b: Disparities in the perceived harm of secondhand smoke 

4.1.c: Disparities in the awareness of available cessation services 

4.1.d: Support for policies to reduce tobacco industry influence 

4.1.e: Support for comprehensive smokefree policies 

Outcome 2: Increased equitable adoption, implementation, and enforcement of tobacco 

prevention and control policies 

4.2.a: Policies that regulate tobacco retail sales 

4.2.b: Policies that regulate tobacco marketing 

4.2.c: Retail licensing for tobacco sales 

4.2.d: Policies that regulate the number, type, location, and density of tobacco retail outlets 

4.2.e: Policies that regulate tobacco promotions, discounts, and coupons 

CHAPTER 2 – LOGIC MODEL 19 
 

GOAL AREA 4 

4.2.f: Policies that prohibit the sale of flavored tobacco products 

4.2.g: Comprehensive smokefree policies for indoor public places 

4.2.h: Smokefree policies for casinos 

4.2.i: Employed population covered by workplace smokefree policies 

4.2.j: Smokefree policies in multiunit housing 

4.2.k: Home and vehicle smokefree rules 

4.2.l: Tobacco product price 

4.2.m: Minimum price policies 

4.2.n: Equitable enforcement of tobacco control policies 

Outcome 3: Increased health systems changes and coverage that promote and support 

cessation in populations experiencing tobacco-related disparities 

4.3.a: Healthcare systems that have implemented evidence-based cessation guidelines 

4.3.b: Disparities in health care professional screening for tobacco use 

4.3.c: Disparities in health care provider advise to quit tobacco use 

4.3.d: Disparities in health care professionals’ assistance in quitting tobacco use

4.3.e: Proportion of behavioral health treatment facilities that offer evidence-based 

tobacco treatment 

4.3.f: Behavioral health treatment facilities with tobacco-free policies 

4.3.g: Disparities in access to comprehensive evidence-based cessation services 

Outcome 4: Decreased tobacco industry and environmental influences that contribute to 

tobacco-related disparities 

4.4.a: Disparities in density of stores selling tobacco 

4.4.b: Disparities in the amount and type of retail tobacco advertising 

4.4.c: Disparities in exposure to tobacco marketing 

4.4.d: Consumer-focused industry promotions 

4.4.e: Disparities in exposure to tobacco discounts and promotions 

4.4.f: Disparities in tobacco product sales to minors 

4.4.g: Disparities in youth and young adult access to tobacco products 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 20 
GOAL AREA 4 

Outcome 5: Increased quit attempts, quit attempts using evidence-based cessation services, 

and successful cessation among populations experiencing tobacco-related disparities 

4.5.a: Disparities in the intention to quit 

4.5.b: Disparities in quit attempt 

4.5.c: Disparities in quit attempts using an evidence-based cessation treatment(s) 

4.5.d: Use of quitline services among populations experiencing disparities 

4.5.e: Disparities in recent cessation success 

4.5.f: Disparities in sustained abstinence from tobacco use 

Outcome 6: Eliminate disparities in tobacco use initiation 

4.6.a: Disparities in the average age at which young people first tried a tobacco product 

4.6.b: Disparities in the initiation of tobacco use using a flavored tobacco product 

4.6.c: Disparities in the proportion of youth and young adults who report never having 

tried a tobacco product 

Outcome 7: Eliminate disparities in tobacco use 

4.7.a: Disparities in tobacco use prevalence 

4.7.b: E-cigarette use among youth and young adults 

4.7.c: Disparities in the use of flavored tobacco products 

4.7.d: Menthol flavored cigarette use 

4.7.e: Disparities in polytobacco product use 

4.7.f: Disparities in the daily use of tobacco products 

4.7.g: Disparities in nicotine dependence 

Outcome 8: Eliminate disparities in secondhand smoke exposure 

4.8.a: Disparities in exposure to secondhand smoke among people who do not smoke 

4.8.b: Disparities in exposure to secondhand smoke in the workplace 

4.8.c: Disparities in exposure to secondhand smoke in indoor public places 

4.8.d: Disparities in exposure to secondhand smoke in homes and vehicles 

4.8.e: Disparities in exposure to secondhand smoke among multiunit housing residents 

CHAPTER 2 – LOGIC MODEL 21 

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CHAPTER 3 

PROCESS INDICATORS 
 

► 

GOAL AREA 4 

PROCESS INDICATORS 

Increased capacity to develop and implement interventions to 

identify and eliminate tobacco-related disparities 

Adequate capacity and infrastructure are necessary to develop and implement evidence-based 

strategies that can improve tobacco-related outcomes among populations experiencing 

tobacco-related disparities.1-4 In this guidance, building capacity refers to increasing the 

infrastructure, systems, skills and resources of organizations and communities to develop and 

implement evidence-based, culturally-appropriate strategies that lead to sustainable communityand individual-level changes to improve tobacco-related health outcomes.

4-7 The guidance in 

this section predominately focuses on building capacity of state and local public health agencies 

because they are in a prime position to promote health equity, connect to social movements, 

and support broader community capacity and social and environmental changes necessary to 

reduce tobacco-related health disparities. 

Certain factors have been identified as central to the concept of capacity, including supportive 

and informed leadership, adequate funding and resources, multisectoral partnerships, workforce 

capacity, support for community values, and the ability to identify and address community 

issues.

6-11 Many of these factors can affect practices that can enable or hinder efforts to identify 

and eliminate tobacco-related disparities. Increasing the capacity of public health agencies can 

foster practices and decisions that facilitate culturally appropriate efforts to reduce tobaccorelated disparities and can better position these agencies to work with multisectoral partners 

and communities to address structural and social determinants that contribute to tobaccorelated disparities.12-14 

Studies have shown that opportunities exist to enhance capacity to support implementation of 

effective strategies to address tobacco-related disparities. For example, Wong et al. found wide 

variations across health departments in the level of understanding of health equity and health 

disparities, which created challenges in setting priorities and program goals.

15 The same 

assessment found that public health department leaders often expressed uncertainty about the 

support of local officials to address disparities, which hindered staff’s ability to take action.15 

Moreover, a study of local health departments found that while many stressed the importance of 

diversity, few had considered or implemented recruitment and hiring practices to build an 

inclusive workforce reflective of the communities they served.15 Additionally, ongoing data 

collection on population subgroups remains challenging for many programs, impeding efforts to 

inform and evaluate efforts to address tobacco-related disparities.14 

Building capacity to identify and eliminate health disparities requires engagement at multiple 

levels of the community between community members and the institutions that serve them.4,13 

Building multisectoral partnerships with community organizations and members can provide 

grassroots support, infrastructure, and stakeholder representation to inform and drive 

community changes that can reduce tobacco-related disparities.1-3 For example, a program in 

Eastern Tennessee used a community participatory approach along with actionable data as a 

means to inform and strengthen tobacco prevention and control actions, policies, and programs 

in disproportionately impacted communities.16 Many communities disproportionally burdened by 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 24 
► 

GOAL AREA 4 

PROCESS INDICATORS 

tobacco use are also affected by other health, economic, and social issues, such as limited 

access to healthcare services and poverty, that can hinder efforts to address disparities.4,17,18 

Some communities, such as rural communities with tobacco farming history and economic ties, 

may have tobacco use engrained in their community culture.

4,17 Meaningful community 

engagement can help tobacco control programs better understand these issues and can 

empower community members and leaders to advance sustainable changes – both public 

health and non-public health-related – in their communities to improve health outcomes and 

reduce tobacco-related disparities. 

The capacity-building measures put forth in this section are not exhaustive. These indicators are 

useful in assessing and understanding key community capacity factors that can promote or 

impede efforts to address tobacco-related disparities. These indicators can also help stimulate 

thinking on components of capacity building and their role in reducing disparities. State and 

community assessments can help identify additional capacity building indicators to advance 

tobacco control in their communities. Programs should consider their organization and 

community context when using and selecting indicators in this section, as some may not be 

appropriate for an organization given its community context. 

The following indicators are associated with this outcome: 

1: Decision-maker support to address tobacco-related disparities 

2: Commitment to address tobacco-related disparities 

3: Resources to address tobacco-related disparities 

4: Culturally competent workforce to address tobacco-related disparities 

5: Data systems to identify, monitor, and evaluate tobacco-related disparities 

6: Multisectoral coalitions and partnerships to address tobacco-related disparities 

7: State-tribal-local collaborations to address tobacco-related disparities NR 

8: Community engagement to address tobacco-related disparities 

NR Denotes an indicator that is not rated. 

CHAPTER 3 - PROCESS INDICATORS 25 
 

► 

GOAL AREA 4 

PROCESS INDICATORS 

References 

1. Brunton CT, Smedley BD. Building public health capacity to advance equity. J Public Health 

Manag Pract. 2019 Jul/Aug;25(4):411-2. 

2. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco 

control programs—2014. Atlanta (GA): 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. Accessed March 

23, 2020. https://www.cdc.gov/tobacco/stateandcommunity/best-practices-healthequity/index.htm 

3. Centers for Disease Control and Prevention, Division of Community Health. A practitioner’s

guide for advancing health equity: community strategies for preventing chronic disease. 

Atlanta (GA): U.S. Department of Health and Human Services; 2013. Accessed February 9, 

2021. https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equityguide/index.htm 

4. Centers for Disease Control and Prevention. Best practices user guide: health equity in 

tobacco prevention and control. Atlanta (GA): 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; 2015. 

5. Liberato SC, Brimblecombe J, Ritchie J, Ferguson M, Coveney J. Measuring capacity 

building in communities: a review of the literature. BMC Public Health. 2011 Nov 9;11:850. 

6. Goodman RM. A construct for building the capacity of community-based initiatives in racial 

and ethnic communities: a qualitative cross-case analysis. J Public Health Manag Pract. 

2008 Nov;14 Suppl:S18-25. 

7. Báezconde-Garbanati L, Beebe LA, Pérez-Stable EJ. Building capacity to address tobaccorelated disparities among American Indian and Hispanic/Latino communities: conceptual 

and systemic considerations. Addiction. 2007 Oct;102 Suppl 2:112-22. 

8. Lavinghouze SR, Snyder K, Rieker PP. The component model of infrastructure: a practical 

approach to understanding public health program infrastructure. Am J Public Health. 2014 

Aug;104(8):e14-24. 

9. U.S. 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, National Institutes of Health, National Cancer Institute. NIH 

Pub. No. 06-6058, October 2006. 

10. Robinson RG. Community development model for public health applications: overview of a 

model to eliminate population disparities. Health Promot Pract. 2005 Jul;6(3):338-46. 

11. DeCorby-Watson K, Mensah G, Bergeron K, Abdi S, Rempel B, Manson H. Effectiveness of 

capacity building interventions relevant to public health practice: a systematic review. BMC 

Public Health. 2018 Jun 1;18(1):684. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 26 
► 

GOAL AREA 4 

PROCESS INDICATORS 

12. Griffith DM, Allen JO, DeLoney EH, et al. Community-based organizational capacity building 

as a strategy to reduce racial health disparities. J Prim Prev. 2010 Apr;31(1-2):31-9. 

13. Gilbert KL, Quinn SC, Ford AF, Thomas SB. The urban context: a place to eliminate health 

disparities and build organizational capacity. J Prev Interv Community. 2011;39(1):77-92. 

14. Bergeron K, Abdi S, DeCorby K, Mensah G, Rempel B, Manson H. Theories, models and 

frameworks used in capacity building interventions relevant to public health: a systematic 

review. BMC Public Health. 2017 Nov 28;17(1):914. 

15. Wong Croal N, Whitley J, Smedley BD. Building public health capacity to advance racial 

equity: a national environmental scan of tribal, state, and local governmental public health. 

Washington: National Collaborative for Health Equity; 2018. 

16. Robertson C, Mamudu HM, Littleton M, et al. Using a collaborative approach to tobacco 

control efforts in marginalized communities. Online J Public Health Inform. 2017 

May;9(1):e074. 

17. Talbot JA, Williamson ME, Pearson KB, et al. Advancing tobacco prevention and control in 

rural America. Washington, DC: National Network of Public Health Institutes; 2019. 

18. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

CHAPTER 3 - PROCESS INDICATORS 27 
Increased capacity to develop and implement interventions to identify and 

eliminate tobacco-related disparities 

 

Indicator Rating 

←○ ◕ ●→ better 

► 

-

-

-

-

-

-

-= 

GOAL AREA 4 

PROCESS INDICATORS 

Number Indicator 

1 

Decision-maker support to 

address tobacco-related 

disparities 

2 Commitment to address 

tobacco-related disparities 

3 Resources to address 

tobacco-related disparities 

4 

Culturally competent 

workforce to address 

tobacco-related disparities 

5 

Data systems to identify 

monitor, and evaluate 

tobacco-related disparities 

6 

Multisectoral coalitions and

partnerships to address 

tobacco-related disparities 

7 

State-tribal-local 

collaborations to address 

NR tobacco-related disparities 

8 

Community engagement to

address tobacco-related 

disparities 

Overall 

Quality 

low ↔ high

Resources Needed Strength of Evaluation 

Evidence 

UtilityFace 

V

alidity 

Accepted Practice 

$ ● ● ● ●

$ ● ● ● ●

$ ● ● ● ●

$ ● ● ● ●

$$ ● ● ● ●

$ ● ◕ ● ●

NR NR NR NR NR NR 

$ ● ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data 

to measure the indicator. 

NR Denotes an indicator that is not rated. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 28 
Decision-Maker Support to Address Tobacco-Related Disparities 

Indicator 

number 

1 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Level of support among decision-makers of state, tribal, territorial, and local 

tobacco control programs to implement interventions to identify and 

eliminate tobacco-related disparities. 

Rationale Because of their strong influence, decision-makers play a vital role in 

building capacity to achieve program goals. 

1-4 Leaders with decisionmaking authority drive strategic and funding decisions that can have a 

4 strong impact on tobacco control efforts.

Applying 

health 

disparities 

framing 

The National Stakeholder Strategy for Achieving Health Equity outlines the 

importance of having strong, supportive leadership to promote community 

solutions to address disparities. 

5 Supportive decision makers can yield 

significant benefits by helping to prioritize evidence-based practices, by 

developing action plans, and by allocating funding to address tobaccorelated disparities.6-8 Moreover, decision-makers can help build political will 

and secure commitments from multisectoral partners to address 

6-7 disparities. 

Example 

survey 

question(s) 

Adapted from the Component Model of Infrastructure (CMI)8 

On a scale of 1 (no support) to 5 (high level of support), what level of 

decision-maker support does your program have to address disparities: 

• Within the health department but external to the tobacco control 

program (e.g., health commissioner, chronic disease program 

director)? 

• From other state and local government agencies (e.g., local health

department, directors, superintendents, mental health agency 

director)? 

• From tribal governments and agencies (e.g., tribal health 

departments, tribal health boards)? 

• From other non-government agencies (e.g., directors of communitybased organizations, American Lung Association)? 

• From a policymaker (e.g., governor, mayor, state legislator, 

congressperson)? 

On a scale of 1 (strongly disagree) to 5 (strongly agree), to what extent do 

you agree with the following statements about your most influential 

decision-makers? 

• Decision-makers include tobacco-related disparities as a priority in 

action/strategic plans. 

► 

GOAL AREA 4 

PROCESS INDICATORS 

CHAPTER 3 - PROCESS INDICATORS 29 
 

 

 

 

► 

- I 

$ ● ● ● ●

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GOAL AREA 4 

PROCESS INDICATORS 

• Decision-makers’ funding decisions reflect their commitment to

address tobacco-related disparities. 

• Decision-makers’ decisions promote an inclusive and culturally 

competent workforce. 

• Decision-makers help build multisectoral partnerships with public, 

non-profit, and private entities to drive actions to reduce tobaccorelated disparities. 

• Decision-makers help garner support for community strategies that 

can reduce tobacco-related disparities. 

Comments Tobacco control programs may want to assess whether decision-maker 

support is written or verbal and how it is perceived by the respondents. 

Furthermore, tobacco control programs may want to assess support for 

healthy equity initiatives as they can promote reductions in disparities. Data 

collected on policymaker support are for informational purposes only, to 

better understand factors that may affect work on tobacco-related 

disparities. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

References 1. Jones PR, Waters CM, Oka RK, McGhee EM. Increasing community 

capacity to reduce tobacco‐related health disparities in African 

American communities. Public Health Nurs. 2010;27(6):552-60. 

2. Goodman RM. A construct for building the capacity of communitybased initiatives in racial and ethnic communities: a qualitative crosscase analysis. J Public Health Manag Pract. 2008 Nov;14 Suppl:S18-

25. 

3. Báezconde-Garbanati L, Beebe LA, Pérez-Stable EJ. Building capacity 

to address tobacco-related disparities among American Indian and 

Hispanic/Latino communities: conceptual and systemic considerations. 

Addiction. 2007 Oct;102(2):112-22. 

4. Centers for Disease Control and Prevention. Best practices user guide: 

program infrastructure in tobacco 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, 2017. 

5. National Partnership for Action to End Health Disparities. National 

stakeholder strategy for achieving health equity. Rockville, MD: 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 30 
► 

GOAL AREA 4 

PROCESS INDICATORS 

Department of Health and Human Services, Office of Minority Health; 

2011. 

6. Lettlow HA. Engaging culturally competent, community-based 

programs in reducing tobacco-related health disparities. Am J Public 

Health, 2008;98(11):1936-9. 

7. David AM, Lew R, Lyman AK, Otto C, Robles R, Cruz GJ. Eliminating 

tobacco-related disparities among Pacific Islanders through leadership 

and capacity building: promising practices and lessons learned. Health 

Promot Pract. 2013;14 Suppl:S10-7. 

8. Lavinghouze SR, Snyder K, Rieker PP. The component model of 

infrastructure: a practical approach to understanding public health 

program infrastructure. Am J Public Health. 2014 Aug;104(8):e14-24. 

CHAPTER 3 - PROCESS INDICATORS 31 
Indicator 

number 

2 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Level of commitment demonstrated by tobacco control program decisionmakers to identify and eliminate tobacco-related disparities. 

Rationale Formalized commitments from public health programs in the way of 

statues, strategic plans, program goals, and funding priorities serve as a 

guide to focus programmatic efforts, decisions, and clarify priorities to 

partners.1-3 For example, strategic plans and funding requirements help 

communicate the program focus areas and goals to partners. 

Applying health 

disparities 

framing 

Tobacco control programs can clarify their commitment to address 

disparities by including actionable goals with targets to eliminate tobaccorelated disparities in strategic plans.1-3 Formal strategic statements can 

facilitate and drive strategies focused on eliminating tobacco-related 

disparities.2 Moreover, practices such as frequently discussing tobaccorelated disparities at meetings with decision makers and integrating 

processes to provide culturally-tailored interventions and services can 

help reinforce and institutionalize commitments to address tobaccorelated disparities. 

Example survey 

question(s) 

Adapted from Component Model of Infrastructure (CMI)4 

Is addressing health disparities included as a priority in your state 

health/strategic plan? Yes/No 

Does your program have goals with targets that are tracked to reduce 

tobacco-related disparities? Yes/No 

Does your program have a standalone plan to address tobacco-related 

disparities and/or health equity? Yes/No 

On a scale of 1 (strongly disagree) to 5 (strongly agree), to what extent do 

you agree with the following statements about your tobacco control 

program? 

• The program includes a disparities component in tobacco-relate

funding requirements. 

d 

• Workforce hiring and trainings decisions promote inclusivity and 

cultural competence. 

• Topics to address disparities are frequently included in meeting 

agendas with decision-makers. 

• Data and information on tobacco-related disparities are frequently 

included in major reports produced by the program. 

► 

GOAL AREA 4 

PROCESS INDICATORS 

Commitment to Address Tobacco-Related Disparities 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 32 
► 

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$ ● ● ● ●

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GOAL AREA 4 

PROCESS INDICATORS 

• The program has processes in place to integrate culturally and 

linguistically appropriate services and resources into tobacco 

prevention and control interventions and products. 

Comments When assessing this indicator, tobacco control programs may also want to 

examine program strategies to promote health equity as they can promote 

reductions in disparities. Moreover, commitment to address tobaccorelated disparities may be part of a larger plan and/or initiative to reduce 

health disparities within the health department. 

Rating Strength 

of Overall quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

References 1. Centers for Disease Control and Prevention, Division of Community 

Health. A practitioner’s guide for advancing health equity: community 

strategies for preventing chronic disease. Atlanta(GA): US Department

of Health and Human Services; 2013. Accessed March 23, 2020. 

https://www.cdc.gov/nccdphp/dnpao/state-local-programs/healthequity-guide/index.htm 

2. Centers for Disease Control and Prevention. Best practices user 

guide: health equity in tobacco prevention and control. Atlanta (GA): 

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, 

2015. 

3. Wong Croal N, Whitley J, Smedley BD. Building public health capacity 

to advance racial equity: a national environmental scan of tribal, state, 

and local governmental public health. Washington: National 

Collaborative for Health Equity; 2018. Accessed February 9, 2021. 

https://www.nationalcollaborative.org/our-programs/building-capacitypublic-health-advance-equity-program/ 

4. Lavinghouze SR, Snyder K, Rieker PP. The component model of 

infrastructure: a practical approach to understanding public health 

program infrastructure. Am J Public Health. 2014 Aug;104(8):e14-24. 

CHAPTER 3 - PROCESS INDICATORS 33 
 

► 

GOAL AREA 4 

PROCESS INDICATORS 

Resources to Address Tobacco-Related Disparities 

Indicator 

number 

3 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Proportion of resources* allocated by tobacco control programs to 

implement interventions to identify and eliminate tobacco-related 

disparities. 

Rationale Effective implementation of strategies to achieve tobacco prevention and 

control goals requires adequate resources, including sufficient funding and 

skilled staff to oversee programs and conduct technical assistance and 

training at all levels of the implementation process.1-2 CDC provides 

recommended funding levels for tobacco control programs to effectively 

3 reduce tobacco use. 

Applying Budgetary constraints that typically exist in underserved communities can 

health create barriers to the implementation of evidence‐based and tailored, 

disparities culturally appropriate programs to reduce health disparities. Research has 

framing shown that funding allocation to address tobacco-related disparities has 

4-6 often not been commensurate with the disparities being addressed. 

Example Adapted from APPEAL Stages of Community Readiness Model5 

survey Does your program have funding dedicated to address tobacco-related 

question(s) disparities? Yes/No 

What percentage of your program’s tobacco control funding is dedicated to

address tobacco-related disparities? 

Does your tobacco control program have staff dedicated to implement 

interventions to address disparities? Yes/No 

How many full-time employees does your program have working on 

tobacco-related disparities? 

What percentage of staff’s time is dedicated to implement interventions to 

reduce tobacco-related disparities? 

Comments *This indicator focuses on resources related to funding and staffing; these 

are similar but different constructs that tobacco control programs may want 

to examine separately, as a program may have adequate funding but not 

adequate staffing and vice versa. Both constructs were lumped into one 

indicator for simplicity. When measuring this indicator, tobacco control 

programs may want to consider whether resources allocated are 

commensurate with the disparities being addressed. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 34 
► 

- I 

$ ● ● ● ●

←○ ◕ ●→better

GOAL AREA 4 

PROCESS INDICATORS 

Tobacco control programs can expand on this indicator by further 

examining the proportion of workplan strategies that are directed towards 

identifying and eliminating tobacco-related disparities; this can reflect the 

extent to which resources are translating into the implementation of 

interventions to address disparities. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

References 1. Centers for Disease Control and Prevention. Best practices user guide: 

health equity in tobacco prevention and control. Atlanta (GA): 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;, 

2015. 

2. Farrelly MC, Pechacek TF, Thomas KY, Nelson D. The impact of 

tobacco control programs on adult smoking. Am J Public Health. 

2008;98(2):304-9. 

3. Centers for Disease Control and Prevention. Best practices for 

comprehensive tobacco control programs—2014. Atlanta, GA: US Dept 

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. 

4. Jones PR, Waters CM, Oka RK, McGhee EM. Increasing community 

capacity to reduce tobacco‐related health disparities in African 

American communities. Public Health Nurs. 2010;27(6):552-60. 

5. Lew R, Tanjasiri S, Kagawa-Singer M, Yu J. Using a stages of 

readiness model to address community capacity on tobacco control in 

the Asian American and Pacific Islander community. Asian Am Pac Isl J 

Health. 2001 Winter-Spring;9(1):66-73. 

6. Báezconde-Garbanati L, Beebe LA, Pérez-Stable EJ. Building capacity 

to address tobacco-related disparities among American Indian and 

Hispanic/Latino communities: conceptual and systemic considerations. 

Addiction. 2007 Oct;102 Suppl 2:112-22. 

CHAPTER 3 - PROCESS INDICATORS 35 
 

► 

GOAL AREA 4 

PROCESS INDICATORS 

Culturally Competent Workforce to Address Tobacco-Related Disparities 

Indicator 

number 

4 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Extent to which state, tribal, territorial, and local tobacco control programs 

have an inclusive workforce that is culturally competent 

Rationale A culturally competent workforce has the skills, beliefs, attitudes, 

knowledge, and cultural humility to more effectively plan, implement, and 

evaluate tailored and culturally appropriate strategies to address tobaccorelated disparities.1,2 Hiring culturally competent staff and ongoing 

development of competencies among existing staff can help fill knowledge 

gaps and create a workforce that is better positioned to implement 

strategies to achieve program goals.1-3 

Applying Successful efforts to identify and eliminate health disparities require staff 

health with the skills and competencies to understand the causes of disparities 

disparities and inequities and the strategies and multisectoral partnerships that can 

framing help address them.2,4 Research has found wide variation in workforce 

capacity, awareness, and training within health departments on health 

equity and disparities.5 

Example 

survey 

question(s) 

On a scale of 1 (strongly disagree) to 5 (strongly agree), to what 

extent do you agree with the following statements about the 

program’s workforce?

• Program staff have a clear understanding of health disparities 

and health equity-related concepts. 

• Program staff are trained to implement culturally appropriate 

interventions to address tobacco-related disparities. 

• Program staff work well with people of different cultures and 

backgrounds. 

• Program staff always engage multisectoral partners and 

members representing populations experiencing tobaccorelated disparities when planning and evaluating 

interventions. 

• The program has persons representing populations 

experiencing disparities in leadership/decision-making roles. 

• Diversity is reflected in my program’s employee base.

On a scale of 1 (strongly disagree) to 5 (strongly agree), to what extent do 

you agree with the following statements about your program/organization’s 

procedures and policies to promote cultural competence? 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 36 
► 

-I 

$ ● ● ● ●

GOAL AREA 4 

PROCESS INDICATORS 

• The program/organization conducts ongoing cultural competency 

assessments and trainings. 

• The program/organization has strategies that promote recruitment, 

hiring, retention, and promotion of qualified culturally diverse staff. 

• The program/organization has an equal opportunity employment 

policy. 

• The program/organization includes inclusive language (i.e., 

language that does not marginalize groups of people) in job 

postings. 

• The program/organization actively recruits employees who have 

experience working with populations reflecting diverse cultural and 

linguistic backgrounds. 

• The program/organization promotes building diversity in the 

employee base through internships, fellowships, and student 

assistant opportunities. 

Comments Tobacco control programs may also want to assess the extent to which 

program communication materials, services, and interventions are 

culturally tailored and/or targeted to population groups experiencing 

disparities. This information can help identify gaps in skills and 

competencies that need to be filled. 

Definition of Terms: 

• Cultural competence: a set of congruent behaviors, attitudes, and 

policies that come together in a system, agency, or among 

professionals and enables effective work in cross-cultural situations. 6-7 

• Cultural humility: The ability to maintain an interpersonal stance that is 

other-oriented (or open to the other) in relation to aspects of cultural 

identity that are most important to the person. Cultural humility is one 

construct for understanding and developing a process-oriented 

approach to competency 6,8 

• Diversity: an appreciation and respect for differences, similarities and 

opportunities inherent in the individuals and organizational 

characteristics that shape the workplace.9 

• Inclusion: a set of behaviors that encourage employees to feel valued 

for their unique qualities and experience a sense of belonging.9 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

CHAPTER 3 - PROCESS INDICATORS 37 
 

► 

GOAL AREA 4 

PROCESS INDICATORS 

References 1. Centers for Disease Control and Prevention, Division of Community 

Health. A practitioner’s guide for advancing health equity: community 

strategies for preventing chronic disease. Atlanta (GA): US Department 

of Health and Human Services; 2013. Accessed March 23, 2020. 

https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equityguide/index.htm 

2. Wong Croal N, Whitley J, Smedley BD. Building public health capacity 

to advance racial equity: a national environmental scan of tribal, state, 

and local governmental public health. Washington: National 

Collaborative for Health Equity; 2018. Accessed February 9, 2021. 

https://www.nationalcollaborative.org/our-programs/building-capacitypublic-health-advance-equity-program/ 

3. Centers for Disease Control and Prevention. Best practices user guide: 

program infrastructure in tobacco 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, 2017. 

4. Lettlow HA. Engaging culturally competent, community-based programs 

in reducing tobacco-related health disparities. Am J Public Health. 

2008;98(11):1936-9. 

5. Hofrichter, R. Advancing health equity in local public health practice: 

challenges and possibilities. Washington: National Association of 

County and City Health Officials; 2017. 

6. Tervalon M, Murray-García J. Cultural humility versus cultural 

competence: a critical distinction in defining physician training 

outcomes in multicultural education. J Health Care Poor Underserved. 

1998 May;9(2):117-25. 

7. Centers for Disease Control and Prevention. NCHHSTP Social 

Determinants of Health. Accessed February 9, 2021. 

http://medbox.iiab.me/modules/encdc/www.cdc.gov/nchhstp/socialdeterminants/definitions.html 

8. Hook JN, Davis DE, Owen J, Worthington EL, Utsey SO. Cultural 

humility: measuring openness to culturally diverse clients. J Couns 

Psychol. 2013 Jul;60(3):353-366. 

9. Centers for Disease Control and Prevention. Diversity and inclusion 

management. Accessed February 9, 2021. 

https://www.cdc.gov/minorityhealth/diversityandinclusion/index.html 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 38 
► 

GOAL AREA 4 

PROCESS INDICATORS 

Data Systems to Identify, Monitor, and Evaluate Tobacco-Related Disparities 

Indicator 

number 

5 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Extent to which state, tribal, territorial, and local tobacco control programs 

have data systems* to identify and monitor tobacco-related disparities. 

Rationale Data from surveillance systems and evaluation studies are foundational 

resources to help inform public health action, to garner decision-maker 

support, and to ensure that resources and efforts reflect community 

needs.1 

Applying Data systems to identify, monitor, and evaluate tobacco-related disparities 

health are a foundational need for tobacco control programs seeking to address 

disparities tobacco-related disparities.1,2 disaggregated data on population groups and 

framing community factors, including data on social determinants of health, can 

inform the development of strategies to address disparities and support 

evaluation of those strategies. 

2-3 While many national and state 

surveillance systems monitor trends in tobacco use, most do not collect 

and report, or face challenges collecting and reporting, disaggregated 

population and community-level data, which are important to help inform 

1,3 and evaluate efforts to reduce tobacco-related disparities. 

Example Adapted from Component Model of Infrastructure (CMI)4 

survey Does your program’s surveillance system collect and monitor data on the

following population groups? Yes/No question(s) 

• African American/Black 

• American Indian/Alaska Native 

• Asian American/Pacific Islander 

• Disability/Limitation 

• Hispanic/Latino 

• Mental Health Conditions 

• Substance Use Disorders 

• LGBTQ+ 

• Education 

• Income 

• Military/Veteran 

• Occupation 

• Rural/Urban 

• Youth (<18 years old) 

On a scale of 1 to 5, to what extent do you agree with the following 

statements about your tobacco control program surveillance system? 

CHAPTER 3 - PROCESS INDICATORS 39 
► 

- I 

$$ ● ● ● ●

←○ ◕ ●→better

GOAL AREA 4 

PROCESS INDICATORS 

• Surveillance systems routinely collect and monitor data on 

population groups experiencing tobacco-related disparities. 

• Community/local level surveillance data are used to augment 

understanding of tobacco-related disparities. 

• Surveillance questions are written in an inclusive, culturally 

appropriate manner. 

• Sample sizes are large enough to disaggregate data to identify and 

monitor tobacco-related disparities. 

• Geographic information systems are used to identify geographic 

disparities in tobacco-related interventions and outcomes. 

• Data on community level factors (e.g., density of tobacco retailers, 

social determinants of health) that influence disparities are routinely 

collected and analyzed. 

• Surveillance data are used to prioritize tobacco-related disparities 

efforts. 

On a scale of 1 to 5, to what extent do you agree with the following 

statements about your tobacco control program evaluation efforts? 

• Evaluation activities are in place to assess the effectiveness of 

interventions in influencing tobacco-related outcomes among 

populations experiencing disparities. 

• Evaluation processes, including planning, implementation, 

interpretation, dissemination, and use, incorporate strategies that 

promote inclusivity and cultural relevance. 

• The evaluation stakeholders represent those affected by the 

program being evaluated. 

• Evaluation findings are used to prioritize tobacco-related disparities 

efforts. 

Comments *This indicator focuses on data systems related to surveillance and 

evaluation. These were lumped into one indicator for simplicity, but tobacco 

control program may want to consider examining them separately. 

Tobacco control programs can assess this indicator by priority population 

group as there may be variation in the extent to which surveillance and/or 

evaluation data adequately capture data for all populations experiencing 

tobacco-related disparities in the state and/or jurisdiction. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 40 
► 

GOAL AREA 4 

PROCESS INDICATORS 

References 1. Fagan P, King G, Lawrence D, et al. Eliminating tobacco-related health 

disparities: directions for future research. Am J Public Health. 2004 

Feb;94(2):211-7. 

2. Tong EK, Lew R. Moving communities toward policy change: 

APPEAL’s 4-prong policy change model. Promot Pract. 2013;14 Suppl 

5:29S-35S. 

3. Wong Croal N, Whitley J, Smedley BD. Building public health capacity 

to advance racial equity: a national environmental scan of tribal, state, 

and local governmental public health. Washington: National 

Collaborative for Health Equity; 2018. Accessed February 9, 2021. 

https://www.nationalcollaborative.org/our-programs/building-capacitypublic-health-advance-equity-program/ 

4. Lavinghouze SR, Snyder K, Rieker PP. The component model of 

infrastructure: a practical approach to understanding public health 

program infrastructure. Am J Public Health. 2014 Aug;104(8):e14-24. 

CHAPTER 3 - PROCESS INDICATORS 41 
► 

GOAL AREA 4 

PROCESS INDICATORS 

Multisectoral Coalitions and Partnerships to Address Tobacco-Related Disparities 

Indicator 

number 

6 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Extent to which tobacco control program coalitions and partnerships have 

diverse representation from institutions/organizations that can influence 

tobacco-related disparities. 

Rationale Coalitions have often led the way in safeguarding community health by 

promoting social norm change and policy adoption. Studies have found 

that local coalitions founded on collaborative partnerships are powerful 

forces for innovative change.1-3 Coalitions and partnerships provide an 

opportunity to leverage expertise, resources, and community assets and 

strengthen efforts to address health disparities.4 

Applying Multisectoral coalitions with partners from public, non-profit, and private 

health entities can provide the infrastructure and stakeholder representation that 

disparities is key to successful development, implementation and adoption of 

framing strategies to reduce tobacco-related disparities.4-6 Moreover, multisectoral 

coalitions that include partners that can improve structural and community 

conditions that contribute to health disparities (e.g., social conditions, built 

environment, education, employment) are better positioned to address 

disparities. 

4,6 By having members and representatives of the populations 

experiencing tobacco-related disparities in coalitions and partnerships, 

programs ensure that the voice, needs, and perceptive are included in the 

development of efforts to address disparities and advance health equity.1-

3,7 

Example 

survey 

question(s) 

Adapted from Component Model of Infrastructure (CMI)8 

Does your state have a state tobacco control coalition in place? Yes/No 

Please indicate whether your tobacco control coalition has representation 

from each of the following organizations and how many organizations are 

represented. (For each, select Represented Yes/No and provide number of 

organizations actively represented within each category) 

• Community (e.g., community organizations, community champions, 

local coalitions) 

• Community members representing members of populations 

experiencing tobacco-related disparities 

• Education (e.g., school administrators, PTA, Department of 

Education representative) 

• Faith-based organizations (e.g., churches) 

• Government health agencies (e.g., state cancer program, mental 

health agency) 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 42 
► 

-I 

←○ ◕ ●→better $ ● ◕ ● ●

GOAL AREA 4 

PROCESS INDICATORS 

• Health care providers (e.g., hospitals, doctors, dentists, healthcare 

associations) 

• Higher professional education (e.g., schools of medicine, 

prevention research centers) 

• Housing (e.g., Department of Housing and Development) 

• Legal system (e.g., law enforcement agencies, attorneys) 

• Policymakers and/or decision-makers 

• Retail tobacco (retail tobacco outlets and their representatives) 

• Third-party payers (e.g., managed care organizations, health 

insurance companies, Medicaid) 

• Voluntary health organizations (e.g. American Lung Association) 

• Worksite and business (e.g., representatives from local businesses 

and business organizations) 

• Youth-focused organizations (e.g., YMCA/YWCA, 4-H, Boys/Girls 

Clubs 

Does your state participate in coalitions or work in partnership with 

organizations outside of tobacco control that can influence social 

determinants of health? Yes/No 

Comments In addition to examining the composition and organization of the coalition, 

tobacco control programs should also consider assessing the extent to 

which: 

• Coalitions are meeting their intended goals; 

• Disparities efforts are being facilitated through the coalition and the 

effects of those efforts; and 

• The right partners that can influence community changes are at the 

table (these can vary depending on the strategies and priority 

populations). 

• Partners are actively engaged in efforts to promote health equity. 

Because addressing social determinants of health is important for reducing 

health disparities, tobacco control programs may also want to assess the 

extent to which multisectoral coalitions and partnerships can effect 

changes to address social determinants of health. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

CHAPTER 3 - PROCESS INDICATORS 43 
 

 

► 

GOAL AREA 4 

PROCESS INDICATORS 

References 1. Tong EK, Fagan P, Cooper L, et al. Working to eliminate cancer health 

disparities from tobacco: a review of the National Cancer Institute’s 

Community Network Program. Nicotine Tob Res. 2015 Jul 

11;17(8):908-23. 

2. Kegler MC, Steckler A, Mcleroy K, Malek SH. Factors that contribute to 

effective community health promotion coalitions: A study of 10 Project 

ASSIST coalitions in North Carolina. Health Educ Behav. 1998 

Jun;25(3):338-53. 

3. Douglas MR, Manion CA, Hall-Harper VD, Terronez KM, Love CA, 

Chan A. Case studies from community coalitions: advancing local 

tobacco control policy in a preemptive state. Am J Prev Med. 2015 Jan 

1;48(Suppl 1):S29-35. 

4. Centers for Disease Control and Prevention, Division of Community 

Health. A practitioner’s guide for advancing health equity: community 

strategies for preventing chronic disease. Atlanta (GA): US Department 

of Health and Human Services; 2013. Accessed February 9, 2021. 

https://www.cdc.gov/nccdphp/dnpao/state-local-programs/healthequity-guide/index.htm 

5. Butterfoss FD, Lachance LL, Orians CE. Building allies coalitions: why 

formation matters. Health Promot Pract. 2006 Apr;7 Suppl 2:23S-33S. 

6. Centers for Disease Control and Prevention. Best practices user guide: 

health equity in tobacco prevention and control. Atlanta (GA): 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; 2015. 

7. Centers for Disease Control and Prevention. A sustainable planning 

guide for healthy communities. Atlanta (GA): Centers for Disease 

Control and Prevention; 2016. Accessed February 9, 2021. 

https://healthysafechildren.org/resource/sustainability-planning-guidehealth-communities 

8. Lavinghouze SR, Snyder K, Rieker PP. The component model of 

infrastructure: a practical approach to understanding public health 

program infrastructure. Am J Public Health. 2014 Aug;104(8):e14-24. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 44 
► 

GOAL AREA 4 

PROCESS INDICATORS 

State-Tribal-Local Collaborations to Address Tobacco-Related Disparities NR 

Indicator 

number 

7 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Level of collaboration between state tobacco control programs, and tribal and 

local tobacco control programs on efforts to identify and eliminate tobaccorelated disparities. 

Rationale Collaboration across state, tribal, and local tobacco control programs is 

essential to ensure proper infrastructure and capacity to effectively implement 

efforts at different levels of government and jurisdictions that have an impact 

on tobacco-related outcomes.1-3 Because health is heavily influenced by 

community-level factors, working closely and coordinating with programs at the 

community level can strengthen the effectiveness and impact of state tobacco 

control efforts. 

Applying Factors that influence health disparities occur at several levels and are the 

health result of interactions between the individual, the community, and existing 

disparities social, environmental, and political structures. Consequently, state tobacco 

framing control program collaboration with tribal and local tobacco control programs 

can support leveraging of resources and assets and strengthen 

implementation of interventions to reduce tobacco-related disparities.2,4 

Example On a scale of 1 (strongly disagree) to 5 (strongly agree), to what extent do you 

survey agree with the following statements about your program’s efforts to coordinate

question(s) with tribal and local tobacco control programs? 

• The program has processes in place to collaborate and/or coordinate 

strategies to identify and eliminate tobacco-related disparities. 

• Tribal and local multisector coalitions and partners are members of the 

state tobacco control coalition. 

• There is a designated individual or office that serves as a liaison to foster 

collaboration between state, and tribal and local tobacco control programs. 

• Frequent meetings are held between state, and tribal and tobacco control 

programs to support coordination and collaboration of tobacco-related 

disparities efforts. 

• The program always collaborates and coordinates with tribal and local 

tobacco control programs on planning, implementation, and evaluation of 

tribal/local efforts to eliminate tobacco-related disparities. 

(Strength of Tobacco Control Index (SoTC)1 

During the last 12 months, what have you been doing concerning tobacco 

control activities with personnel from (name appropriate state, local or tribal 

organization)? Code for highest level: 

CHAPTER 3 - PROCESS INDICATORS 45 
 

► 

GOAL AREA 4 

PROCESS INDICATORS 

0= no contact 

1 = networking (exchanging information for mutual benefit) 

2 = coordinating (exchanging information and altering activities for 

mutual benefit and a common purpose) 

3 = cooperating (exchanging information, altering activities, and sharing 

resources for mutual benefit and a common purpose) 

4 = collaborating (exchanging information, altering activities, sharing 

resources, and enhancing each other’s capacity for mutual benefit and 

a common purpose) 

Comments When examining this indicator, tobacco control programs should also 

consider the frequency of contact and the type of coordination and 

collaboration to assess if these efforts are truly functional and thus more 

likely to produce the desired outcome. 

Rating Not rated. 

References 1. U.S. 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, National Institutes of Health, National Cancer Institute. NIH 

Pub. No. 06-6058, October 2006. 

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

Health. National stakeholder strategy for achieving health equity. 2011. 

U.S. Department of Health and Human Services. Accessed April 10, 

2020. Available at: 

https://minorityhealth.hhs.gov/npa/files/Plans/NSS/CompleteNSS.pdf. 

3. Wong Croal N, Whitley J, Smedley BD. Building public health capacity 

to advance racial equity: a national environmental scan of tribal, state, 

and local governmental public health. Washington: National 

Collaborative for Health Equity; 2018. Accessed February 9, 2021. 

https://www.nationalcollaborative.org/our-programs/building-capacitypublic-health-advance-equity-program/ 

4. Task Force on the Principles of Community Engagement, et al. 

Principles of community engagement. 2nd ed. Washington, DC: 

Department of Health and Human Services, National Institutes of 

Health, Centers for Disease Control and Prevention, Agency for Toxic 

Substances and Disease Registry, Clinical and Translational Science 

Awards; 2011. Accessed February 9, 2021. 

https://www.atsdr.cdc.gov/communityengagement/ 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 46 
► 

GOAL AREA 4 

PROCESS INDICATORS 

Community Engagement to Address Tobacco-Related Disparities 

Indicator 

number 

8 

Goal area 4. Identify and eliminate tobacco-related disparities 

What to 

measure 

Level of community engagement to identify and eliminate tobacco-related 

disparities. 

Rationale The importance of community engagement is rooted in the recognition that health 

behaviors, health conditions, and health outcomes are impacted by structural and 

social determinants, some of which includes Social and community context, 

economic stability, neighbourhood and built environments and cultural norms. 

Subsequently these determinants can be best influenced by engaging community 

partners who can bring their own lived experiences, perspectives, and 

understanding of community life and health issues to public health interventions.1,2 

Applying Meaningful community engagement in planning, implementation, and evaluation of 

health efforts to address disparities can foster trust and understanding of community 

disparities issues, and empowers community members to advance sustainable change in their 

framing communities based on their community needs, values, and perspectives.1-4 

Moreover, because tobacco-related disparities do not have one single cause or 

solution, bringing the lived experiences of community members who understand 

community issues into the development of tobacco control interventions can 

increase the likelihood that key factors that contribute to disparities are accounted 

for and addressed.1-4 Studies have shown that community engagement approaches 

can lead to improved health behaviors and outcomes among populations 

5,6 experiencing tobacco-related disparities. 

Example 

survey 

question(s) 

What percentage of your tobacco-related disparities interventions are communityled (e.g., local community coalitions and/or community members lead planning and 

implementation of tobacco-related efforts)? 

On a scale of 1 (strongly disagree) to 5 (strongly agree), to what extent do you 

agree with the following statements about your program efforts to address tobaccorelated disparities? 

• Local multisectoral coalitions and partnerships support planning, 

implementation, and evaluation of interventions to address disparities. 

• A community endorsed champion or influential person is engaged in planning 

and implementation of program efforts. 

• Community-level tobacco control efforts are frequently led by community 

leaders or members representing the community. 

• Local community members representing the target population are actively 

engaged in planning, implementation, and evaluation of tobacco-related efforts. 

• Frequent events are held to engage communities disproportionately affected by 

tobacco use. 

CHAPTER 3 - PROCESS INDICATORS 47 
► 

$ ● ● ● ●

←○ ◕ ●→better

GOAL AREA 4 

PROCESS INDICATORS 

Comments Tobacco control program can also consider assessing whether it has adequate 

processes to maintain and increase participation from communities and populations 

that experience tobacco-related disparities. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

References 1. Task Force on the Principles of Community Engagement, et al. Principles of community 

engagement. 2nd ed. Washington, DC: Department of Health and Human Services, 

National Institutes of Health, Centers for Disease Control and Prevention, Agency for 

Toxic Substances and Disease Registry, Clinical and Translational Science Awards; 

2011. Accessed February 9, 2021. https://www.atsdr.cdc.gov/communityengagement/ 

2. Centers for Disease Control and Prevention. Best practices user guide: health equity in 

tobacco prevention and control. Atlanta (GA): 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; 2015. 

3. Centers for Disease Control and Prevention, Division of Community Health. A 

practitioner’s guide for advancing health equity: community strategies for preventing

chronic disease. Atlanta(GA): US Department of Health and Human Services; 2013. 

Accessed February 9, 2021. https://www.cdc.gov/nccdphp/dnpao/state-localprograms/health-equity-guide/index.htm 

4. Wong Croal N, Whitley J, Smedley BD. Building public health capacity to advance racial 

equity: a national environmental scan of tribal, state, and local governmental public 

health. Washington: National Collaborative for Health Equity; 2018. Accessed February 

9, 2021. https://www.nationalcollaborative.org/our-programs/building-capacity-publichealth-advance-equity-program/ 

5. Cyril S, Smith BJ, Possamai-Inesedy A, Renzaho AM. Exploring the role of community 

engagement in improving the health of disadvantaged populations: a systematic review. 

Glob Health Action. 2015 Dec 18;8:29842. 

6. Hahn EJ, Rayens MK, Adkins S, Begley K, York N. A controlled community‐based trial 

to promote smoke‐free policy in rural communities. J Rural Health. 2015 Jan;31(1):76-

88. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 48 

CHAPTER 4 

OUTCOME INDICATORS 
► 

GOAL AREA 4 

OUTCOME 1 

Outcome 1: Increased knowledge of the harms of tobacco use 

among populations experiencing tobacco-related disparities and 

support for evidence-based tobacco control interventions 

Increasing knowledge about the harms of tobacco use can help change perceptions about 

tobacco use and attitudes toward tobacco industry practices, which can in turn increase support 

for tobacco prevention and control interventions, reduce the likelihood of tobacco use, and 

promote quitting.

1-5 The tobacco industry spends billions of dollars each year marketing tobacco 

products.6,7 Tobacco industry marketing practices, including advertising, promotions, and 

sponsorships, influence attitudes about tobacco products and are associated with susceptibility, 

initiation, and use of tobacco products.1,2,7-9 Research has shown that tobacco industry practices 

have contributed to tobacco-related disparities and disproportionately higher tobacco use 

among certain population groups, including youth, racial/ethnic minorities, persons with low 

3,7-9 educational attainment, and persons with low income. 

Increasing knowledge of the health consequences of tobacco use through culturally tailored 

anti-tobacco media campaigns and other evidence-based interventions can decrease 

susceptibility to tobacco use, reduce tobacco use, and promote cessation behaviors among the 

general population and populations experiencing tobacco-related disparities.

5,10 Studies have 

shown that many of the same population groups targeted by the tobacco industry have lower 

harm perceptions of tobacco use, including youth, African American or Black persons, and 

LGBTQ+ persons.11,12 Additionally, increasing knowledge of the harms of tobacco use and of 

tobacco industry practices can increase public and decision-maker support for evidence-based 

interventions to reduce tobacco industry influence and address disparities. For example, public 

perception of the harmful effects of secondhand smoke (SHS) exposure is associated with 

15,16 support for smokefree policies and actions to reduce exposure to SHS. 

In addition to changing knowledge and perceptions of tobacco use, it is important to increase 

awareness of evidence-based cessation services among people who use tobacco to increase 

the use of cessation services and increase the likelihood of successfully quitting.17,18 Research 

has found that Latino/Hispanic persons, persons with low income, and Medicaid enrollees are 

less likely to be aware of available evidence-based cessation services and treatment.19-22 

Monitoring indicators in this outcome provides evidence for changes in knowledge and attitudes 

about tobacco use and secondhand smoke exposure. These factors are important to survey 

within specific populations in order to develop effective, targeted strategies to reduce tobacco use 

and secondhand smoke exposure in communities disproportionately affected by tobacco use. 

CHAPTER 4 - OUTCOME INDICATORS 51 
► 

GOAL AREA 4 

OUTCOME 1 

The following indicators are associated with this outcome: 

4.1.a: Disparities in the perceived harm of tobacco use 

4.1.b: Disparities in the perceived harm of secondhand smoke 

4.1.c: Disparities in the awareness of available evidence-based cessation services 

4.1.d: Support for policies to reduce tobacco industry influence 

4.1.e: Support for comprehensive smokefree policies 

References 

1. 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, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 

2. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: 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. 

3. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

4. Song AV, Morrell HE, Cornell JL, et al. Perceptions of smoking-related risks and benefits as 

predictors of adolescent smoking initiation. Am J Public Health. 2009 Mar;99(3):487-92. 

5. U.S. National Cancer Institute. The role of the media in promoting and reducing tobacco 

use. Tobacco Control Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. 

Department of Health and Human Services, National Institutes of Health, National Cancer 

Institute; June 2008. 

6. Federal Trade Commission. Cigarette report for 2018. Accessed March 26, 2020. 

https://www.ftc.gov/reports/federal-trade-commission-cigarette-report-2018-smokelesstobacco-report-2018 

7. Federal Trade Commission. Smokeless tobacco report for 2018. Accessed March 26, 2020. 

https://www.ftc.gov/reports/federal-trade-commission-cigarette-report-2018-smokelesstobacco-report-2018 

8. Cruz TB, Rose SW, Lienemann BA, et al. Pro-tobacco marketing and anti-tobacco 

campaigns aimed at vulnerable populations: a review of the literature. Tob Induc Dis. 2019 

Sep 18;17:68. 

9. Lempert LK, Glantz SA. Tobacco industry promotional strategies targeting American 

Indians/Alaska Natives and exploiting Tribal sovereignty. Nicotine Tob Res. 2019;21(7):940-8. 

10. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco 

control programs—2014. Atlanta, GA: 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. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 52 
 

► 

GOAL AREA 4 

OUTCOME 1 

11. Ganz O, Johnson AL, Cohn AM, et al. Tobacco harm perceptions and use among sexual 

and gender minorities: findings from a national sample of young adults in the United States. 

Addict Behav. 2018;81:104-8. 

12. Cohn AM, Rose SW, D'Silva J, Villanti AC. Menthol smoking patterns and smoking 

perceptions among youth: findings from the population assessment of tobacco and health 

study. Am J Prev Med. 2019;56(4):e107-e116. 

13. Blake KD, Viswanath K, Blendon RJ, Vallone D. The role of tobacco-specific media 

exposure, knowledge, and smoking status on selected attitudes toward tobacco control. 

Nicotine Tob Res. 2010;12(2):117-26. 

14. Wilson N, Weerasekera D, Blakely T, Edwards R, Thomson G, Gifford H. What is behind 

smoker support for new smokefree areas? National survey data. BMC Public Health. 

2010;10:498. 

15. Kruger J, Patel R, Kegler M, Babb SD, King BA. Perceptions of harm from secondhand 

smoke exposure among U.S. adults, 2009- 2010. Tob Induc Dis. 2016 Feb;14:3 

16. Hyland A, Cummings MK. Using tobacco control policies to increase consumer demand for 

smoking cessation. Am J Prev Med. 2010;38(3S):S347–50. 

17. Hammond D, McDonald PW, Fong GT, Borland R. Do smokers know how to quit? 

Knowledge and perceived effectiveness of cessation assistance as predictors of cessation 

behavior. Addiction. 2004 Aug;99(8):1042-8. 

18. Willems RA, Willemsen MC, Nagelhout GE, de Vries H. Understanding smokers’ motivations

to use evidence-based smoking cessation aids. Nicotine Tob Res. 2012 Sep;15(1):167-76. 

19. Knox B, Mitchell S, Hernly E, Rose A, Sheridan H, Ellerbeck EF. Barriers to utilizing 

Medicaid smoking cessation benefits. Kansas J Med. 2017 Nov;10(4):88. 

20. McMenamin SB, Halpin HA, Bellows NM. Knowledge of Medicaid coverage and 

effectiveness of smoking treatments. Am J Med. 2006;31(5):369–374. 

21. Carter-Pokras OD, Feldman RH, Kanamori M, et al. Barriers and facilitators to smoking 

cessation among Latino adults. J Natl Med Assoc. 2011 May 1;103(5):423-31. 

22. Young-Wolff KC, Adams SR, Tan AS, et al. Disparities in knowledge and use of tobacco 

treatment among smokers in California following healthcare reform. Prev Med Rep. 2019 

Jun 1;14:100847. 

CHAPTER 4 - OUTCOME INDICATORS 53 
 

Indicator Rating 

←○ ◕ ●→ better 

► 

-

-

-

GOAL AREA 4 

OUTCOME 1 

Increased knowledge of the harms of tobacco use among populations 

experiencing tobacco-related disparities and support for evidence-based tobacco 

control interventions 

Number Indicator 

Disparities in the perceived 4.1.a harm of tobacco use 

Disparities in the perceived 

4.1.b harm of secondhand 

smoke 

Disparities in the 

awareness of available 4.1.c evidence-based cessation

services 

Support for policies to 

4.1.d reduce tobacco industry 

influence 

Support for comprehensive 4.1.e 

smokefree policies 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

$$ ● ● ◕ ●

$$ ● ● ● ●

$$ ● ● ● ●

$$ ● ● ● ●

$$ ● ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data

to measure the indicator. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 54 
 

 

► 

GOAL AREA 4 

OUTCOME 1 

Disparities in the Perceived Harm of Tobacco Use 

Indicator 

number 

4.1.a 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 1. Increased knowledge of tobacco-related disparities and support for 

evidence-based interventions 

What to 

measure 

Proportion of the population that thinks tobacco products are harmful, 

overall, and among population groups experiencing tobacco-related 

disparities 

Differences in the proportion of the population that thinks tobacco products 

are harmful by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.1.c, “Level of perceived risk of tobacco products among 

tobacco users.”

Rationale Harm perceptions about tobacco products can influence initiation, 

sustained use, and cessation.1,2 Research supports the relationship 

between increased harm perceptions and reductions in tobacco use.1-3 

Monitoring perceptions of harm can help inform interventions to prevent 

tobacco use, promote cessation, and garner support for evidence-based 

tobacco control interventions. 

Applying 

health 

disparities 

framing 

Studies have shown that certain population groups, including youth, African 

Americans or Black persons, and LGBTQ+ persons have 

disproportionately lower harm perceptions of tobacco use.4-6 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Population Assessment of Tobacco and Health Youth Survey (PATH-Y), 

2016-2017 

Population Assessment of Tobacco and Health Adult Survey (PATH-A), 

2016-2017 

CHAPTER 4 - OUTCOME INDICATORS 55 
► 

$$ ● ● ◕ ●

GOAL AREA 4 

OUTCOME 1 

Example 

survey 

question(s) 

From NYTS (2020) 

How much do you think people harm themselves when they smoke 

cigarettes some days but not every day? 

• No harm 

• A little harm 

• Some harm 

• A lot of harm 

From PATH-Y Survey (2016-2017) 

How much do you think people harm themselves when they use ecigarettes or other electronic nicotine products? 

• No harm 

• A little harm 

• Some harm 

• A lot of harm 

From PATH-A Survey (2016-2017) 

How harmful do you think cigarettes are to health? 

• Not at all harmful 

• Slightly harmful 

• Somewhat harmful 

• Very harmful 

• Extremely harmful 

Comments Consider measuring this indicator by product type, as harm perceptions 

may vary by tobacco product. Tobacco control programs may also want to 

measure absolute and relative harm perceptions. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 56 
► 

GOAL AREA 4 

OUTCOME 1 

References 1. Song AV, Morrell HE, Cornell JL, et al. Perceptions of smoking-related 

risks and benefits as predictors of adolescent smoking initiation. Am J 

Public Health. 2009 Mar;99(3):487-92. 

2. Bernat JK, Ferrer RA, Margolis KA, Blake KD. US adult tobacco users' 

absolute harm perceptions of traditional and alternative tobacco 

products, information-seeking behaviors, and (mis) beliefs about 

chemicals in tobacco products. Addict Behav. 2017;71:38-45. 

3. Saddleson ML, Kozlowski LT, Giovino GA, et al. Risky behaviors, ecigarette use and susceptibility of use among college students. Drug 

Alcohol Depend. 2015 Apr 1;149:25-30. 

4. Feirman SP, Donaldson EA, Parascandola M, Snyder K, Tworek C. 

Monitoring harm perceptions of smokeless tobacco products among 

US adults: Health Information National Trends Survey 2012, 2014, 

2015. Addict Behav. 2018;77:7-15. 

5. Ganz O, Johnson AL, Cohn AM, et al. Tobacco harm perceptions and 

use among sexual and gender minorities: findings from a national 

sample of young adults in the United States. Addict Behav. 

2018;81:104–108. 

6. Cohn AM, Rose SW, D'Silva J, Villanti AC. Menthol smoking patterns 

and smoking perceptions among youth: findings from the population 

assessment of tobacco and health study. Am J Prev Med. 

2019;56(4):e107-e116. 

CHAPTER 4 - OUTCOME INDICATORS 57 
 

 

 

 

 

 

► 

GOAL AREA 4 

OUTCOME 1 

Disparities in the Perceived Harm of Secondhand Smoke 

Indicator 

number 

4.1.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 1. Increased knowledge of tobacco-related disparities and support for 

evidence-based interventions 

What to 

measure 

Proportion of the population that thinks that secondhand smoke is harmful 

by population group characteristics, overall, and among population groups 

experiencing tobacco-related disparities 

Differences in the proportion of the population that thinks that secondhand 

smoke is harmful by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.1.c, “Proportion of the population that thinks secondhand

smoke is harmful.”

Rationale The perception that exposure to secondhand smoke is harmful is 

associated with strong support for adoption of smokefree policies.1-4 

Increasing people’s knowledge of the harms of exposure to secondhand

smoke can help change attitudes toward the acceptability of exposing 

people who do not smoke to secondhand smoke and can increase the 

favorability toward smokefree environments. 

Applying 

health 

disparities 

framing 

Studies have shown that certain population groups, including men, 

American Indian/Alaska Native persons, non-Hispanic White persons, 

persons residing in the Midwestern geographic areas of the U.S., and 

persons residing in states that do not have comprehensive smokefree 

policies have disproportionately lower harm perceptions of secondhand 

smoke.5-6 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Population Assessment of Tobacco and Health Youth Survey (PATH-Y), 

2016-2017 

Population Assessment of Tobacco and Health Adult Survey (PATH-A), 

2016-2017 

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Example 

survey 

question(s) 

From NYTS (2020) 

Not including the vapor from e-cigarettes, do you think that breathing 

smoke from other people’s cigarettes or other tobacco product causes...

• No harm 

• Little harm 

• Some harm 

• A lot of harm 

From PATH-Y and PATH-A Survey (2016-2017) 

How harmful is it to be around people who are smoking shisha or hookah 

tobacco? 

• Not at all harmful 

• Slightly harmful 

• Somewhat harmful 

• Very harmful 

• Extremely harmful 

Comments In addition to assessing harm perceptions of secondhand smoke, tobacco 

control programs may want to examine harm perceptions of e-cigarette 

aerosol. Secondhand smoke and secondhand aerosol should be measured 

separately. Refer to the Eliminating Exposure to Secondhand Smoke: 

Outcome Indicators for Comprehensive Tobacco Control Programs—

2017, 

7 E-Cigarette Addendum 2.1, “Proportion of the population that thinks

secondhand aerosol from e-cigarettes is harmful.” Additionally, tobacco 

control programs many want to assess this indicator by occupation. 

Rating Strength 

of 

Overall quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

CHAPTER 4 - OUTCOME INDICATORS 59 
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References 1. U.S. Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

the Surgeon General. Atlanta, GA: 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. 

2. International Agency for Research on Cancer (IARC). IARC Handbooks 

of Cancer Prevention, Tobacco Control, Vol. 13: Evaluating the 

effectiveness of smoke-free policies. Lyon, France: IARC; 2009. 

3. Blake KD, Viswanath K, Blendon RJ, Vallone D. The role of tobaccospecific media exposure, knowledge, and smoking status on selected 

attitudes toward tobacco control. Nicotine Tob Res. 2010;12(2):117–26. 

4. Wilson N, Weerasekera D, Blakely T, Edwards R, Thomson G, Gifford 

H. What is behind smoker support for new smokefree areas? National 

survey data. BMC Public Health. 2010;10:498. 

5. Kruger J, Patel R, Kegler M, Babb SD, King BA. Perceptions of harm 

from secondhand smoke exposure among U.S. adults, 2009- 2010. 

Tob Induc Dis. 2016 Feb;14:3. 

6. King BA, Dube SR, Babb SD. Perceptions about the harm of 

secondhand smoke exposure among U.S. middle and high school 

students: findings from the 2012 National Youth Tobacco Survey.Tob 

Induc Dis. 2013 Jul 17;11(1):16. 

7. Centers for Disease Control and Prevention. Eliminating exposure to 

secondhand smoke: outcome indicators for comprehensive tobacco 

control programs–2017. Atlanta, GA: Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2017. 

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Disparities in the Awareness of Available Evidence-Based Cessation Services 

Indicator 

number 

4.1.c 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 1. Increased knowledge of tobacco-related disparities and support for 

evidence-based interventions 

What to 

measure 

Proportion of tobacco users who are aware of available cessation services 

(e.g., FDA-approved cessation medications, state quitlines, overall, and 

among population groups experiencing tobacco-related disparities 

Differences in the proportion of tobacco users who are aware of available 

cessation services (e.g., FDA-approved cessation medications, state 

quitlines) by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.1.e, “Proportion of tobacco users who are aware of

available cessation services.”

Rationale The availability of evidence-based cessation services has a limited effect if 

tobacco users are not aware, and thus not using these services.1-3 

Increased awareness of available evidence-based cessation services is 

1,4 associated with use of services. 

Applying Research demonstrates that certain population groups, including 

health Latino/Hispanic persons, persons with low income, and Medicaid enrollees, 

disparities are less likely to be aware of available evidence-based cessation services 

framing and treatment.5-8 

Example data 

source(s) 

Behavioral Risk Factor Surveillance System (BRFSS), 2011 

National Adult Tobacco Survey (NATS), 2009-2010 

Example From BRFSS (2011) 

survey A telephone quitline is a free telephone-based service that connects people question(s) who smoke cigarettes with someone who can help them quit. Are you 

aware of any telephone quitline services that are available to help quit 

smoking? 

• Yes 

• No 

• Don’t know/not sure

• Refused 

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From NATS (2009-2010) 

Are you aware of any individual or group counseling services, other than 

quitlines, that are available to help you quit smoking cigarettes? 

• Yes 

• No 

• Don’t know/not sure 

Comments Tobacco control programs may want to consider assessing this indicator by 

insurance type to determine the extent to which differences exist by 

insurance coverage. Moreover, when changes in cessation coverage 

occur, programs may want to assess the extent to which beneficiaries and 

providers are aware of changes in cessation services covered by the 

health insurance. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

2. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: 

U.S. Department of Health and Human Services, Public Health Service; 

May 2008. 

3. The Guide to Community Preventive Services. Reducing tobacco use 

and secondhand smoke exposure. Accessed February 9, 2021. 

https://www.thecommunityguide.org/topic/tobacco 

4. Keller PA, Christiansen B, Kim SY, et al. Increasing consumer demand 

among Medicaid enrollees for tobacco dependence treatment: the 

Wisconsin “Medicaid Covers It” campaign. Am J Health Promot. 

2011;25(6):392–5. 

5. Knox B, Mitchell S, Hernly E, Rose A, Sheridan H, Ellerbeck EF. 

Barriers to utilizing Medicaid smoking cessation benefits. Kansas J 

Med. 2017 Nov;10(4):88. 

6. McMenamin SB, Halpin HA, Bellows NM. Knowledge of Medicaid 

coverage and effectiveness of smoking treatments. Am J Med. 

2006;31(5):369–374. 

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7. Carter-Pokras OD, Feldman RH, Kanamori M, Rivera I, Chen L, 

Baezconde-Garbanati L, Nodora J, Noltenius J. Barriers and facilitators 

to smoking cessation among Latino adults. J Natl Med Assoc. 2011 

May 1;103(5):423-31. 

8. Young-Wolff KC, Adams SR, Tan AS, Adams AS, Klebaner D, 

Campbell CI, Satre DD, Salloum RG, Carter-Harris L, Prochaska JJ. 

Disparities in knowledge and use of tobacco treatment among smokers 

in California following healthcare reform. Prev Med Rep. 2019 Jun 

1;14:100847. 

CHAPTER 4 - OUTCOME INDICATORS 63 
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Support for Policies to Reduce Tobacco Industry Influence 

Indicator 

number 

4.1.d 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 1. Increased knowledge of tobacco-related disparities and support for 

evidence-based interventions 

What to 

measure 

Proportion of adults who support adopting policies to decrease tobacco 

industry influence, overall, and among population groups experiencing 

tobacco-related disparities 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale An extensive body of research demonstrates that tobacco industry 

marketing practices are associated with susceptibility, experimentation, 

initiation, and use of tobacco products.1-9 Because of their strong influence 

on tobacco-related behaviors, policies that decrease tobacco industry can 

have a strong impact on tobacco initiation, use, and cessation behaviors. 

However, tobacco control policies are unlikely to be adopted without 

support from policy makers and the public.1,10 Changes in support for 

policies to reduce tobacco industry influence may also reflect changing 

public attitudes about tobacco use. 

Applying Studies have shown that tobacco industry influence is a strong contributor 

health to tobacco-related disparities.1-4,8-9 The tobacco industry has a history of 

disparities targeting certain population groups, including youth, racial/ethnic 

framing minorities, LGBTQ+ persons, persons with low educational attainment, and 

persons with low income.1-5,8-9 

Example data 

source(s) 

California Adult Tobacco Survey (CATS), 2018 

State policy tracking system 

Example 

survey 

question(s) 

From CATS (2018) 

Please indicate whether you agree or disagree with each statement. 

Response options: Strongly agree, agree, disagree, strongly disagree 

• Raising legal sale of age for tobacco products will reduce youth 

smoking. 

• Store owners should need a license to sell cigarettes (just like 

alcoholic beverages). 

• Local communities should strongly enforce laws that prevent people 

from selling cigarettes to minors. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 64 
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• The number of tobacco stores should be reduced. 

• Stores that sell tobacco products should not be allowed near 

schools. 

• Tobacco products should be treated like other foods and drugs, 

with each package having full disclosure of potentially harmful 

contents. 

• Flavored tobacco products like candy-flavored little cigars should 

not be allowed to be sold. 

• The sale of menthol cigarettes should not be allowed. 

• Tobacco products like cigarillos or little cigars should be sold in 

packages of 10 instead of individually. 

How much additional tax on a pack of cigarettes would you be willing to 

support? Please mark the highest tax you are willing to support: 

• $0.25 a pack 

• $0.50 a pack 

• $0.75 a pack 

• $1.00 a pack 

• $1.50 a pack 

• $2.00 a pack 

• $3.00 a pack 

• More than $3.00 

Tobacco control programs may also want to track and monitor pertinent 

laws that may preempt or preclude these types of policies from being 

adopted. 

Comments Tobacco control programs may want to focus this indicator on priority 

policies in their state and/or jurisdiction. As discussed more fully with 

respect to Outcome 2, below, policies to decrease tobacco industry 

influence can include, but are not limited to, policies to regulate the 

number, type, location, and density of tobacco stores, and policies that 

prohibit the sale of all flavored tobacco products. 

Tobacco control programs may want to measure support for each policy 

separately as support can vary by policy. Differences were not assessed 

for this indicator because policy adoption requires support from all 

population groups. 

CHAPTER 4 - OUTCOME INDICATORS 65 
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Rating Overall Strength 

quality of 

Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

$$ ● ● ● ●

←○ ◕ ●→ better 

References 1. 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, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health; 

2014. 

2. U.S. Department of Health and Human Services. Preventing tobacco use 

among youth and young adults: a report of the Surgeon General. Atlanta, 

GA: 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. 

3. U.S. National Cancer Institute. A socioecological approach to addressing 

tobacco-related health disparities. National Cancer Institute Tobacco 

Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: 

U.S. Department of Health and Human Services, National Institutes of 

Health, National Cancer Institute; 2017. 

4. Cruz TB, Rose SW, Lienemann BA, et al. Pro-tobacco marketing and antitobacco campaigns aimed at vulnerable populations: A review of the 

literature. Tob Induc Dis. 2019 Sep 18;17:68. 

5. Lempert LK, Glantz SA. Tobacco industry promotional strategies targeting 

American Indians/Alaska Natives and exploiting Tribal sovereignty. 

Nicotine Tob Res. 2019;21(7):940-8. 

6. Soneji S, Pierce JP, Choi K, et al. Engagement with online tobacco 

marketing and associations with tobacco product use among US youth. J 

Adolesc Health. 2017;61(1):61-9. 

7. Portnoy DB, Wu CC, Tworek C, Chen J, Borek N. Youth curiosity about 

cigarettes, smokeless tobacco, and cigars: prevalence and associations with 

advertising. Am J Prev Med. 2014;47(2 Suppl 1):S76–86. 

8. Anderson SJ. Marketing of menthol cigarettes and consumer perceptions: 

a review of tobacco industry documents. Tob Control. 2011;20(Suppl 

2):ii20-8. 

9. Kostygina G, Ling PM. Tobacco industry use of flavourings to promote 

smokeless tobacco products. Tob Control. 2016;25(Suppl 2):ii40-9. 

10. Burstein P. The impact of public opinion on public policy: a review and an 

agenda. Polit Res Q. 2003 Mar;56(1):29-40. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 66 
 

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Support for Comprehensive Smokefree Policies 

Indicator 

number 

4.1.e 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 1. Increased knowledge of tobacco-related disparities and support for 

evidence-based interventions 

What to 

measure 

Proportion of adults who support adopting comprehensive smokefree 

policies,* overall, and among population groups experiencing tobaccorelated disparities 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.1.d, “Level of support for adopting smokefree policies in

public places and workplaces.”

Rationale Comprehensive smokefree policies can protect people who do not smoke 

from the harms of secondhand smoke exposure, reduce tobacco 

consumption, motivate quitting, and reduce the social acceptability of 

tobacco use.1,2 Public and decision-maker support increases the likelihood 

of adoption and compliance with smokefree policies. 

1,3,4 Changes in 

support for smokefree policies may also reflect changing public attitudes 

about tobacco use and/or secondhand exposure. 

Applying While support for smokefree policies is high, studies have shown that 

health support is lower among certain population groups, including youth, 

disparities American Indian/Alaska Natives, persons with low educational attainment, 

framing low income earners, and persons residing in rural areas and jurisdictions 

without comprehensive smokefree policies.5,6 Many of these same groups 

are also disproportionally exposed to secondhand smoke.2,7 

Example data 

source(s) 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

2018-2019 

State policy tracking system 

Example From TUS-CPS (2018-2019) 

survey In indoor work areas, do you THINK that smoking SHOULD be allowed in question(s) ALL areas, allowed in SOME areas, or NOT allowed at ALL? 

• Allowed in ALL areas 

• Allowed in SOME areas 

• NOT Allowed at ALL 

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Inside bars, cocktail lounges, and clubs, do you THINK that smoking 

SHOULD be allowed in ALL areas, allowed in SOME areas, or NOT 

allowed at ALL? 

• Allowed in ALL areas 

• Allowed in SOME areas 

• NOT Allowed at ALL 

Inside casinos, do you THINK that smoking SHOULD be allowed in ALL 

areas, allowed in SOME areas, or NOT allowed at ALL? 

• Allowed in ALL areas 

• Allowed in SOME areas 

• NOT Allowed at ALL 

Tobacco control programs may also want to track and monitor pertinent 

laws that may preempt or preclude these types of policies from being 

adopted. 

Comments *A comprehensive smokefree policy is defined by the CDC Office on 

Smoking and Health as a policy that does not allow smoking in any indoor 

areas of workplaces, restaurants, and bars, with no exceptions. Since 

private settings are a major source of secondhand smoke exposure, 

tobacco control programs can consider assessing the level of support for 

smokefree policies in multiunit housing settings and other private settings. 

For additional guidance, tobacco control programs can refer to Eliminating 

Exposure to Secondhand Smoke: Outcome Indicators for Comprehensive 

Tobacco Control Programs—2017, 

8 Indicator 2.1.g “Level of support for 

adopting smokefree rules for homes or vehicles.”

Tobacco control programs may want to focus this indicator on priority 

smokefree policies in their state and/or jurisdiction. Moreover, tobacco 

control programs may want to measure each policy separately as support 

can vary by policy. Differences were not assessed for this indicator 

because policy adoption requires support from all population groups. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 68 
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References 1. U.S. Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: 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; 2006. 

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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

3. Satterlund TD, Cassady D, Treiber J, Lemp C. Barriers to adopting and 

implementing local-level tobacco control policies. J Community Health. 

2011;36(4):616–23. 

4. Burstein P. The impact of public opinion on public policy: A review and 

an agenda. Polit Res Q. 2003 Mar;56(1):29-40. 

5. King BA, Dube SR, Tynan MA. Attitudes toward smoke-free 

workplaces, restaurants, and bars, casinos, and clubs among US 

adults: findings from the 2009–2010 National Adult Tobacco Survey. 

Nicotine Tob Res. 2013;15(8):1464-70. 

6. Stillman FA, Tanenbaum E, Wewers ME, Chelluri D, Mumford EA, 

Groesbeck K, Doogan N, Roberts M. Variations in support for 

secondhand smoke restrictions across diverse rural regions of the 

United States. J Prev Med. 2018;116:157-65. 

7. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

8. Centers for Disease Control and Prevention. Eliminating exposure to 

secondhand smoke: outcome indicators for comprehensive tobacco 

control programs–2017. Atlanta, GA: Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2017. 

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Outcome 2: Increase equitable adoption, implementation, and 

enforcement of tobacco prevention and control policies 

Tobacco control policies are the cornerstone of state and local tobacco control efforts.1 Policies 

can address the environmental and social factors that contribute to tobacco use while 

complementing other evidence-based tobacco prevention and control approaches. Since 

tobacco control policies affect the social-environmental context, have the ability to change social 

norms, and the potential to reach everyone, they can have a strong impact on reducing tobaccorelated disparities.1,2 

Policies that regulate the sale of tobacco and decrease access to tobacco products can reduce 

tobacco industry influence among populations disproportionately burdened by tobacco use. 

Tobacco marketing, advertising, and promotional strategies are often targeted at low income 

earners, racial/ethnic minorities, and youth and young adult populations.1-3 Tobacco products 

are also more accessible in low-income communities and communities with high proportions of 

racial/ethnic minorities. These communities often have a high concentration of tobacco retailers 

that also have more tobacco product advertisements and sell tobacco products at lower prices 

than in more affluent communities.2-5 Tobacco retailer licensing is an effective intervention for 

implementing other retail policies, such as addressing the number, type, location, and density of 

tobacco retailers, and prohibiting sales of flavored tobacco products.6 Limiting the number of 

tobacco retail outlets through licensing in communities with higher-than-average tobacco outlet 

density, such as low income and predominately African American or Black neighborhoods, can 

decrease the availability of tobacco products and may have a side benefit of reducing the 

number of tobacco advertisements in those communities, thereby reducing tobacco industry 

influence.7,8 

Comprehensive smokefree air laws prohibiting smoking in workplaces, restaurants, and bars 

protect people who do not smoke from the harms of secondhand smoke exposure.1,9,10 These 

policies have the added benefit of motivating and helping people who smoke to quit and 

reducing the social acceptability of smoking.11 However, demographic, occupational, and 

geographic disparities still exist in smokefree law protections. Persons of low socioeconomic 

status, certain racial/ethnic minorities, those living in states and jurisdictions without 

comprehensive smokefree laws, and persons who work in service and hospitality jobs are 

disproportionately exposed to secondhand smoke.1-3,11 Moreover, as more indoor public spaces 

and workplaces are covered by comprehensive smokefree policies, private settings remain a 

major source of secondhand smoke for people who do not smoke and the main source of 

secondhand smoke exposure for children.1,12 Implementing smokefree policies in multiunit 

housing facilities and voluntary smokefree rules in private settings can protect people who do 

not smoke, especially children, from the harmful effects of secondhand smoke exposure and 

1,12 reinforce tobacco-free social norms. 

Increasing the price of tobacco products is one of the most effective tobacco prevention and 

control strategies.1,2,9,10,13,14 Increases in the price of tobacco products can motivate people who 

use tobacco products to quit or reduce their consumption and/or intensity of tobacco use, and 

can prevent initiation of tobacco use.1,2,9,10,15 Price discounts and promotions disproportionately 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 70 
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GOAL AREA 4 

OUTCOME 2 

affect low-income and racial/ethnic minority smokers, who are more sensitive to price.3 Evidence 

shows that increasing the price of tobacco products can reduce income-based tobacco-related 

disparities and prevent and decrease youth tobacco use.13,14 

While adoption of effective tobacco control policies is important, subsequent enforcement and 

compliance is also essential for the policies to be successful at achieving intended outcomes. 

Uneven implementation and enforcement of tobacco control policies may attenuate the intended 

effects of the policy and may prevent the benefits of these policies from reaching some 

segments of the population, thereby exacerbating tobacco-related disparities.2 Inequitable 

implementation and enforcement of tobacco control policies can stem from several factors: 

communities may lack resources for full implementation and enforcement; inconsistent 

enforcement may lead to unequal effects in different settings or for different groups; weak 

policies can create or increase disparities by exempting certain settings (e.g., casino workers 

remaining unprotected by workplace smokefree laws because the policy exempts casinos); 

policies not reaching some populations because of differences in implementation or provisions 

in policies that inadvertently exclude or hinder the ability of the policy to benefit everyone.

9 

Because of their effect, all these factors should be considered when evaluating the 

implementation and impact of tobacco control policies. 

The following indicators are associated with this outcome: 

Policies to Reduce Tobacco Industry Influence 

4.2.a: Policies that regulate tobacco retail sales 

4.2.b: Policies that regulate tobacco marketing 

4.2.c: Retail licensing to sell tobacco products 

4.2.d: Policies that regulate the number, type, location, and density of tobacco retail 

outlets 

4.2.e: Policies that regulate tobacco promotions, discounts, and coupons 

4.2.f: Policies that prohibit the sale of flavored tobacco products 

Policies to Reduce Exposure to Secondhand Smoke 

4.2.g: Comprehensive smokefree policies for indoor public places HP 

4.2.h: Smokefree policies for casinos NR 

4.2.i: Employed population covered by workplace smokefree policies 

4.2.j: Smokefree policies in multiunit housing 

4.2.k: Home and vehicle smokefree rules HP 

Policies to Increase the Price of Tobacco Products 

4.2.l: Tobacco product price 

4.2.m: Minimum price policies 

Enforcement of Tobacco Control Policies 

4.2.n: Equitable enforcement of tobacco control policies 

NR Denotes an indicator that is not rated. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

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GOAL AREA 4 

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References 

1. 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, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 

2. Centers for Disease Control and Prevention. Best practices user guide: health equity in 

tobacco 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, 2015. 

3. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

4. Rodriguez D, Carlos HA, Adachi-Mejia AM, Berke EM, Sargent JD. Predictors of tobacco 

outlet density nationwide: a geographic analysis. Tob Control. 2013;22:349-355. 

5. Counter Tobacco. Disparities in point-of-sale advertising and retailer density. Accessed 

March 25, 2020. https://countertobacco.org/resources-tools/evidence-summaries/disparitiesin-point-of-sale-advertising-and-retailer-density/ 

6. Myers AE, Knocke K, Leeman J. Tapping Into multiple data "springs" to strengthen policy 

streams: a guide to the types of data needed to formulate local retail tobacco control policy. 

Prev Chronic Dis. 2019 Apr 4;16:E43. 

7. Lee JGL, Sun DL, Schleicher NM, Ribisl KM, Luke DA, Henriksen L. Inequalities in tobacco 

outlet density by race, ethnicity and socioeconomic status, 2012, USA: results from the 

ASPiRE Study. J Epidemiol Community Health. 2017;71(5):487-92. 

8. Ackerman A, Etow A, Bartel S, Ribisl KM. Reducing the density and number of tobacco 

retailers: policy solutions and legal issues. Nicotine Tob Res. 2017 Feb;19(2):133-40. 

9. Dinno A, Glantz S. Tobacco control policies are egalitarian: a vulnerabilities perspective on 

clean indoor air laws, cigarette prices, and tobacco use disparities. Soc Sci Med. 

2009;68:1439-47. 

10. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco 

control programs—2014. Atlanta, GA: 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. 

11. Babb S, Liu B, Kenemer B, et al. Changes in self-reported smokefree workplace policy 

coverage among employed adults-United States, 2003 and 2010-2011. Nicotine Tob Res. 

2018 Sep 25;20(11):1327-1335. 

12. US Department of Health and Human Services. The health consequences of involuntary 

exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: US Department 

of Health and Human Services, Centers for Disease Control and Prevention; 2006. 

13. Community Preventive Services Task Force. Reducing tobacco use and secondhand smoke 

exposure: interventions to increase unit price for tobacco products. The Guide to Community 

Preventive Services website. Accessed. March 26,2020. 

http://www.thecommunityguide.org/tobacco/RRincreasingunitprice.html 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 72 
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GOAL AREA 4 

OUTCOME 2 

14. U.S. National Cancer Institute and World Health Organization. The economics of tobacco 

and tobacco control. NCI tobacco control monograph no. 21. NIH publication no. 16-CA8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes 

of Health, National Cancer Institute; and Geneva: World Health Organization; 2016. 

15. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: 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. 

CHAPTER 4 - OUTCOME INDICATORS 73 
► 

-I 

GOAL AREA 4 

OUTCOME 2 

Increase equitable adoption, implementation, and enforcement of tobacco 

prevention and control policies 

Indicator Rating 

←○ ◕ ●→ better

Number Indicator 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

4.2.a Policies that regulate 

tobacco retail sales $$ ● ● ● ●

4.2.b Policies that regulate 

tobacco marketing $$ ● ● ● ●

4.2.c Retail licensing to sell 

tobacco products $$ ◕ ● ● ●

4.2.d 

Policies that regulate the 

number, type, location, 

and density of tobacco 

retail outlets 

$$ ● ● ● ●

4.2.e 

Policies that regulate 

tobacco promotions, 

discounts, and coupons 

$ ● ● ● ●

4.2.f 

Policies that prohibit the 

sale of flavored tobacco 

products 

$ ● ● ● ●

4.2.g 

Comprehensive smokefree 

policies for indoor public 

places HP 

$ ● ● ● ●

4.2.h Smokefree policies for 

casinos NR NR NR NR NR NR NR 

4.2.i 

Employed population 

covered by workplace 

smokefree policies 

$$ ● ● ● ●

4.2.j Smokefree policies in 

multiunit housing $$ ● ● ● ●

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 74 
► 

-

GOAL AREA 4 

OUTCOME 2 

Home and vehicle 4.2.k HP smokefree rules 

4.2.l Tobacco product price 

4.2.m Minimum price policies 

Equitable enforcement o 4.2.n tobacco control policies 

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data 

to measure the indicator. 

NR Denotes an indicator that is not rated. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

f 

$$ ● ● ● ●

$$ ● ● ● ●

$$$ ● ● ● ●

$$$ ◕ ◕ ● ●

CHAPTER 4 - OUTCOME INDICATORS 75 
 

► 

GOAL AREA 4 

OUTCOME 2 

Policies That Regulate Tobacco Retail Sales 

Indicator 

number 

4.2.a 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of jurisdictions with policies that regulate the sale of tobacco 

products 

Proportion of jurisdictions that are disproportionately burdened by tobacco 

product use with policies that regulate the sale of tobacco products 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Policies regulating retail tobacco sales have been shown to reduce 

tobacco consumption and also aid in cessation.1,2 These policies can 

include restrictions on the distribution of tobacco products (including 

prohibiting sales to individuals of any age), requiring tobacco products to 

be placed behind the counter, and prohibiting the sale of flavored tobacco 

products.3 

Applying 

health 

disparities 

framing 

The tobacco industry has a history of targeting specific groups and 

communities through their influence on the tobacco product landscape, the 

retail environment, and product marketing.4,5 Consequently, policies that 

regulate the sale of tobacco products can have a strong influence on 

tobacco-related disparities. 

Example data 

source(s) 

American Lung Association’s State Legislated Actions on Tobacco Issues 

(SLATI) 

American Nonsmokers’ Rights (ANR) Foundation U.S. Tobacco Control 

Laws Database 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

Comments Tobacco controls program may want to consider tracking this indicator 

across jurisdictions and/or communities to identify differences that may 

contribute to tobacco-related disparities. Below are pertinent national laws, 

policies, and/or regulations related to this indicator. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 76 
► 

$$ • • • 

GOAL AREA 4 

OUTCOME 2 

The 2009 Family Smoking and Prevention Act (Tobacco Control Act) 

granted the Food and Drug Administration (FDA) the authority to regulate 

the manufacturing, marketing, and sale of tobacco products and allows 

states and local jurisdictions the ability to implement additional or more 

stringent regulations on the sale of tobacco products. 

On December 20, 2019, the Federal Food, Drug, and Cosmetic Act was 

amended and raised the federal minimum legal sales age for tobacco 

products from 18 to 21 years, effective immediately.6 Federal law requires 

manufacturers of products that are put on the market after February 2007 

to get FDA authorization before selling their products. On September 9, 

2021, FDA announced that it denied marketing orders for nearly one 

million e-cigarette products. 7,8 On October 12, 2021, FDA announced that 

it had authorized the marketing of three e-cigarette products – the first ecigarette products for which it issued marketing orders. 9

FDA has said that 

it will make enforcement decisions on a case-by-case basis with respect to 

products that need to come off the market while it continues to review the 

remaining marketing applications filed by e-cigarette companies.10 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. Luke DA, Sorg AA, Combs T, Robichaux CB, Moreland-Russell S, 

Ribisl KM, Henriksen L. Tobacco retail policy landscape: a longitudinal 

survey of US states. Tob Control. 2016 Oct;25(Suppl 1):i44-i51. 

2. Myers AE, Hall MG, Isgett LF, Ribisl KM. A comparison of three policy 

approaches for tobacco retailer reduction. Prev Med. 2015 May;74:67-

73. 

3. U.S. Food and Drug Administration. Family Smoking Prevention and 

Tobacco Control Act - An Overview. Accessed March 26, 2020. 

https://www.fda.gov/tobacco-products/rules-regulations-andguidance/family-smoking-prevention-and-tobacco-control-act-overview 

4. 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, Georgia: 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, 1998. 

5. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

CHAPTER 4 - OUTCOME INDICATORS 77 
 

 

 

► 

GOAL AREA 4 

OUTCOME 2 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

6. U.S. Food and Drug Administration. Tobacco 21. Accessed February 9, 

2021. https://www.fda.gov/tobacco-products/retail-sales-tobaccoproducts/tobacco-21 

7. U.S. Food and Drug Administration. FDA Makes Significant Progress in 

Science-Based Public Health Application Review, Taking Action on 

Over 90% of More Than 6.5 Million ‘Deemed’ New Tobacco Products

Submitted. Accessed December 3, 2021. https://www.fda.gov/newsevents/press-announcements/fda-makes-significant-progress-sciencebased-public-health-application-review-taking-action-over-90 

8. U.S. Food and Drug Administration. Perspective: FDA’s Progress on

Tobacco Product Application Review and Related Enforcement. 

Accessed December 3, 2021. https://www.fda.gov/tobaccoproducts/ctp-newsroom/perspective-fdas-progress-tobacco-productapplication-review-and-related-enforcement/ 

9. U.S. Food and Drug Administration. FDA Permits Marketing of ECigarette Products, Marking First Authorization of Its Kind by the 

Agency. Accessed December 3, 2021. https://www.fda.gov/newsevents/press-announcements/fda-permits-marketing-e-cigaretteproducts-marking-first-authorization-its-kind-agency 

10. U.S. Food and Drug Administration. Perspective: FDA’s Progress on

Tobacco Product Application Review and Related Enforcement. 

Accessed December 3, 2021. https://www.fda.gov/tobaccoproducts/ctp-newsroom/perspective-fdas-progress-tobacco-productapplication-review-and-related-enforcement/ 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 78 
 

 

 

 

 

 

 

 

 

 

► 

GOAL AREA 4 

OUTCOME 2 

Policies That Regulate Tobacco Marketing 

Indicator 

number 

4.2.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of local jurisdictions with policies that restrict the time, place, or 

manner of retail tobacco marketing (either inside or outside stores), such 

as laws that prohibit electronic advertisements or the proportion of 

advertisements on store windows 

Proportion of jurisdictions that are disproportionately burdened by tobacco 

product use with policies that restrict the time, place, or manner of retail 

tobacco marketing 

Similar Goal 1 (2014) 1.4.a, “Proportion of jurisdictions with strong policies that 

existing regulate tobacco advertising.”

indicator(s) Goal 3 (2015) 3.4.a, “Proportion of jurisdictions with policies that regulate

from other tobacco retail sales and marketing.”

goal areas 

Rationale Tobacco products are one of the most heavily marketed consumer 

products in the United States. 

1,2 The tobacco industry spends billions of 

dollars annually on promoting and advertising their products. 

1,2 There is a 

causal relationship between exposure to tobacco marketing and tobacco 

initiation and increased and sustained tobacco use.3-5 Tobacco advertising 

in stores increases unplanned cigarette purchases, the probability of 

3-6 smoking, and cravings to smoke. 

Applying The tobacco industry has a history of targeting certain population groups 

health and communities through advertising, promotions, and by sponsoring 

disparities events and making financial contributions to academic institutions, elected 

framing officials, and community organizations.7-14 Many studies have found that 

tobacco marketing is more common in communities with high proportions 

of racial/ethnic minorities, including African American or Black persons, 7,9,11,15- and communities with a high proportion of persons with low income. 19 

Example data State and/or jurisdiction policy tracking system 

source(s) American Nonsmokers’ Rights (ANR) Foundation U.S. Tobacco Control

Laws Database 

American Lung Association’s State Legislated Actions on Tobacco Issues 

(SLATI) 

CHAPTER 4 - OUTCOME INDICATORS 79 
► 

$$ • • • 

GOAL AREA 4 

OUTCOME 2 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

Comments Advertising restrictions are legally complex policy interventions that are 

best able to withstand legal challenges if they are content neutral (i.e. not 

focused on or specifically intended to address tobacco products) See the 

Public Health Law Center website at 

https://www.publichealthlawcenter.org/ for additional information. Tobacco 

control programs may want to consider tracking this indicator across 

jurisdictions and/or communities to identify differences that may contribute 

to disparities. Moreover, tobacco control programs can expand on this 

indicator by assessing the proportion of the population, including 

population groups experiencing tobacco-related disparities, that are 

protected by policies that regulate retail marketing. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 

March 26, 2020. 

1. Federal Trade Commission. Cigarette Report for 2018. Accessed 

https://www.ftc.gov/reports/federal-trade-commissioncigarette-report-2018-smokeless-tobacco-report-2018 

2. Federal Trade Commission. Smokeless Tobacco Report for 2018. 

Accessed March 26, 2020. https://www.ftc.gov/reports/federal-tradecommission-cigarette-report-2018-smokeless-tobacco-report-2018 

3. Brown T, Platt S, Amos A. Equity impact of interventions and policies to 

reduce smoking in youth: systematic review. Tob Control. 2014 

Nov;23(e2):e98-105. 

4. Robertson L, McGee R, Marsh L, Hoek J. A systematic review on the 

impact of point-of-sale tobacco promotion on smoking. Nicotine Tob 

Res. 2015 Jan;17(1):2-17. 

5. Siahpush M, Shaikh RA, Cummings KM, Hyland A, Dodd M, Carlson L, 

Kessler AS, Meza J, Wan N, Wakefield M. The association of point-ofsale cigarette marketing with cravings to smoke: results from a crosssectional population-based study. Tob Control. 2016 Jul;25(4):402-5. 

6. Shadel WG, Martino SC, Setodji CM, Scharf DM, Kusuke D, Sicker A, 

Gong M. Hiding the tobacco power wall reduces cigarette smoking risk 

in adolescents: using an experimental convenience store to assess 

tobacco regulatory options at retail point-of-sale. Tob Control. 2015 

Nov 23;25(6):679-84. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 80 
 

► 

GOAL AREA 4 

OUTCOME 2 

7. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

8. 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, Georgia: 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,1998. 

9. Centers for Disease Control and Prevention. Best practices user guide: 

Health equity in tobacco 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, 2015. 

10. Stevens P, Carlson LM, Hinman JM. An analysis of tobacco industry 

marketing to lesbian, gay, bisexual, and transgender (LGBT) 

populations: strategies for mainstream tobacco control and prevention. 

Health Promot Pract. 2004;5(3)(suppl):129S-34S. 

11. Kong AY, Queen TL, Golden SD, Ribisl KM. Neighborhood disparities 

in the availability, advertising, promotion, and youth appeal of little 

cigars and cigarillos, United States, 2015. Nicotine Tob Res. 2020 Jan 

9:ntaa005. 

12. Muggli ME, Pollay RW, Lew R, Joseph AM. Targeting of Asian 

Americans and Pacific Islanders by the tobacco industry: results from 

the Minnesota Tobacco Document Depository. Tob Control. 

2002;11:201-9. 

13. Balbach ED, Gasior RJ, Barbeau EM. R.J. Reynolds’ targeting of 

African Americans: 1988-2000. Am J Public Health. 2003;93(5):822-7. 

14. Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate 

activity, and health disparities: tobacco industry targeting of inner cities. 

J Health Care Poor Underserved. 2007 Nov;18(4 Suppl):10-38. 

15. Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A 

systematic review of neighborhood disparities in point-of-sale tobacco 

marketing. Version 2. Am J Public Health. 2015 Sep;105(9):e8-18. 

16. Ribisl KM, D'Angelo H, Feld AL, et al. Disparities in tobacco marketing 

and product availability at the point of sale: results of a national study. 

Prev Med. 2017 Dec;105:381-8. 

CHAPTER 4 - OUTCOME INDICATORS 81 
► 

GOAL AREA 4 

OUTCOME 2 

17. John R, Cheney MK, Azad MR. Point-of-sale marketing of tobacco 

products: taking advantage of the socially disadvantaged? J Health 

Care Poor Underserved. 2009;20(2):489-506. 

18. Seidenberg AB, Caughey RW, Rees VW, Connolly GN. Storefront 

cigarette advertising differs by community demographic profile. Am J 

Health Promot. 2010;24(6):e26-31. 

19. Begay C, Soto C, Baezconde-Garbanati L, et al. Cigarette and ecigarette retail marketing on and near California Tribal Lands. Health 

Promot Pract. 2020 Jan;21(1 Suppl):18S-26S. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 82 
 

 

 

 

 

 

► 

$$ ◕ ● ● ●

GOAL AREA 4 

OUTCOME 2 

Retail Licensing to Sell Tobacco Products 

Indicator 

number 

4.2.c 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of jurisdictions with strong policies that require retail licenses to 

sell tobacco products 

Proportion of jurisdictions that are disproportionately burdened by tobacco 

product use with strong policies that require licenses to sell tobacco 

products 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.3.b, “Proportion of jurisdictions with strong policies that 

require retail licenses to sell tobacco products.”

Rationale Tobacco retailer licensing is an effective mechanism for reducing the 

number, type, location, and density of tobacco retailers, restricting sales of 

tobacco products, and restricting price promotions at the point of sale, all of 

which contribute to tobacco use 1-4 . 

Applying Tobacco licensing can have a strong impact on factors that contribute to 

health tobacco-related disparities, such as the concentration of tobacco retailers. 

disparities Research has found that the number of retail tobacco outlets and 

framing promotions are higher in communities with a high proportion of racial/ethnic 

minorities, including African American or Black persons, and persons with 

low income.5-8 

Example data 

source(s) 

American Lung Association’s State Legislated Actions on Tobacco Issues 

(SLATI) 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

CHAPTER 4 - OUTCOME INDICATORS 83 
 

► 

GOAL AREA 4 

OUTCOME 2 

Comments Tobacco control programs may want to consider tracking this indicator 

across jurisdictions/communities to identify differences that may contribute 

to disparities. Moreover, tobacco control programs can expand on this 

indicator by assessing the proportion of the population, including population 

groups experiencing tobacco-related disparities, that are impacted by 

tobacco retailer licensing. 

Tobacco control programs should determine the scope of the policy 

standards before evaluating the presence/absence and reach of such 

policies. “Strong” licensure includes, among other things: a requirement to 

obtain a license and renew it annually; a license fee set high enough to 

cover costs associated with administration, implementation, and 

enforcement of the license; and provisions authorizing a penalty to the 

business, including suspension or revocation of the license for any 

violations of local, state, or federal tobacco laws. 

References 1. McLaughlin I. License to kill? Tobacco retailer licensing as an effective

enforcement tool. St. Paul, MN: Tobacco Control Legal Consortium; 

2010. Accessed February 9, 2021. 

https://www.publichealthlawcenter.org/resources/license-kill-tobaccoretailer-licensing-effective-enforcement-tool 

2. Myers AE, Knocke K, Leeman J. Tapping into multiple data "springs" to 

strengthen policy streams: A guide to the types of data needed to 

formulate local retail tobacco control policy. Prev Chronic Dis. 2019 Apr 

4;16:E43. 

3. Ackerman A, Etow A, Bartel S, Ribisl KM. Reducing the density and 

number of tobacco retailers: policy solutions and legal issues. Nicotine 

Tob Res. 2017 Feb;19(2):133-140. 

4. Counter Tobacco. Licensing, zoning, and retailer density. Accessed 

March 27, 2020. https://countertobacco.org/policy/licensing-and-zoning/ 

5. Levy DT, Tam J, Kuo C, Fong GT, Chaloupka F. The impact of 

implementing tobacco control policies: the 2017 tobacco control policy 

scorecard. J Public Health Manag Pract. 2018 Sep/Oct;24(5):448-457. 

6. Lee JGL, Sun DL, Schleicher NM, Ribisl KM, Luke DA, Henriksen L. 

Inequalities in tobacco outlet density by race, ethnicity and 

socioeconomic status, 2012, USA: results from the ASPiRE Study. J 

Epidemiol Community Health. 2017;71(5):487-92. 

7. Ribisl KM, Luke DA, Bohannon DL, Sorg AA, Moreland-Russell S. 

Reducing disparities in tobacco retailer density by banning tobacco 

product sales near schools. Nicotine Tob Res. 2017 Feb;19(2):239-44. 

8. Kong AY, Queen TL, Golden SD, Ribisl KM. Neighborhood disparities 

in the availability, advertising, promotion, and youth appeal of little 

cigars and cigarillos, United States, 2015. Nicotine Tob Res. 2020 Jan 

9:ntaa005. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 84 
 

 

► 

GOAL AREA 4 

OUTCOME 2 

Policies That Regulate the Number, Type, Location, and Density of Tobacco Retail 

Outlets 

Indicator 

number 

4.2.d 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increased equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

d. Proportion of jurisdictions with policies that control the number, type, 

location, and density of tobacco retail outlets 

Proportion of jurisdictions that are disproportionately burdened by tobacco 

product use with policies that control the number, type, location, and 

density of tobacco retail outlets 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.3.c, “Proportion of jurisdictions with policies that control the 

type, location, number, and/or density of retail outlets.”

Rationale High tobacco retail density and the proximity of tobacco retailers to youthoriented facilities have been associated with youth initiation, higher number 

of cigarettes smoked per day, and lower prevalence of successful 

cessation.1-5 Licensing requirements and zoning restrictions are effective 

policies for regulating the number, type, location and density of tobacco 

retail outlets.5-9 Examples of policies enacted through retailer licensing 

requirements or zoning restrictions include prohibiting the sale of tobacco 

in pharmacies and restricting tobacco retailers within close proximity to 

youth-oriented facilities, such as schools. 

Applying 

health 

disparities 

framing 

Studies have shown that the density and number of tobacco retailers are 

disproportionately higher in communities with a high proportion of 

racial/ethnic minorities, including African American or Black persons, 

Latino/Hispanic persons, and LGBTQ+ persons, as well as persons with 

low income.4,5,9-11 Research also indicates that the density of retail outlets 

is higher in urban and some rural communities.4,12 

Example data 

source(s) 

American Lung Association’s State Legislated Actions on Tobacco Issues 

(SLATI) 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

This indicator is best measured by tracking and monitoring pertinent 

tobacco laws, ordinances, or regulations. 

Comments Tobacco control programs may want to consider measuring the number or 

concentration of licensed retailers by geographic location (e.g., within 

CHAPTER 4 - OUTCOME INDICATORS 85 
► 

GOAL AREA 4 

OUTCOME 2 

wards or city districts) when assessing this indicator, as well as differences 

across jurisdictions and/or communities. Moreover, tobacco control 

programs can expand on this indicator by assessing the proportion of the 

population, including population groups experiencing tobacco-related 

disparities, that are protected by policies that regulate the number, type, 

location, and density of tobacco retailers. 

See the Public Health Law Center website at 

https://www.publichealthlawcenter.org/ for additional information. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better

References 1. Chan WC, Leatherdale ST. Tobacco retailer density surrounding

schools and youth smoking behavior: a multi-level analysis. Tob Induc

Dis. 2011;9(1):9.

2. Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS,

Fortmann SP. Is adolescent smoking related to the density and

proximity of tobacco outlets and retail cigarette advertising near

schools? Prev Med. 2008;47(2):210-4.

3. Reitzel LR, Cromley EK, Li Y, et al. The effect of tobacco outlet density

and proximity on smoking cessation. Am J Public Health.

2011;101(2):315–320.

4. U.S. National Cancer Institute. A socioecological approach to

addressing tobacco-related health disparities. National Cancer Institute

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A.

Bethesda, MD: U.S. Department of Health and Human Services,

National Institutes of Health, National Cancer Institute; 2017.

5. Counter Tobacco. Licensing, Zoning, and Retailer Density. March 27,

2020. https://countertobacco.org/policy/licensing-and-zoning/

6. Ribisl KM, Luke DA, Bohannon DL, Sorg AA, Moreland-Russell S.

Reducing disparities in tobacco retailer density by banning tobacco

product sales near schools. Nicotine Tob Res. 2016;19(2):239-44.

7. Ackerman A, Etow A, Bartel S, Ribisl KM. Reducing the density and

number of tobacco retailers: policy solutions and legal issues. Nicotine

Tob Res. 2017 Feb;19(2):133-140.

8. Myers AE, Hall MG, Isgett LF, Ribisl KM. A comparison of three policy

approaches for tobacco retailer reduction. Prev Med. 2015;74:67-73.

Identifying and Eliminating Tobacco-Related Disparities: 86 Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 

$$ ● ● ● ●
► 

GOAL AREA 4 

OUTCOME 2 

9. Lee JG, Pan WK, Henriksen L, Goldstein AO, Ribisl KM. Is there a 

relationship between the concentration of same-sex couples and 

tobacco retailer density? Nicotine Tob Res. 2016 Feb;18(2):147-55. 

10. Lee JG, Sun DL, Schleicher NM, Ribisl KM, Luke DA, Henriksen L. 

Inequalities in tobacco outlet density by race, ethnicity and 

socioeconomic status, 2012, USA: results from the ASPiRE Study. J 

Epidemiol Community Health. 2017;71(5):487-92. . 

11. Giovenco DP, Spillane TE, Mauro CM, Hernández D. Evaluating the 

impact and equity of a tobacco-free pharmacy law on retailer density in 

New York City neighbourhoods. Tob Control. 2019 Sep;28(5):548-54. 

12. Hall J, Cho HD, Maldonado-Molina M, George TJ Jr, Shenkman EA, 

Salloum RG. Rural-urban disparities in tobacco retail access in the 

southeastern United States: CVS vs. the dollar stores. Prev Med Rep. 

2019;15:100935. 

CHAPTER 4 - OUTCOME INDICATORS 87 
 

 

 

 

 

 

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GOAL AREA 4 

OUTCOME 2 

Policies That Regulate Tobacco Promotions, Discounts, and Coupons 

Indicator 

number 

4.2.e 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of jurisdictions with policies that regulate the extent and type of 

tobacco promotions, discounts, and coupons 

Proportion of jurisdictions that are disproportionately burdened by tobacco 

product use with policies that regulate the extent and type of tobacco 

promotions, discounts, and coupons 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.4.b, “Proportion of jurisdictions with policies that regulate

the extent and type of consumer-directed tobacco promotions.”

Rationale Policies that increase the price of tobacco products have been found to be 

one of the most effective ways to reduce tobacco use.1-4 However, the 

tobacco industry utilizes tobacco promotions, discounts, and coupons to 

counteract the impact of price increases.2 According to the Federal Trade 

Commission, price promotions accounted for 62.2% of the industry’s

advertising and promotional expenditures in 2018.5 

Applying 

health 

disparities 

framing 

Studies show that tobacco product promotions, discounts, and coupons 

occur more frequently among retailers in communities with high proportions 

of racial/ethnic minorities including African American or Black persons, 

Latino/Hispanic persons, and American Indians/Alaska Native persons, as 

well as persons with low educational attainment, and persons with low 

income. 

6-10 Policies that regulate the extent and type of tobacco 

promotions, discounts, and coupons are important to reduce exposure to 

these tobacco industry marketing tactics and to support equitable 

implementation of policies to increase tobacco product prices. 

Example data 

source(s) 

American Lung Association’s State Legislated Actions on Tobacco Issues 

(SLATI) 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

Comments Example policies are those that prohibit the redemption of discount 

coupons and value-added sales for tobacco products. Tobacco control 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 88 
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$ • • • 

GOAL AREA 4 

OUTCOME 2 

programs can consider different types of tobacco promotions, discounts, 

and coupons including digital or print.8 

Tobacco control programs may want to consider tracking this indicator 

across jurisdictions and/or communities to identify differences that may 

contribute to disparities. Moreover, tobacco control programs can expand 

on this indicator by also assessing the proportion of the population, 

including population groups experiencing tobacco-related disparities, that 

are protected by policies that regulate tobacco promotions, discounts, and 

coupons. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

2. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

3. Levy DT, Tam J, Kuo C, Fong GT, Chaloupka F. The impact of 

implementing tobacco control policies: the 2017 tobacco control policy 

scorecard. J Public Health Manag Pract. 2018 Sep/Oct;24(5):448-457. 

4. Golden SD, Smith MH, Feighery EC, Roeseler A, Rogers T, Ribisl KM. 

Beyond excise taxes: a systematic review of literature on non-tax policy 

approaches to raising tobacco product prices. Tob Control. 2016 

Jul;25(4):377-85. 

5. FTC releases reports on cigarette and smokeless tobacco sales and 

marketing expenditures for 2018. Washington, DC: Federal Trade 

Commission; 2019 Dec. Accessed February 9, 2021. 

https://www.ftc.gov/news-events/press-releases/2019/12/ftc-releasesreports-cigarette-smokeless-tobacco-sales-marketing 

6. Moran MB, Heley K, Pierce JP, Niaura R, Strong D, Abrams D. Ethnic 

and socioeconomic disparities in recalled exposure to and self-reported 

CHAPTER 4 - OUTCOME INDICATORS 89 
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OUTCOME 2 

impact of tobacco marketing and promotions. Health Commun. 2019 

Mar;34(3):280-289. 

7. Barnoya J, Colditz G, Moreland-Russell S, Cyr J, Snider D, Schootman 

M. Prevalence of cigarette advertising and other promotional strategies 

at the point of sale in St Louis, Missouri: analysis by store type and 

distance from a school. Prev Chronic Dis. 2014 Apr 17;11:E61. 

8. Choi K, Chen JC, Tan ASL, Soneji S, Moran MB. Receipt of tobacco 

direct mail/email discount coupons and trajectories of cigarette smoking 

behaviors in a nationally representative longitudinal cohort of US adults. 

Tob Control. 2018 Jun 19;28(3):282-8. 

9. Lempert LK, Glantz SA. Tobacco industry promotional strategies 

targeting American Indians/Alaska Natives and exploiting Tribal 

sovereignty. Nicotine Tob Res. 2019;21(7):940-8. 

10. Richardson A, Ganz O, Vallone D. Tobacco on the web: surveillance 

and characterisation of online tobacco and e-cigarette advertising. Tob 

Control. 2015 Jul;24(4):341-7. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 90 
 

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OUTCOME 2 

Policies that Prohibit the Sale of Flavored Tobacco Products 

Indicator 

number 

4.2.f 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of jurisdictions with policies that prohibit the sale of all flavored 

tobacco products, including menthol products 

Proportion of jurisdictions that are disproportionately burdened by tobacco 

product use with policies that prohibit the sale of all flavored tobacco 

products, including menthol products 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Flavored tobacco products are associated with tobacco initiation, 

experimentation, and sustained use.1-4 Policies prohibiting the sale of 

flavored tobacco products can be an effective strategy to reduce tobacco 

use. 

5-7 Policies that have passed at federal, state, and/or local levels and 

vary in composition and the level of comprehensiveness, with some 

exempting certain tobacco products and/or flavors.8 Research has shown 

that the availability of flavors is associated with tobacco use, particularly 

among youth. 1,2,9-11 Moreover, menthol cigarettes are particularly appealing 

to African Americans or Black persons; nearly 9 in 10 African Americans or 

Black people ages 12 and older who smoke use menthol cigarettes. 9-10 

Applying 

health 

disparities 

framing 

The tobacco industry has historically marketed flavored tobacco products to 

certain populations and communities disproportionately burdened by 

tobacco use, including those with a high proportion of racial/ethnic 

minorities, particularly those with a high concentration of African Americans 

or Black persons, LGBTQ+ persons, persons with low educational 

attainment, and persons with low income.9,11-13 

Example data 

source(s) 

American Nonsmokers’ Rights (ANR) Foundation U.S. Tobacco Control

Laws Database 

Campaign for Tobacco Free Kids (CTFK) 

Truth Initiative 

Example 

survey 

question(s) 

This indicator is best measured by tracking and monitoring pertinent 

tobacco laws, ordinances, or regulations. 

CHAPTER 4 - OUTCOME INDICATORS 91 
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Comments Federal law requires manufacturers of products that are put on the market 

after February 2007 to get FDA authorization before selling their products. 

On January 2, 2020, FDA announced that, beginning February 7, 2020, it 

would prioritize its enforcement activities to remove from the market any 

flavored cartridge-based e-cigarette product other than tobacco- or 

menthol-flavored cartridge-based products, unless and until it authorized 

any of those types of products for sale. 

14 On October 12, 2021, FDA 

announced that it had authorized the marketing of three e-cigarette 

products – the first e-cigarette products for which it issued marketing 

orders. None of these e-cigarettes authorized for sale are flavored 

products. FDA will post information about any additional products that it has 

authorized for sale on its website: https://www.fda.gov/tobaccoproducts/market-and-distribute-tobacco-product/tobacco-productsmarketing-orders. 

Tobacco control programs may want to consider tracking this indicator 

across jurisdictions and/or communities to identify differences in the policy 

(e.g., provisions) and/or implementation of the policy that may contribute to 

disparities. Moreover, tobacco control programs can expand on this 

indicator by assessing the proportion of the population, including population 

groups experiencing tobacco-related disparities, that are protected by 

policies that prohibit the sale of all flavored tobacco products, including 

menthol products. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. Villanti AC, Johnson AL, Glasser AM, et al. Association of flavored 

tobacco use with tobacco initiation and subsequent use among US 

youth and adults, 2013-2015. JAMA Netw Open. 2019;2(10):e1913804. 

2. Cullen KA, Liu ST, Bernat JK, et al. Flavored Tobacco product use 

among middle and high school students — United States, 2014–2018. 

MMWR Morb Mortal Wkly Rep. 2019;68:839–844. 

3. Odani S, Armour B, Agaku IT. Flavored tobacco product use and its 

association with indicators of tobacco dependence among US adults, 

2014–2015. Nicotine Tob Res. 2019 Oct;22(6):1004-15. 

4. Giovino GA, Villanti AC, Mowery PD, et al. Differential trends in 

cigarette smoking in the USA: is menthol slowing progress? Tob 

Control. 2013;24(1):28-37. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 92 
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OUTCOME 2 

5. Courtemanche CJ, Palmer MK, Pesko MF. Influence of the flavored 

cigarette ban on adolescent tobacco use. Am J Prev Med. 2017;52(No 

5):e139-e46. 

6. Farley SM, Johns M. New York City flavoured tobacco product sales 

ban evaluation. Tob Control. 2017;26(No 1):78-84. 

7. Lester JM, Gagosian SY. Finished with menthol: An evidence-based 

policy option that will save lives. J Law Med Ethics. 2017 Mar;45(1 

Suppl):41-4. 

8. Campaign for Tobacco-Free Kids. States and localities that have 

restricted the sale of flavored tobacco products. Washington, DC: 

Campaign for Tobacco-Free Kids; 2020 Feb. 

9. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. Bethesda, MD: U.S. Department of 

Health and Human Services, National Institutes of Health, National 

Cancer Institute; 2017. 

10. Rath JM, Villanti AC, Williams VF, Richardson A, Pearson JL, Vallone 

DM. Correlates of current menthol cigarette and flavored other tobacco 

product use among U.S. young adults. Addict Behav. 2016 Nov;62:35-

41. 

11. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and 

associated factors among middle and high school students - United 

States, 2019. MMWR Surveill Summ. 2019 Nov 6;68(12):1-22. 

12. Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate 

activity, and health disparities: tobacco industry targeting of inner cities. 

J Health Care Poor Underserved. 2007 Nov;18(4 Suppl):10-38. 

13. Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted 

advertising, promotion, and price for menthol cigarettes in California 

high school neighborhoods. Nicotine Tob Res. 2012;14(1):116–21. 

14. U.S. Food and Drug Administration. FDA finalizes enforcement policy 

on unauthorized flavored cartridge-based e-cigarettes that appeal to 

children, including fruit and mint. Accessed February 9, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-finalizesenforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettesappeal-children 

CHAPTER 4 - OUTCOME INDICATORS 93 
 

 

 

 

 

 

 

 

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OUTCOME 2 

Comprehensive Smokefree Policies for Indoor Public Places HP 

Indicator 

number 

4.2.g 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of jurisdictions that have comprehensive smokefree policies that 

prohibit smoking in all indoor areas of workplaces, including restaurants, 

and bars 

Proportion of jurisdictions that are disproportionately burdened by 

secondhand smoke exposure that have comprehensive smokefree policies 

that prohibit smoking in all indoor areas of workplaces, including 

restaurants, and bars 

Similar Goal 2 (2017) 2.2.a, “Proportion of jurisdictions with comprehensive 

existing smokefree policies for indoor public places.”

indicator(s) Goal 2 (2017) Addendum E-cigarette 2.2, “Proportion of jurisdictions with 

from other comprehensive smokefree policies, including e-cigarettes, for indoor public 

goal areas places.”

Rationale Evidence shows that comprehensive smokefree policies making indoor 

workplaces and public areas smokefree are highly effective in protecting 

people who do not smoke from exposure to secondhand smoke.1,2 These 

policies can also motivate and support smoking cessation by reducing the 

social acceptability of smoking, limiting opportunities to smoke, and 

increasing the inconvenience of smoking.1-5 Despite the progress that has 

been made in creating smokefree environments in past years, coverage 

varies across states and localities, leaving some U.S. populations less 

protected.5-9 

Applying Comprehensive smokefree policy coverage is lower in some communities, 

health including those with a high proportion racial/ethnic minorities, including 

disparities African American or Black persons, and persons with low educational 

framing attainment.5-8 Additionally, communities in the Southern U.S., and some 

Midwestern geographic areas of the U.S. also experience lower levels of 

5-7,9-10 smokefree policy coverage. 

Example data 

source(s) 

American Nonsmokers’ Rights (ANR) Foundation U.S. Tobacco Control

Laws Database 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 94 
 

 

 

 

► 

$ ● ● ● ●

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OUTCOME 2 

Comments A comprehensive smokefree policy is defined by the CDC Office on 

Smoking and Health as a policy that does not allow smoking in any indoor 

areas of workplaces, restaurants, and bars, with no exceptions. States or 

jurisdictions that have already adopted comprehensive smokefree policies 

or are attempting to adopt comprehensive smokefree policies can consider 

enhancing their policies to include e-cigarettes. Refer to Eliminating 

Exposure to Secondhand Smoke: Outcome Indicators for Comprehensive 

Tobacco Control Programs—2017, 

11 E-cigarette Addendum 2.2, 

“Proportion of jurisdictions with comprehensive smoke-free policies, 

including e-cigarettes, for indoor public places” for more information. 

Tobacco control programs may want to consider tracking this indicator 

across jurisdictions and/or communities to identify differences that may 

contribute to disparities. Moreover, tobacco control programs can expand 

on this indicator by also assessing the proportion of population, including 

population groups experiencing tobacco-related disparities, that are 

protected by comprehensive smokefree policies. 

This indicator supports the Healthy People 2030 objective TU-17: Increase 

the number of states, territories, and District of Columbiathat prohibit 

smoking in worksites, restaurants, and bars. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

2. International Agency for Research on Cancer. Evaluating the 

effectiveness of smoke-free policies. IARC handbooks of cancer 

prevention: tobacco control. Vol. 13. Lyon, France: International 

Agency for Research on Cancer; 2009. 

3. Hamilton WL, Biener L, Brennan RT. Do local tobacco regulations 

influence perceived smoking norms? Evidence from adult and youth 

surveys. Health Educ Res. 2008;23(4):709-22. 

CHAPTER 4 - OUTCOME INDICATORS 95 
► 

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OUTCOME 2 

4. Garrett BE, Dube SR, Babb S, McAfee T. Addressing the social 

determinants of health to reduce tobacco-related disparities. Nicotine 

Tob Res. 2014;17(8):892-7. 

5. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017 

6. American for Nonsmokers’ Rights Foundation. U.S.100% Smokefree 

Laws in Non-Hospitality Workplaces and Restaurants and Bars. 

Accessed March 27, 2020. https://no-smoke.org/materialsservices/lists-maps/#1518200878061-ebc83fdc-2d6c 

7. Gonzalez M, Sanders-Jackson A, Song AV, Cheng K-w, Glantz SA. 

Strong smoke-free law coverage in the United States by race/ethnicity: 

2000–2009. Am J Public Health. 2013;103(5):e62-e6. 

8. Huang J, King BA, Babb SD, Xu X, Hallett C, Hopkins M. 

Sociodemographic disparities in local smoke-free law coverage in 10 

States. Am J Public Health. 2015 Sep;105(9):1806-13. 

9. Hafez AY, Gonzalez M, Kulik MC, Vijayaraghavan M, Glantz SA. 

Uneven access to smoke-free laws and policies and its effect on health 

equity in the United States: 2000-2019. Am J Public Health. 

2019;109(11):1568-75. 

10. Buettner-Schmidt K, Miller DR, Maack B. Disparities in rural tobacco 

use, smoke-free policies, and tobacco taxes. West J Nurs Res. 2019 

Aug;41(8):1184-202. 

11. Centers for Disease Control and Prevention. Eliminating exposure to 

secondhand smoke: outcome indicators for comprehensive tobacco 

control programs–2017. Atlanta, GA: Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2017. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 96 
 

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Smokefree Policies for Casinos NR 

Indicator 

number 

4.2.h 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of jurisdictions that have policies that prohibit smoking in all 

indoor areas of casinos 

Proportion of jurisdictions that are disproportionately burdened by 

secondhand smoke exposure that have policies that prohibit smoking in all 

indoor areas of casinos 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Despite wide support for smokefree casinos, state and local 

comprehensive smokefree policies often exempt casinos.1,2 Moreover, 

casinos on tribal lands are exempt from state and local policies because of 

tribal sovereignty.3,4 Studies of air quality in casinos that allow smoking 

have found high levels of secondhand smoke exposure, as demonstrated 

by elevated secondhand smoke constituents, including high concentrations 

of particulate matter and particulate polycyclic aromatic hydrocarbons, and 

tobacco-specific biomarkers in the blood, urine, and saliva. 

2,3 Smoking 

inside casinos involuntarily exposes casino patrons and employees to the 

harms of secondhand smoke.3-6 

Applying 

health 

disparities 

framing 

Women and racial/ethnic minorities, including African American or Black 

persons and Latino/Hispanic persons, make up close to half of gaming 

employees in non-tribal commercial casinos in the United States and 

consequently experience a higher risk of exposure to secondhand smoke 

in casinos that allow smoking.6 Additionally, American Indian/Alaska Native 

persons often comprise a large number of tribal casino employees and 

patrons, and thus experience an increased risk of secondhand smoke 

exposure in tribal casinos that allow smoking.3 

Example data 

source(s) 

American Nonsmokers’ Rights (ANR) Foundation U.S. Tobacco Control

Laws Database 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

CHAPTER 4 - OUTCOME INDICATORS 97 
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Comments Tobacco control programs can also consider assessing this indicator in 

jurisdictions with a large proportion of casinos without comprehensive 

smokefree policies. 

Tobacco control programs may want to consider tracking this indicator 

across jurisdictions and/or communities to identify differences that may 

contribute to disparities. Moreover, tobacco control programs can expand 

on this indicator by also assessing the proportion of population groups 

experiencing tobacco-related disparities, including those employed in 

casinos, that are protected by smokefree policies in casinos. 

Rating Not rated. 

References 1. Tynan MA, Wang TW, Marynak KL, Lemos P, Babb SD. Attitudes 

toward smoke-free casino policies among US adults, 2017. Public 

Health Rep. 2019 May/Jun;134(3):234-40. 

2. Tynan, MA, Holmes, CB, Promoff, G, Hallett, C, Hopkins, M, Frick, B. 

State and local comprehensive smoke-free laws for worksites, 

restaurants, and bars—United States, 2015. MMWR Morb Mortal Wkly 

Rep. 2016;65(24):623-6. 

3. Babb S, McNeil C, Kruger J, Tynan MA. Secondhand smoke and 

smoking restrictions in casinos: a review of the evidence. Tob Control. 

2015 Jan;24(1):11-7. 

4. Public Health Law Center, Casinos. Accessed April 28, 2020. 

https://www.publichealthlawcenter.org/topics/commercial-tobaccocontrol/smoke-free-tobacco-free-places/casinos 

5. American Gaming Association. State of the states 2019: the AGA 

survey of casino entertainment. Accessed March 30, 2020. 

https://www.americangaming.org/resources/state-of-the-states-2019-

the-aga-survey-of-the-commercial-casino-industry 

6. American Gaming Association. Gaming Careers: Gateway to the 

Middle Class. Accessed April 30, 2020. 

https://www.oxfordeconomics.com/recent-releases/gaming-careersgateway-to-the-middle-class 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 98 
 

 

 

 

 

 

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OUTCOME 2 

Disparities in the Population Covered by Workplace Smokefree Policies 

Indicator 

number 

4.2.i 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of the employed population that is covered by a workplace 

smokefree policy, overall, and among occupations and/or settings with 

disproportionately higher risk of exposure to secondhand smoke 

Differences in the proportion of the employed population that is covered by 

a workplace smokefree policy by population group characteristics and 

occupation 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.2.c, “Proportion of the employed population covered by a 

workplace smokefree policy.”

Rationale Because employed adults spend a substantial amount of their time at work, 

workplaces without smokefree policies are a major source of secondhand 

smoke exposure for nonsmoking adults.1,2 Smokefree workplaces protect 

workers from secondhand smoke exposure, reduce the social acceptability 

of smoking, and increase the likelihood of successful cessation among 

workers who use tobacco.1-5 This indicator is especially relevant for 

evaluation in states that exempt some workplaces from state smokefree air 

laws (e.g., casinos, hotels/motels). 

Applying 

health 

disparities 

framing 

Research has shown that persons with low income and persons working in 

certain occupations, including blue collar and service workers and casino 

and other gaming facility workers, experience a higher risk of secondhand 

smoke exposure in the workplace.1,2,4,6-8 Additionally, persons living in rural 

areas are less likely to be covered by a workplace smokefree policy.1,2,7,9 

Example data 

source(s) 

American Nonsmokers’ Rights (ANR) Foundation U.S. Tobacco Control

Laws Database 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

2018-2019 

Example 

survey 

question(s) 

From TUS-CPS (2018-2019) 

Is smoking restricted in ANY WAY at your place of work? 

• Yes 

• No 

CHAPTER 4 - OUTCOME INDICATORS 99 
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OUTCOME 2 

Which of these best describes the smoking policy at your place of work for 

INDOOR work areas? 

• Not allowed in ANY work areas 

• Allowed in SOME work areas 

• Allowed in ALL work areas 

• NOT APPLICABLE 

Which of these best describes the smoking policy at your place of work for 

INDOOR PUBLIC OR COMMON AREAS, such as lobbies, rest rooms, and 

lunch rooms? 

• Not allowed in ANY public areas 

• Allowed in SOME public areas 

• Allowed in ALL public areas 

• NOT APPLICABLE 

Comments Tobacco control programs may want to assess this indicator by occupation 

type and across jurisdictions/communities. Moreover, tobacco control 

programs can expand on this indicator by also assessing the proportion of 

the population, including population groups experiencing tobacco-related 

disparities, such as those that work in occupations with high risk of 

secondhand smoke exposure, who are protected by a smokefree policy in 

the workplace. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

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

consequences of involuntary exposure to tobacco smoke: 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; 2006. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 100 
► 

GOAL AREA 4 

OUTCOME 2 

3. International Agency for Research on Cancer (IARC). IARC Handbooks 

of Cancer Prevention, Tobacco Control, Vol. 13: Evaluating the 

effectiveness of smoke-free policies. Lyon, France: IARC; 2009. 

4. Babb S, Liu B, Kenemer B, et al. Changes in self-reported smokefree 

workplace policy coverage among employed adults-United States, 2003 

and 2010-2011. Nicotine Tob Res. 2018 Sep 25;20(11):1327-1335. 

5. Guide to Community Preventive Services. Reducing tobacco use and 

secondhand smoke exposure: smoke-free policies. Available at: 

http://www.thecommunityguide.org/tobacco/smokefreepolicies.html 

6. Babb S, McNeil C, Kruger J, Tynan MA. Secondhand smoke and 

smoking restrictions in casinos: a review of the evidence. Tob Control. 

2015;24:11-7. 

7. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. Bethesda, MD: U.S. Department of 

Health and Human Services, National Institutes of Health, National 

Cancer Institute; 2017. 

8. Syamlal G, King BA, Mazurek JM. Workplace smoke-free policies and 

cessation programs among U.S. working adults. Am J Prev Med. 

2019;56(4):548-62. 

9. Buettner-Schmidt K, Miller DR, Maack B. Disparities in rural tobacco 

use, smoke-free policies, and tobacco taxes. West J Nurs Res. 2019 

Aug;41(8):1184-1202. 

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OUTCOME 2 

Smokefree Policies in Multiunit Housing 

Indicator 

number 

4.2.j 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of multiunit housing operators that have adopted voluntary 

smokefree policies that prohibit smoking in all indoor areas of multiunit 

housing 

Differences in the proportion of multiunit housing operators that have 

adopted voluntary smokefree policies that prohibit smoking in all indoor 

areas of multiunit housing by type of multiunit housing (subsidized, market 

rate) and community and population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.2.i, “Proportion of multiunit housing operators that have 

adopted a smokefree policy in their buildings.”

Rationale The home is a major source of secondhand exposure, especially for 

children.1 Persons living in multiunit housing, such as apartment buildings 

and condominiums, are at particular risk of exposure to secondhand smoke 

because smoke can transfer from neighboring units and public areas.1,2 In 

2016, the U.S. Department of Housing and Urban Development issued a 

smokefree rule prohibiting smoking in all indoor areas of public housing.3 

However, many subsidized and private multiunit complexes still do not 

have smokefree policies in place.4 

Applying Certain types of multiunit housing, including government-subsidized 

health housing, are occupied by large proportions of vulnerable population groups 

disparities that are at higher risk for chronic disease and poor health outcomes, 

framing including older adults and children, racial/ethnic minorities, persons with 

1,2,5 low income, and persons with disabilities. 

Example data UC Davis, Center for Evaluation and Research, Tobacco Control 

source(s) Evaluation Center, Multi-Unit Housing: Public Intercept Survey (MUHPIS), 

2018 

UC Davis, Center for Evaluation and Research, Tobacco Control 

Evaluation Center, Colusa County Tobacco Education Project, 

Owners/Managers of Multi-Unit Housing Complexes (MUHMI), 2017 

Social Climate Survey of Tobacco Control (SCS-TC), 2014 

Identifying and Eliminating Tobacco-Related Disparities: 

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Example From the Experience with Smoke-Free Policies in Affordable Multiunit 

survey Housing Study (2016) 

question(s) What best describes the rules about smoking in residential units? 

• Smoking is allowed in all residential units 

• Smoking is allowed in some residential units 

• Smoking is not allowed in any residential units 

From SCS-TC (2014) 

Which of the following best describes the building in which you live? Would 

you say: 

• A mobile home 

• A one-family house detached from any other house 

• A one-family house attached to one or more houses 

• An apartment or condominium building 

• Other 

Does your property manager allow smoking in your apartment/condo units? 

• Yes 

• No 

Does your property manager allow smoking on the property? 

• Yes 

• No 

Comments In addition to self-reported data, this indicator can be assessed through 

resources such as air quality studies. This indicator is best measured by 

state and local policy tracking systems; however, survey data can be 

helpful in providing estimates. 

Tobacco control programs may want to assess this indicator across 

jurisdictions and/or communities to identify differences that may contribute 

to disparities. Moreover, tobacco control programs may want to expand on 

this indicator by assessing the proportion of multiunit housing residents that 

are covered by smokefree policies. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. US Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

CHAPTER 4 - OUTCOME INDICATORS 103 
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the Surgeon General. Atlanta, GA: US Department of Health and 

Human Services, Centers for Disease Control and Prevention; 2006. 

2. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of 

the scientific literature. Tob Control. 2016;25(1):9-20. 

3. U.S. Department of Housing and Urban Development. Smoke-free 

public housing and multifamily properties. Accessed March 30, 2020. 

https://www.hud.gov/program_offices/healthy_homes/smokefree 

4. Centers for Disease Control and Prevention. Best practices user guide: 

health equity. Atlanta, GA: 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; 2015. 

5. King BA, Babb SD, Tynan MA, Gerzoff RB. National and state 

estimates of secondhand smoke infiltration among US multiunit housing 

residents. Nicotine Tob Res. 2012;15(7):1316-21. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 104 
 

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Home and Vehicle Smokefree Rules HP 

Indicator 

number 

4.2.k 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Proportion of the population reporting 100% smokefree rules in their 

homes, overall, and among population groups experiencing tobacco-related 

disparities and differences in the proportion of the population reporting 

100% smokefree rules in their homes by population group characteristics 

Proportion of the population reporting 100% smokefree rules in their 

vehicles, overall, and among population groups experiencing tobaccorelated disparities and differences in the proportion of the population 

reporting 100% smokefree rules in their vehicles by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.2.f, “Proportion of the population reporting 100% 

smokefree rules for homes or vehicles.”

Rationale Home and vehicles remain a significant source of secondhand smoke 

exposure, especially for children.1 Smokefree home and vehicle rules can 

reduce exposure to secondhand smoke among people who do not smoke, 

encourage smoking cessation, prevent relapse, and reduce the social 

acceptability of tobacco use.1,2 Despite program in increasing voluntary 

smokefree home and vehicle rules in the U.S., nonsmoking adults and 

children continue to be exposed to secondhand smoke in these settings.1,3,4 

Applying Studies have found that certain populations, including African American or 

health Black persons, LGBTQ+ persons, persons with low educational attainment, 

disparities and persons with low income are less likely to be protected by voluntary 

framing smokefree home and vehicle rules.5-8 

Example data Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

source(s) 2014-2015 

National Adult Tobacco Survey (NATS), 2013-2014 

Social Climate Survey of Tobacco Control (SCS-TC), 2014 

Example From TUS-CPS (2014-2015) 

survey Which statement best describes the rules about smoking INSIDE YOUR question(s) HOME? 

• No one is allowed to smoke anywhere INSIDE YOUR HOME 

CHAPTER 4 - OUTCOME INDICATORS 105 
 

 

 

 

 

 

 

 

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• Smoking is allowed in some places or at sometimes INSIDE YOUR 

HOME 

• Smoking is permitted anywhere INSIDE YOUR HOME 

From NATS (2013-2014) 

Not counting motorcycles, in the vehicles that you or family members who 

live with you own or lease, is smoking...?

• Always allowed 

• Sometimes allowed in at least one vehicle 

• Never allowed in any vehicle 

• Respondents’ family does not own or lease a vehicle

• Don’t know/Not sure

• Refused 

From SCS-TC (2014) 

Which statement best describes the rules about smoking in your home...?

• No one is allowed to smoke anywhere 

• Smoking is permitted in some places or at some times 

• Smoking is permitted anywhere 

Comments This indicator supports the Healthy People 2030 objective TU-18: Increase 

the proportion of smoke free homes. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. US Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

the Surgeon General. Atlanta, GA: US Department of Health and 

Human Services, Centers for Disease Control and Prevention; 2006. 

2. US Department of Health and Human Services. Preventing tobacco use 

among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 106 
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3. King BA, Dube SR, Homa DM. Smoke-free rules and secondhand 

smoke exposure in homes and vehicles among US adults, 2009-2010. 

Prev Chronic Dis. 2013 May 16;10:E79. 

4. Hopkins DP, Razi S, Leeks KD, Priya Kalra G, Chattopadhyay SK, 

Soler RE. Task force on community preventive services. Am J Prev 

Med. 2010 Feb; 38(2 Suppl):S275-89. 

5. Nguyen KH, Gomez Y, Homa DM, King BA. Tobacco use, secondhand 

smoke, and smoke-free home rules in multiunit housing. Am J Prev 

Med. 2016;51(5):682-92. 

6. Kruger J, Jama A, Homa DM, Babb SD, King BA. Smoke-free home 

and vehicle rules by tobacco use status among US adults. Prev Med. 

2015;78:9–13. 

7. King B, Hyland A, Borland R, McNeill A, Cummings KM. Socioeconomic 

variation in the prevalence, introduction, retention, and removal of 

smoke-free policies among smokers: findings from the International 

Tobacco Control (ITC) Four Country Survey. Int J Environ Res Public 

Health. 2011;8(2):411-34. 

8. Murphy-Hoefer R, Madden P, Maines D, Coles C. Prevalence of 

smoke-free car and home rules in Maine before and after passage of a 

smoke-free vehicle law, 2007–2010. Prev Chronic Dis. 

2014;11:130132. 

CHAPTER 4 - OUTCOME INDICATORS 107 
 

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Tobacco Product Price 

Indicator 

number 

4.2.l 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Average price paid by a consumer for a unit of tobacco product adjusted for 

inflation and including industry discounts and applicable taxes and fees, 

overall, and among population groups experiencing tobacco-related 

disparities 

Proportion of jurisdictions that have an average retail price of at least 

$10.00 for a pack of cigarettes and the proportion of jurisdictions that are 

disproportionately burdened by tobacco product use that have an average 

retail price of at least $10.00 for a pack of cigarettes 

Similar Goal 1 (2014) 1.8.b, “Price paid for tobacco product.”

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.4.f, “Tobacco product price.”

Rationale Increasing the price of tobacco product is one of the most effective 

strategies in reducing tobacco consumption.1-4 Studies have shown that 

increases in the price of tobacco products prevents initiation of tobacco 

use, promotes cessation, and reduces tobacco consumption and 

prevalence overall, and among populations experiencing tobacco-related 

disparities.1-8 Research has shown that increasing the cost of cigarettes to 

$10.00 per pack can substantially decrease tobacco product use, 

particularly among youth and young adults.2 A mechanism to increase the 

price of tobacco products is through excise taxes. However, the tobacco 

industry utilizes tobacco promotions, discounts, and coupons to counteract 

the impact of price increases.8 

Applying Studies show that tobacco promotions, discounts, and coupons occur more 

health frequently among retailers in communities with high proportions of 

disparities racial/ethnic minorities, including African American or Black persons, 

framing Latino/Hispanic persons, and American Indian/Alaska Native persons, as 

well as persons with low education attainment, persons with low income, 

and persons living in the communities in the Southeastern and Midwestern 

U.S. 

9-14 Many of these subgroups, as well as youth, are often more 

responsive to changes in tobacco prices.5-7,14,15 Coupled with cessation 

interventions, price increases can have a strong impact on reducing 

socioeconomic inequalities in smoking.5-7 

Identifying and Eliminating Tobacco-Related Disparities: 

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Example data 

source(s) 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

2018-2019 

Nielsen Store Scanner Tobacco Product Pricing Data 

Example From TUS-CPS (2018-2019) 

survey What price did you pay for the last pack of cigarettes you bought? question(s) 

Please report the cost after using discounts or coupons. 

• Includes dollar amount and cents 

• Don’t know

• Refused 

What price did you pay for the last carton of cigarettes you bought? Please 

report the cost after using discounts or coupons. 

• Includes dollar amount and cents 

• Don’t know

• Refused 

Did you use coupons, rebates, or any other special promotions when you 

bought your last (PACK or CARTON) of cigarettes? 

• Yes 

• No 

• Don’t know

• Refused 

Comments This indicator is best measured by store scanner data or retail observation. 

However, self-reported data captured through population-based surveys 

can provide estimates on changes in price paid for tobacco products. 

Tobacco control programs can consider assessing this indicator by product 

type and across priority jurisdictions and/or communities that are 

disproportionately burdened by tobacco use. Programs may also want to 

examine whether price changes had unintended consequences, such as 

consumers switching to a lower priced tobacco product (if discounts are still 

allowed or there are not laws establishing tax parity among products). 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

CHAPTER 4 - OUTCOME INDICATORS 109 
► 

GOAL AREA 4 

OUTCOME 2 

Atlanta, GA: US Department of Health and Human Services, Centers 

for Disease Control and Prevention, 2012. 

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, 2014. 

3. Centers for Disease Control and Prevention. Best practices for 

comprehensive tobacco control programs— 2014. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease 

Control and Prevention, 2014. 

4. U.S. National Cancer Institute and World Health Organization. The 

economics of tobacco and tobacco control. National Cancer Institute 

Tobacco Control Monograph 21. Bethesda, MD; Geneva, CH: U.S. 

Department of Health and Human Services, National Institutes of 

Health, National Cancer Institute; and World Health Organization, 2016. 

NIH Publication No. 16-CA-8029A. 

5. Hill S, Amos A, Clifford D, Platt S. Impact of tobacco control 

interventions on socioeconomic inequalities in smoking: review of the 

evidence. Tob Control. 2014 Nov;23(e2):e89-97. 

6. Brown T, Platt S, Amos A. Equity impact of interventions and policies to 

reduce smoking in youth: systematic review. Tob Control. 2014 

Nov;23(e2):e98-105. 

7. Centers for Disease Control and Prevention. Best practices user guide: 

health equity in tobacco 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, 2015. 

8. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

9. Moran MB, Heley K, Pierce JP, Niaura R, Strong D, Abrams D. Ethnic 

and socioeconomic disparities in recalled exposure to and self-reported 

impact of tobacco marketing and promotions. Health Commun. 2019 

Mar;34(3):280-289. 

10. Barnoya J, Colditz G, Moreland-Russell S, Cyr J, Snider D, Schootman 

M. Prevalence of cigarette advertising and other promotional strategies 

at the point of sale in St Louis, Missouri: analysis by store type and 

distance from a school. Prev Chronic Dis. 2014 Apr 17;11:E61. 

11. Choi K, Chen JC, Tan ASL, Soneji S, Moran MB. Receipt of tobacco 

direct mail/email discount coupons and trajectories of cigarette smoking 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 110 
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GOAL AREA 4 

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behaviors in a nationally representative longitudinal cohort of US adults. 

Tob Control. 2018 Jun 19;28(3):282-8. 

12. Lempert LK, Glantz SA. Tobacco industry promotional strategies 

targeting American Indians/Alaska Natives and exploiting Tribal 

sovereignty. Nicotine Tob Res. 2019;21(7):940-8. 

13. Richardson A, Ganz O, Vallone D. Tobacco on the web: surveillance 

and characterisation of online tobacco and e-cigarette advertising. Tob 

Control. 2015 Jul;24(4):341-7. 

14. Campaign for Tobacco-Free Kids. 2020. State cigarette excise tax rates 

& rankings. Accessed February 10, 2020. 

https://www.tobaccofreekids.org/assets/factsheets/0097.pdf 

15. Centers for Disease Control and Prevention. STATE System Excise 

Tax Fact Sheet. Accessed March 30, 2020. 

https://www.cdc.gov/statesystem/factsheets/excisetax/ExciseTax.html 

CHAPTER 4 - OUTCOME INDICATORS 111 
 

 

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Minimum Price Policies 

Indicator 

number 

4.2.m 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to Proportion of jurisdictions that have strong minimum price policies 

measure Proportion of jurisdictions that are disproportionately burdened by tobacco 

use that have strong minimum price policies 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.4.d, “Proportion of jurisdictions with strong minimum 

tobacco product price laws.”

Rationale Minimum price policies are associated with higher cigarette prices.1 

Minimum price laws are one way for states and localities to counteract 

tobacco industry strategies to lower tobacco product prices through price 

promotions, discounts, and coupons and undermine efforts to raise the 

price of tobacco products.2,3 Price increases can reduce tobacco use 

overall, prevent initiation of tobacco use, and promote cessation among 

populations experiencing disparities.4-12 

Applying 

health 

disparities 

framing 

Research has shown that minimum price policies can reduce incomebased tobacco-related disparities.12,13 Tobacco industry price promotions, 

discounts, and coupons occur more frequently in communities with high 

proportions of racial/ethnic minorities including African American or Black 

persons, Latino/Hispanic persons, and American Indian/Alaska Native 

persons, as well as persons with low educational attainment and persons 

with low income.14-18 

Example data 

source(s) 

State and/or jurisdiction policy tracking system 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

pertinent tobacco laws, ordinances, or regulations. 

Comments “Strong” laws may include those that prohibit trade discounts from the

minimum price calculation, set a minimum price by mandating a high 

percentage markup for tobacco wholesalers and retailers, and are applied 

to a breadth of tobacco products. Tobacco control programs should 

determine the scope of the policy standards and set an operational 

Identifying and Eliminating Tobacco-Related Disparities: 

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definition of strong minimum tobacco product price laws before evaluating 

the presence/absence and reach of such policies. 

Tobacco control programs should consider assessing this by product type, 

as well as across jurisdictions/communities that are disproportionately 

burdened by tobacco use. When examining this indicator, tobacco control 

programs may want to assess the extent of price promotions, discounts, 

and coupons in the community/jurisdiction with these policies in place to 

better understand their potential impact. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. Huang J, Chriqui JF, DeLong H, Mirza M, Diaz MC, Chaloupka FJ. Do 

state minimum markup/price laws work? Evidence from retail scanner 

data and TUS-CPS. Tob Control. 2016 Oct;25(Suppl 1):i52-9. 

2. Feighery EC, Ribisl KM, Schleicher NC, Zellers L, Wellington N. How 

do minimum cigarette price laws affect cigarette prices at the retail 

level? Tob Control. 2005;14:80–5. 

3. Chaloupka FJ, Cummings KM, Morley CP, Horan JK. Tax, price and 

cigarette smoking: evidence from the tobacco documents and 

implications for tobacco company marketing strategies. Tob Control. 

2002 Mar;11 Suppl 1(Suppl 1):I62-72. 

4. Centers for Disease Control and Prevention. Best practices for 

comprehensive tobacco control programs— 2014. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease 

Control and Prevention, 2014. Department of Health and Human 

Services, Centers for Disease Control and Prevention, 2014. 

5. Garrett BE, Dube SR, Babb S, McAfee T. Addressing the social 

determinants of health to reduce tobacco-related disparities. Nicotine 

Tob Res. 2015;17(8):892–897. 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

7. 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, 2014. 

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8. U.S. National Cancer Institute and World Health Organization. The 

economics of tobacco and tobacco control. National Cancer Institute 

Tobacco Control Monograph 21. Bethesda, MD; Geneva, CH: U.S. 

Department of Health and Human Services, National Institutes of 

Health, National Cancer Institute; and World Health Organization, 2016. 

NIH Publication No. 16-CA-8029A. 

9. Hill S, Amos A, Clifford D, Platt S. Impact of tobacco control 

interventions on socioeconomic inequalities in smoking: review of the 

evidence. Tob Control. 2014 Nov;23(e2):e89-97. 

10. Brown T, Platt S, Amos A. Equity impact of interventions and policies to 

reduce smoking in youth: systematic review. Tob Control. 2014 

Nov;23(e2):e98-105. 

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

use among youth and young adults. Atlanta, GA: US Department of 

Health and Human Services, Centers for Disease Control and 

Prevention, 2012. 

12. Golden SD, Kong AY, Lee JGL, Ribisl KM. Disparities in cigarette tax 

exposure by race, ethnicity, poverty status and sexual orientation, 

2006-2014, USA. Prev Med. 2018 Mar;108:137-44. 

13. Golden SD, Farrelly MC, Luke DA, Ribisl KM. Comparing projected 

impacts of cigarette floor price and excise tax policies on 

socioeconomic disparities in smoking. Tob Control. 2016 Oct;25(Suppl 

1):i60-6. 

14. Moran MB, Heley K, Pierce JP, Niaura R, Strong D, Abrams D. Ethnic 

and socioeconomic disparities in recalled exposure to and self-reported 

impact of tobacco marketing and promotions. Health Commun. 2019 

Mar;34(3):280-9. 

15. Barnoya J, Colditz G, Moreland-Russell S, Cyr J, Snider D, Schootman 

M. Prevalence of cigarette advertising and other promotional strategies 

at the point of sale in St Louis, Missouri: analysis by store type and 

distance from a school. Prev Chronic Dis. 2014 Apr 17;11:E61. 

16. Choi K, Chen JC, Tan ASL, Soneji S, Moran MB. Receipt of tobacco 

direct mail/email discount coupons and trajectories of cigarette smoking 

behaviors in a nationally representative longitudinal cohort of US 

adults. Tob Control. 2018 Jun 19;28(3):282-8. 

17. Lempert LK, Glantz SA. Tobacco industry promotional strategies 

targeting American Indians/Alaska Natives and exploiting Tribal 

sovereignty. Nicotine Tob Res. 2019;21(7):940-8. 

18. Richardson A, Ganz O, Vallone D. Tobacco on the web: surveillance 

and characterisation of online tobacco and e-cigarette advertising. Tob 

Control. 2015 Jul;24(4):341-7. 

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Equitable Enforcement of Tobacco Control Policies 

Indicator 

number 

4.2.n 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 2. Increase equitable adoption, implementation, and enforcement of 

tobacco prevention and control policies 

What to 

measure 

Number and type of commercial or business enforcement actions, 

including warnings, civil penalties, and criminal penalties taken to support 

compliance with tobacco control policies 

Differences in the number and type of commercial or business 

enforcement actions taken to support compliance with tobacco control 

policies across jurisdictions and/or communities and type of retailers 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.3.e, “Number and type of enforcement actions issued for

violations of restrictions on tobacco product availability.”

Goal 1 (2014) 1.4.g, “Number and type of enforcement actions issued for

violations of restrictions on tobacco marketing.”

Rationale While adoption of effective tobacco control policies is important, 

subsequent enforcement and compliance is essential for the policies to be 

successful at achieving intended outcomes. Uneven enforcement of 

tobacco control policies may attenuate the intended effects of the policy 

and may prevent the benefits of these policies from reaching some 

segments of the population, thus creating and/or exacerbating tobaccorelated disparities. An effective means of enforcing tobacco control public 

policies is to conduct regular compliance checks.1,2 

Applying 

health 

disparities 

framing 

Low compliance with tobacco control policies has been documented 

among tobacco retailers located in communities with a high proportion of 

racial/ethnic minorities and persons with low income, which may result in 

those population groups being less likely to benefit from the intended 

effects of the policy.3-6 

Example data 

source(s) 

FDA, Compliance Check Inspection of Tobacco Product Retailers 

Information 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

national, state, and local agencies’ inspection and violation reports. 

Comments Tobacco control programs may want to focus on assessing enforcement 

at the commercial/business level and avoid enforcement activities at the 

individual level as this can have the unintended consequence of 

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exacerbating tobacco-related disparities and/or negatively affecting 

population groups experiencing disparities. 

When assessing differences across jurisdictions and/or communities, 

tobacco control programs may want to examine the community 

composition, such as racial/ethnic characteristics, socioeconomic status, 

and tobacco use prevalence, to assess whether differences in 

enforcement and compliance may be pronounced in communities that are 

disproportionately burdened by tobacco use. 

In addition to assessing enforcement, tobacco control programs can 

consider examining retailer compliance with tobacco control policies and 

changes in compliance over time, as these data can help examine the 

effects of enforcement actions and identify the contextual factors that may 

be moderating the intended impact of the policy. 

Rating Strength 

of Overall quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better 

References 1. Roeseler A, Feighery EC, Cruz TB. Tobacco marketing in California and 

implications for the future. Tob Control. 2010 Apr;19 Suppl 1(Suppl 1):i21-

9. 

2. Institute of Medicine. 2015. Public health implications of raising the 

minimum age of legal access to tobacco products. Washington, DC: The 

National Academies Press. 

3. Lee JG, Landrine H, Torres E, Gregory KR. Inequities in tobacco retailer 

sales to minors by neighbourhood racial/ethnic composition, poverty and 

segregation, USA, 2015. Tob Control. 2016 Dec;25(e2):e142-5. 

4. Lee JG, Baker HM, Ranney LM, Goldstein AO. Neighborhood inequalities 

in retailers' compliance with the Family Smoking Prevention and Tobacco 

Control Act of 2009, January 2014-July 2014. Prev Chronic Dis. 

2015;12:E171. 

5. Lee JGL, Shook-Sa BE, Bowling JM, Ribisl KM. Comparison of sampling 

strategies for tobacco retailer inspections to maximize coverage in 

vulnerable areas and minimize cost. Nicotine Tob Res. 2018 Sep 

25;20(11):1353-8. 

6. U.S. National Cancer Institute. A socioecological approach to addressing 

tobacco-related health disparities. National Cancer Institute Tobacco 

Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: 

U.S. Department of Health and Human Services, National Institutes of 

Health, National Cancer Institute; 2017. 

Identifying and Eliminating Tobacco-Related Disparities: 

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Outcome 3: Increased health systems changes and coverage that 

promote and support cessation in populations experiencing 

tobacco-related disparities 

Health systems changes and clinical protocols to address tobacco use and dependence, 

promote evidence-based treatments for tobacco cessation, and health insurance coverage for 

all evidence-based cessation treatment play a key role in supporting tobacco cessation.1 The 

U.S. Public Health Service’s Clinical Practice Guideline, Treating Tobacco Use and 

Dependence: 2008 Update (hereafter referred to as the Clinical Practice Guideline), 

recommends that clinicians and health care delivery systems consistently identify, document, 

and treat persons who use tobacco by implementing protocols to: (1) ask about tobacco use, 

(2) advise tobacco users to quit, (3) assess willingness to make a quit attempt, (4) assist in quit 

attempt, and (5) arrange for follow-up.1,2 Integration of these guidelines increases the likelihood 

that persons who use a tobacco product will be screened and treated for tobacco use.1 

Approximately 70 percent of people who smoke visit a physician each year, yet over 40 percent 

of adults who smoke do not receive advice to quit from a healthcare provider.1,3 Moreover, 

patient screening and treatment for tobacco use varies by race/ethnicity, educational attainment, 

income level, insurance status, and mental health and substance use disorders (i.e., behavioral 

health conditions).1,4-8 For instance, persons with mental health conditions are less likely to 

receive tobacco use counseling to quit from a health care provider.9 Implementing health 

systems and clinical changes that support cessation in healthcare facilities that serve people 

disproportionally burdened by tobacco use (e.g., behavioral health treatment facilities, federally 

qualified health centers) can increase reach and cessation behaviors among these groups.1 

Additionally, ensuring tobacco-free policies in these facilities creates a supportive environment 

for quitting. 

Beyond implementing health systems and clinical changes, it is important for people who use a 

tobacco product to have access to evidence-based treatment for tobacco cessation. Individual, 

group, and telephone counseling and FDA-approved cessation medications are evidence-based 

treatments that are effective in helping cigarette smokers quit.2 Having comprehensive, barrierfree coverage for these treatments increases access to and use of cessation treatments and 

quit rates among tobacco users.1 However, disparities exist in access to comprehensive 

cessation treatment by level of educational attainment, income level, and insurance status.10-12 

For example, persons with low educational attainment are less likely to have access to 

comprehensive, barrier-free cessation coverage.11 

When assessing indicators under this outcome, tobacco control programs may need to consider 

that some population groups disproportionately affected by tobacco use often encounter barriers 

that limit their ability to access the healthcare they need, such as financial means to pay for 

services and means to reach and physically use services (e.g., lack of transportation). These 

factors are important to consider when evaluating cessation efforts related to health systems 

and insurance coverage changes. 

CHAPTER 4 - OUTCOME INDICATORS 117 
 

 

 

 

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GOAL AREA 4 

OUTCOME 3 

The following indicators are associated with this outcome: 

4.3.a: Healthcare systems that have implemented evidence-based cessation 

guidelines NR 

4.3.b: Disparities in health care professional screening for tobacco use 

4.3.c: Disparities in health care provider advice to quit tobacco use HP 

4.3.d: Disparities in health care professionals’ assistance in quitting tobacco use

4.3.e: Proportion of behavioral health facilities that offer evidence-based cessation 

treatment NR 

4.3.f: Behavioral health facilities with tobacco-free policies 

4.3.g: Disparities in access to comprehensive evidence-based cessation services HP 

NR Denotes an indicator that is not rated. HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

References 

1. U.S. Department of Health and Human Services. Smoking cessation. a report of the 

Surgeon General. Atlanta, GA: 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, 2020. 

2. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. 

Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, 

Public Health Service; May 2008. 

3. Centers for Disease Control and Prevention. National Health Interview Survey. Available at: 

http://www.cdc.gov/nchs/nhis.htm 

4. Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC. Tobacco use screening and 

counseling during physician office visits among adults—National Ambulatory Medical Care 

Survey and National Health Interview Survey, United States, 2005–2009. Morbidity and 

Mortality Weekly Report. 2012 Jun 15;61 Suppl:38–45. 

5. Keith DR, Stanton CA, Gaalema DE, et al. Disparities in US healthcare provider screening 

and advice for cessation across chronic medical conditions and tobacco products. J Gen 

Intern Med. 2017 Sep 1;32(9):974-80. 

6. Kruger J, O’Halloran A, Rosenthal AC, Babb SD, Fiore MC. Receipt of evidence-based brief 

cessation interventions by health professionals and use of cessation assisted treatments 

among current adult cigarette-only smokers: National Adult Tobacco Survey, 2009–2010. 

BMC Public Health. 2016 Dec;16(1):141. 

7. Fortmann SP, Bailey SR, Brooks NB, et al. Trends in smoking documentation rates in safety 

net clinics. Health Serv Res. 2020 Apr;55(2):170-177. 

8. Tran S-TT, Rosenberg KD, Carlson NE. Racial/ethnic disparities in the receipt of smoking 

cessation interventions during prenatal care. Matern Child Health J. 2010;14(6):901-9. 

9. Duffy SA, Kilbourne AM, Austin KL, et al. Risk of smoking and receipt of cessation services 

among veterans with mental disorders. Psychiatr Serv. 2012 Apr 1;63(4):325-32. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 118 
► 

GOAL AREA 4 

OUTCOME 3 

10. DiGiulio A, Jump Z, Babb S, et al. State Medicaid coverage for tobacco cessation treatments 

and barriers to accessing treatments — United States, 2008–2018. MMWR Morb Mortal 

Wkly Rep. 2020;69:155–160. 

11. Zhang L, Babb S, Schauer G, Asman K, Xu X, Malarcher A. Cessation behaviors and 

treatment use among US smokers by insurance status, 2000–2015. Am J Prev Med. 2019 

Oct 1;57(4):478-86. 

12. Land T, Warner D, Paskowsky M, Cammaerts A, Wetherell L, Kaufmann R, Zhang L, 

Malarcher A, Pechacek T, Keithly L. Medicaid coverage for tobacco dependence treatments 

in Massachusetts and associated decreases in smoking prevalence. PLoS One. 2010 Mar 

18;5(3):e9770. 

CHAPTER 4 - OUTCOME INDICATORS 119 
► 

- I 

- I 

- I 

I 

- I 

GOAL AREA 4 

OUTCOME 3 

Increased health system changes and coverage that promote and support 

cessation in populations experiencing tobacco-related disparities 

Indicator Rating 

←○ ◕ ●→ better 

Number Indicator 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted 

Practice 

4.3.a 

Healthcare systems 

that have implemented 

evidence-based 

cessation guidelines NR 

NR NR NR NR NR NR 

4.3.b 

Disparities in health 

care professional 

screening for tobacco 

use 

$$ ● ● ● ●

4.3.c 

Disparities in health 

care provider advice to 

quit tobacco use HP 

$$ ● ● ● ●

4.3.d 

Disparities in health 

care professionals’

assistance in quitting 

tobacco use 

$$ ● ● ● ●

4.3.e 

Proportion of 

behavioral health 

facilities that offer 

evidence-based 

cessation treatment NR 

NR NR NR NR NR NR 

4.3.f 

Behavioral health 

treatment facilities with 

tobacco-free policies 

$$ ● ● ● ●

4.3.g 

Disparities in access to 

comprehensive 

evidence-based 

cessation services HP 

$$ ● ◕ ◕ ●

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 120 
 

► 

GOAL AREA 4 

OUTCOME 3 

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to 

collect and analyze data using the most commonly available data source. The more dollar signs 

(maximum four), the more resources needed. Dollar signs do not represent a specific amount or 

range of costs but are instead a relative measure of expert reviewers’ ratings regarding

resources required to collect and analyze data to measure the indicator. 

NR Denotes an indicator that is not rated. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

CHAPTER 4 - OUTCOME INDICATORS 121 
► 

GOAL AREA 4 

OUTCOME 3 

Healthcare Systems that Have Implemented Evidence-Based Cessation 

Guidelines NR 

Indicator 

number 

4.3.a 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 3. Increased adoption of practices in health care systems to promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of healthcare facilities that have implemented clinical protocols 

consistent with the Clinical Practice Guideline1 to: 1) ask all patients about 

tobacco use, 2) advise patients who use tobacco to quit, 3) assess 

willingness to make a quit attempt, 4) assist in a quit attempt, and 5) 

arrange for follow-up 

Proportion of healthcare facilities that serve population groups experiencing 

tobacco-related disparities that have implemented clinical protocols 

consistent with the Clinical Practice Guideline1 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.3.a, “Proportion of healthcare systems that have fully 

implemented current evidence-based cessation guidelines.” 

Rationale Implementing the Clinical Practice Guideline1 supports integration of 

tobacco dependence treatment into the clinical workflow, and the 

increasing likelihood that health care providers will consistently screen and 

treat patients for tobacco use, thereby increasing rates of cessation.1-3 

Applying Research has shown that integration of cessation interventions remains 

health suboptimal in certain healthcare systems, including mental health and 

disparities substance use disorder treatment facilities. For example, less than half of 

framing mental health and substance use disorder treatment facilities screened for 

tobacco use and offered cessation treatment to patients.4 

Example data 

source(s) 

National Mental Health Services Survey (N-MHSS), 2020 

National Survey of Substance Abuse Treatment Services (N-SSATS), 2020 

Example From N-MHSS (2020) 

survey Which of these services and practices are offered at this facility, at this question(s) location? MARK ALL THAT APPLY 

• Assertive community treatment (ACT) 

• Intensive case management (ICM) 

• Case management (CM) 

• Court-ordered outpatient treatment 

• Chronic disease/illness management (CDM) 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 122 
► 

GOAL AREA 4 

OUTCOME 3 

• Illness management and recovery (IMR) 

• Integrated primary care services 

• Diet and exercise counseling 

• Family psychoeducation 

• Education services 

• Housing services 

• Supported housing 

• Psychosocial rehabilitation services 

• Vocational rehabilitation services 

• Supported employment 

• Therapeutic foster care 

• Legal advocacy 

• Psychiatric emergency walk-in services 

• Suicide prevention services 

• Consumer-run (peer support) services 

• Screening for tobacco use 

• Smoking/tobacco cessation counseling 

• Nicotine replacement therapy 

• Non-nicotine smoking/tobacco cessation medications (by 

prescription) 

• Other (Specify: ____) 

• None of these services and practices are 

From N-SSATS (2020) 

Which of the following services are offered by this facility at this location, 

that is, the location listed on the front cover? MARK ALL THAT APPLY 

Assessment and Pre-Treatment Services 

• Screening for substance abuse 

• Screening for mental disorders 

• Comprehensive substance abuse assessment or diagnosis 

• Comprehensive mental health assessment or diagnosis (for 

example, psychological or 

• psychiatric evaluation and testing) 

• Screening for tobacco use 

• Outreach to persons in the community who may need treatment 

• Interim services for clients when immediate admission is not 

possible 

• Professional interventionist/educational consultant 

• We do not offer any of these assessment and pre-treatment 

services 

Education and Counseling Services 

• HIV or AIDS education, counseling, or support 

CHAPTER 4 - OUTCOME INDICATORS 123 
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GOAL AREA 4 

OUTCOME 3 

• Hepatitis education, counseling, or support 

• Health education other than HIV/AIDS or Hepatitis 

• Substance abuse education 

• Smoking/tobacco cessation counseling 

• Individual counseling 

• Group counseling 

• Family counseling 

• Marital/couples counseling 

• Vocational training or educational support (for example, high school 

coursework, GED preparation, etc.) 

• We do not offer any of these education and counseling services 

Pharmacotherapies 

• Disulfiram (Antabuse®) 

• Naltrexone (oral) 

• Naltrexone (extended-release, injectable, for example, Vivitrol®) 

• Acamprosate (Campral®) 

• Nicotine replacement 

• Non-nicotine smoking/tobacco cessation medications (for 

example, bupropion, varenicline) 

• Medications for psychiatric disorders 

• Methadone 

• Buprenorphine with naloxone 

• Buprenorphine without naloxone 

• Buprenorphine sub-dermal implant (Probuphine®) 

• Buprenorphine (extended-release, injectable, for example, 

Sublocade®) 

• Medications for HIV treatment 

• Medications for Hepatitis C (HCV) treatment 

• Lofexidine 

• Clonidine 

• We do not offer any of these pharmacotherapy services 

Comments Healthcare facilities that serve a large proportion of persons 

disproportionately affected by tobacco use include, but are not limited to, 

the following facilities: 

• Federally Qualified Health Centers 

• Indian Health Service facilities 

• Mental Health Treatment facilities 

• Substance Use Treatment facilities 

• Veterans Health Administration facilities 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 124 
► 

GOAL AREA 4 

OUTCOME 3 

Tobacco control programs can use their state and community level data to 

identify healthcare facilities that serve population groups experiencing 

tobacco-related disparities. Moreover, tobacco control programs may want 

to expand on this indicator by assessing additional healthcare system 

changes consistent with the Million Hearts Tobacco Cessation Change 

5 Package that support cessation. 

Rating Not rated. 

References 1. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: 

U.S. Department of Health and Human Services, Public Health Service; 

May 2008. 

2. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

3. Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, Li W. The effect 

of systematic clinical interventions with cigarette smokers on quit status 

and the rates of smoking-related primary care office visits. PLoS ONE. 

2012;7(7):e41649. 

4. Marynak K, VanFrank B, Tetlow S, Mahoney M, Phillips E, Jamal A, et 

al. Tobacco cessation interventions and smoke-free policies in mental 

health and substance abuse treatment facilities—United States, 2016. 

MMWR Morb Mortal Wkly Rep. 2018;67(18):519-23. 

5. Centers for Disease Control and Prevention. Tobacco cessation 

change package. Atlanta, GA: Centers for Disease Control and 

Prevention, US Department of Health and Human Services; 2020. 

CHAPTER 4 - OUTCOME INDICATORS 125 
 

► 

GOAL AREA 4 

OUTCOME 3 

Disparities in Health Care Provider Screening for Tobacco Use 

Indicator 

number 

4.3.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 3. Increased adoption of practices in health care systems to promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of the population who were asked by a health care professional 

about their tobacco use, overall and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of the population who were asked by a health 

care professional about their tobacco use, by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.3.b, “Proportion of the population that has been asked by 

a health care professional about tobacco use.”

Rationale Asking patients about their tobacco use is a recommendation from the 

Clinical Practice Guideline1 to reduce tobacco use and dependence.1,2 An 

estimated 70 percent of people who smoke visit a physician each year.2 

Evidence shows that when patients are asked about their tobacco use by a 

health care professional and when that response is documented, the rates 

and success of clinician cessation interventions increase.1-3 

Applying Studies have found that certain population groups, including Latino 

health /Hispanic persons and American Indian/Alaska Native persons, persons 

disparities who are underinsured or have public insurance, and persons with mental 

framing health or substance use disorders are less likely to be screened for 

tobacco use by a health care professional.3-8 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

National Health Interview Survey (NHIS), 2017 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2016 

Example From NYTS (2020) 

survey Think about when you have visited a doctor, dentist, or nurse in the past 12 question(s) months. During any of these visits, were you asked if you used any tobacco 

product? 

• I did not see a doctor, dentist, or nurse during the past 12 months 

• Yes 

• No 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 126 
 

► 

GOAL AREA 4 

OUTCOME 3 

Think about when you have visited a doctor, dentist, or nurse in the past 12 

months. During any of these visits, were you asked if you used ecigarettes? 

• I did not see a doctor, dentist, or nurse during the past 12 months 

• Yes 

• No 

From NHIS (2017) 

DURING THE PAST 12 MONTHS, has a doctor or other health 

professional talked to you about your smoking? 

• Yes 

• No 

• Refused 

• Don’t know

From PRAMS (2016) 

During any of your prenatal care visits, did a doctor, nurse, or other health 

care worker ask you any of the things listed below? For each item, check 

No if they did not ask you about it or Yes if they did. 

• Tell me to take a vitamin with folic acid 

• Talk to me about maintaining a healthy weight 

• Talk to me about controlling any medical conditions such as 

diabetes or high blood pressure 

• Talk to me about my desire to have or not have children 

• Talk to me about using birth control to prevent pregnancy 

• Talk to me about how I could improve my health before a 

pregnancy 

• Talk to me about sexually transmitted infections such as chlamydia, 

gonorrhea, or syphilis 

• Ask me if I was smoking cigarettes 

• Ask me if someone was hurting me emotionally or physically 

• Ask me if I was feeling down or depressed 

• Ask me about the kind of work I do 

Comments Tobacco control programs may consider measuring this indicator by 

insurance status, provider specialty, and healthcare facility type, including 

facilities that serve population groups disproportionately affected by 

tobacco use, including, but not limited to: 

• Federally Qualified Health Centers 

• Indian Health Service facilities 

• Mental Health Treatment facilities 

• Substance Use Treatment facilities 

CHAPTER 4 - OUTCOME INDICATORS 127 
► 

- I 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 3 

• Veterans Health Administration facilities 

Tobacco control programs can use their state and community level data to 

identify healthcare facilities that serve population groups experiencing 

tobacco-related disparities. 

Rating 

Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 

2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of 

Health and Human Services, Public Health Service; May 2008. 

2. U.S. Department of Health and Human Services. Smoking cessation. A report 

of the Surgeon General. Atlanta, GA: 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, 2020. 

3. U.S. National Cancer Institute. A socioecological approach to addressing 

tobacco-related health disparities. National Cancer Institute Tobacco Control 

Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: U.S. 

Department of Health and Human Services, National Institutes of Health, 

National Cancer Institute; 2017. 

4. Kruger J, O’Halloran A, Rosenthal AC, Babb SD, Fiore MC. Receipt of 

evidence-based brief cessation interventions by health professionals and use 

of cessation assisted treatments among current adult cigarette-only smokers: 

National Adult Tobacco Survey, 2009–2010. BMC Public Health. 2016 

Dec;16(1):141. 

5. Tran S-TT, Rosenberg KD, Carlson NE. Racial/ethnic disparities in the receipt 

of smoking cessation interventions during prenatal care. Matern Child Health J. 

2010;14(6):901-9. 

6. Keith DR, Stanton CA, Gaalema DE, et al. Disparities in US healthcare 

provider screening and advice for cessation across chronic medical conditions 

and tobacco products. J Gen Intern Med. 2017 Sep 1;32(9):974-80. 

7. Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC. Tobacco use 

screening and counseling during physician office visits among adults—

National ambulatory medical care survey and national health interview survey, 

United States, 2005–2009. MMWR Morb Mortal Wkly Rep. 2012;61(02):38-45. 

8. Fortmann SP, Bailey SR, Brooks NB, et al. Trends in smoking documentation 

rates in safety net clinics. Health Serv Res. 2020 Apr;55(2):170-177. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 128 
 

► 

GOAL AREA 4 

OUTCOME 3 

Disparities in Health Care Provider Advice to Quit Tobacco Use HP 

Indicator 

number 

4.3.c 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 3. Increased adoption of practices in health care systems to promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of people who use tobacco who were advised by a health care 

provider to quit tobacco use, overall, and among population groups 

experiencing tobacco-related disparities 

Differences in the proportion of people who use tobacco who were advised 

by a health care provider to quit tobacco use by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.3.c, “Proportion of tobacco users who have been advised 

to quit tobacco use by a health care professional.”

Rationale Advising patients to quit smoking is a recommendation from Clinical 

Practice Guideline. 

1 Research shows that health care professional advice 

to quit has a positive effect on increasing quit attempts and tobacco 

cessation rates.1-5 However, over 40 percent of adults who smoke do not 

receive advice to quit from a healthcare provider.1 

Applying Studies have shown that certain population groups, including young adults, 

health American Indian/Alaska Native persons, Asian Americans/Pacific Islander 

disparities persons, Latino/Hispanic persons, African American or Black persons, 

framing persons with low educational attainment, persons with low income, persons 

who are uninsured, veterans, and persons residing in the Southern and 

Western geographic areas of the U.S., are less likely to receive advice to 

2,6-13 quit from a health care professional. 

Example data National Youth Tobacco Survey (NYTS), 2020 

source(s) National Health Interview Survey Cancer Control Supplement (NHIS-CCS), 

2015 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

2018-2019 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2016 

Example From NYTS (2020) 

survey Think about when you have visited a doctor, dentist, or nurse in the past 12 question(s) months. During any of these visits, were you given advice not to use any 

tobacco products? 

CHAPTER 4 - OUTCOME INDICATORS 129 
 

► 

GOAL AREA 4 

OUTCOME 3 

• I did not see a doctor, dentist, or nurse during the past 12 months 

• Yes 

• No 

Think about when you have visited a doctor, dentist, or nurse in the past 12 

months. During any of these visits, were you given advice not to use ecigarette? 

• I did not see a doctor, dentist, or nurse during the past 12 months 

• Yes 

• No 

From NHIS-CCS (2015) 

In the past 12 months, has a medical doctor, dentist, or other health 

professional ADVISED you to quit smoking, or to quit using other kinds 

tobacco? 

of 

• Yes 

• No 

• Don’t know

• Refused 

From TUS-CPS (2018-2019) 

During the PAST 12 MONTHS, did any medical doctor ADVISE you to stop 

smoking? 

• Yes 

• No 

From PRAMS (2016) 

During any of your prenatal care visits, did a doctor, nurse, or other health 

care worker advise you to stop smoking? 

• Yes 

• No 

• I had quit smoking before my first prenatal care visit 

Comments Tobacco control programs may consider measuring this indicator by 

insurance status, provider specialty, and healthcare facility type, including 

facilities that serve population groups disproportionately affected by 

tobacco use, including, but not limited to: 

• Federally Qualified Health Centers 

• Indian Health Service facilities 

• Mental Health Treatment facilities 

• Substance Use Treatment facilities 

• Veterans Health Administration facilities 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 130 
 

► 

- I 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 3 

Tobacco control programs can use their state and community level data to 

identify healthcare facilities that serve population groups experiencing 

tobacco-related disparities. 

This indicator is related to Healthy People 2030 objective TU-12: Increase 

the proportion of adults who smoke who get advice to quit from a health 

care provider. 

Rating 

Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: 

U.S. Department of Health and Human Services, Public Health Service; 

May 2008. 

2. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

3. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann‐Boyce J, 

Lancaster T. Physician advice for smoking cessation. Cochrane 

Database Syst Rev. 2013(5):CD000165. 

4. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking 

cessation interventions: a systematic review and meta‐analysis to 

compare advice to quit and offer of assistance. Addiction. 2012 

Jun;107(6):1066-73. 

5. Kruger J, O’Halloran A, Rosenthal AC, Babb SD, Fiore MC. Receipt of

evidence-based brief cessation interventions by health professionals 

and use of cessation assisted treatments among current adult 

cigarette-only smokers: National Adult Tobacco Survey, 2009–2010. 

BMC Public Health. 2016 Dec;16(1):141. 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

CHAPTER 4 - OUTCOME INDICATORS 131 
► 

GOAL AREA 4 

OUTCOME 3 

7. Tan AS, Young-Wolff KC, Carter-Harris L, Salloum RG, Banerjee SC. 

Disparities in the receipt of tobacco treatment counseling within the US 

context of the Affordable Care Act and meaningful use implementation. 

Nicotine Tob Res. 2018 Nov 15;20(12):1474-80. 

8. Landrine H, Corral I, Campbell KM. Racial disparities in healthcare 

provider advice to quit smoking. Prev Med Rep. 2018 Jun 1;10:172-5. 

9. Tran S-TT, Rosenberg KD, Carlson NE. Racial/ethnic disparities in the 

receipt of smoking cessation interventions during prenatal care. Matern 

Child Health J. 2010;14(6):901-9. 

10. Fagan P, Moolchan ET, Lawrence D, Fernander A, Ponder PK. 

Identifying health disparities across the tobacco continuum. Addiction. 

2007;102:5-29. 

11. Hammett PJ, Fu SS, Burgess DJ, et al. Treatment barriers among 

younger and older socioeconomically disadvantaged smokers. Am J 

Manag Care. 2017;23(9):e295-e302. 

12. Duffy SA, Kilbourne AM, Austin KL, et al. Risk of smoking and receipt 

of cessation services among veterans with mental disorders. Psychiatr 

Serv. 2012;63(4):325-32. 

13. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking 

Among Adults — United States, 2000–2015. MMWR Morb Mortal Wkly 

Rep 2017;65:1457–1464. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 132 
 

 

 

 

 

 

► 

GOAL AREA 4 

OUTCOME 3 

Disparities in Health Care Providers’ Assistance in Quitting Tobacco Use 

Indicator 

number 

4.3.d 

Goal area 4. Identity and eliminate tobacco-related disparities 

Outcome 3. Increased health systems changes and coverage that promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of tobacco users who were assisted by a health care provider to 

quit tobacco use, overall and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of tobacco users who were assisted by a 

health care provider to quit, by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.3.e, “Proportion of tobacco users who have been assisted 

in quitting tobacco use by a health care professional.”

Rationale Assisting patients in quitting smoking by offering evidence-based cessation 

treatment is a recommendation from the Clinical Practice Guideline. 

1 There 

is strong evidence that health care professionals’ assistance in cessation

leads to improved quit rates.1-5 

Applying Studies have shown that certain population groups, including young adults 

health and older adults, American Indian/Alaska Native persons, Asian 

disparities American/Pacific Islander persons, Latino/Hispanic persons, African 

framing American or Black persons, non-English speakers, persons with low 

education, persons with low income, persons who are uninsured, Medicaid 

enrollees, persons with mental health conditions, veterans, and persons 

residing in rural areas are less likely to receive assistance to quit from a 

health care professional.6-15 

Example data National Health Interview Survey (NHIS), 2020 

source(s) California Adult Tobacco Survey (CATS), 2018 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2016 

Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers 

and Systems (NAM CAHPS), 2014-2015 

Example From NHIS (2020) 

survey In the past 12 months, has a doctor, dentist, or other health professional question(s) ADVISED you about ways to stop smoking or prescribed medication to 

help you quit? 

• Yes 

• No 

CHAPTER 4 - OUTCOME INDICATORS 133 
 

► 

GOAL AREA 4 

OUTCOME 3 

• Don’t know

• Refused 

From CATS (2018) 

In the last 12 months did your doctor or other health care provider do any 

of the following... 

• Advise you to stop smoking? (Note, this response can be used to 

assess indicator 4.3.c) 

• Suggest that you set a specific date to quit smoking? 

• Prescribe anything to help you to quit smoking? 

• Suggest that you receive any other assistance in quitting? 

• Other assistance (please specify) 

• No assistance 

From PRAMS (2016) 

Listed below are some things about quitting smoking that a doctor, nurse, 

or other health care worker might have done during any of your prenatal 

care visits. For each thing, check No if it was not done or Yes if it was. 

• Spend time with me discussing how to quit smoking 

• Suggest that I set a specific date to stop smoking 

• Suggest I attend a class or program to stop smoking 

• Provide me with booklets, videos, or other materials to help me quit 

smoking on my own 

• Refer me to counseling for help with quitting 

• Ask if a family member or friend would support my decision to quit 

• Refer me to a national or state quitline 

• Recommend using nicotine gum 

• Recommend using a nicotine patch 

• Prescribe a nicotine nasal spray or nicotine inhaler 

• Prescribe a pill like Zyban® (also known as Wellbutrin® or 

Bupropion®) to help me quit 

• Prescribe a pill like Chantix® (also known as Varenicline) to help 

me quit 

From NAM CAHPS (2014-2015) 

In the last 6 months, how often was medication recommended or discussed 

by a doctor or health provider to assist you with quitting smoking or using 

tobacco? 

• Never 

• Sometimes 

• Usually 

• Always 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 134 
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OUTCOME 3 

• Appropriately skipped 

• Multiple mark 

• Missing 

In the last 6 months, how often did your doctor or health provider discuss or 

provide methods and strategies other than medication to assist you with 

quitting smoking or using tobacco? 

• Never 

• Sometimes 

• Usually 

• Always 

• Appropriately skipped 

• Multiple mark 

• Missing 

Comments Tobacco control programs may consider measuring this indicator by 

insurance status, provider specialty, and healthcare facility type, including 

facilities that serve population groups disproportionately affected by 

tobacco use such as: 

• Federally Qualified Health Centers 

• Indian Health Service facilities 

• Mental Health Treatment facilities 

• Substance Use Treatment facilities 

• Veterans Health Administration facilities 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Smoking cessation. A 

report of the surgeon general. Atlanta, GA: 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, 2020. 

2. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking 

cessation interventions: a systematic review and meta‐analysis to compare 

advice to quit and offer of assistance. Addiction. 2012 Jun;107(6):1066-73. 

3. Park ER, Gareen IF, Japuntich S, et al. Primary care provider-delivered 

smoking cessation interventions and smoking cessation among 

participants in the National Lung Screening Trial. JAMA Intern Med. 2015 

Sep 1;175(9):1509-16. 

CHAPTER 4 - OUTCOME INDICATORS 135 
 

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GOAL AREA 4 

OUTCOME 3 

4. Kruger J, O’Halloran A, Rosenthal AC, Babb SD, Fiore MC. Receipt of

evidence-based brief cessation interventions by health professionals and 

use of cessation assisted treatments among current adult cigarette-only 

smokers: National Adult Tobacco Survey, 2009–2010. BMC Public Health. 

2016 Dec;16(1):141. 

5. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; May 

2008. 

6. U.S. National Cancer Institute. A socioecological approach to addressing 

tobacco related health disparities. National Cancer Institute Tobacco 

Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: 

U.S. Department of Health and Human Services, National Institutes of 

Health, National Cancer Institute; 2017. 

7. Vijayaraghavan M, Yuan P, Gregorich S, et al. Disparities in receipt of 5As 

for smoking cessation in diverse primary care and HIV clinics. Pre Med 

Rep. 2017 Jun 1;6:80-7. 

8. Sardana M, Tang Y, Magnani JW, et al. Provider‐level variation in smoking 

cessation assistance provided in the cardiology clinics: insights from the 

NCDR PINNACLE Registry. Journal Am Heart Assoc. 2019 Jul 

2;8(13):e011307. 

9. Gubner NR, Williams DD, Chen E, et al. Recent cessation attempts and 

receipt of cessation services among a diverse primary care population–A 

mixed methods study. Prev Med Rep. 2019 Sep 1;15:100907. 

10. Bailey SR, Heintzman J, Jacob RL, Puro J, Marino M. Disparities in 

smoking cessation assistance in US primary care clinics. American J 

Public Health. 2018 Aug;108(8):1082-90. 

11. Melzer AC, Feemster LC, Collins MP, Au DH. Predictors of 

pharmacotherapy for tobacco use among veterans admitted for COPD: the 

role of disparities and tobacco control processes. J Gen Int Med. 2016 Jun 

1;31(6):623-9. 

12. Tran S-TT, Rosenberg KD, Carlson NE. Racial/ethnic disparities in the 

receipt of smoking cessation interventions during prenatal care. Matern 

Child Health J. 2010;14(6):901-9. 

13. Solberg LI, Parker ED, Foldes SS, Walker PF. Disparities in tobacco 

cessation medication orders and fills among special populations. Nicotine 

Tob Res. 2009;12(2):144-51. 

14. Browning KK, Ferketich AK, Salsberry PJ, Wewers ME. Socioeconomic 

disparity in provider-delivered assistance to quit smoking. Nicotine Tob 

Res. 2008;10(1):55-61. 

15. Duffy SA, Kilbourne AM, Austin KL, et al. Risk of smoking and receipt of 

cessation services among veterans with mental disorders. Psychiatr Serv. 

2012;63(4):325-32. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 136 
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GOAL AREA 4 

OUTCOME 3 

Proportion of Behavioral Health Treatment Facilities that Offer Evidence-Based 

Cessation Treatment NR 

Indicator 

number 

4.3.e 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 3. Increased health systems changes and coverage that promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of mental health treatment facilities that offer evidence-based 

cessation treatment 

Proportion of substance use disorder treatment facilities that offer 

evidence-based cessation treatment 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Many people with mental health conditions and/or substance use disorders 

(i.e., behavioral health conditions) who smoke want to and can quit 

smoking, but may require more intensive treatment to successfully quit.1-5 

Integration of evidence-based cessation treatment into routine clinical 

practice in behavioral health facilities can improve tobacco-related 

outcomes among individuals with mental health and substance use 

disorders.4,7 

Applying 

health 

disparities 

framing 

Persons with mental health conditions and/or substance use disorders are 

more than twice as likely to smoke cigarettes as persons without such 

disorders, and are more likely to die from smoking-related illness than from 

their behavioral health conditions. 

1,3 However, less than half of mental 

health and substance use disorder treatment facilities in the U.S. report 

5 offering evidence-based cessation treatment to patients. 

Example data 

source(s) 

National Mental Health Services Survey (N-MHSS), 2020 

National Survey of Substance Abuse Treatment Services (N-SSATS), 2020 

CHAPTER 4 - OUTCOME INDICATORS 137 
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GOAL AREA 4 

OUTCOME 3 

Example 

survey 

question(s) 

From N-MHSS (2020) 

Which of these services and practices are offered at this facility, at this 

location? MARK ALL THAT APPLY 

• Assertive community treatment (ACT) 

• Intensive case management (ICM) 

• Case management (CM) 

• Court-ordered outpatient treatment 

• Chronic disease/illness management (CDM) 

• Illness management and recovery (IMR) 

• Integrated primary care services 

• Diet and exercise counseling 

• Family psychoeducation 

• Education services 

• Housing services 

• Supported housing 

• Psychosocial rehabilitation services 

• Vocational rehabilitation services 

• Supported employment 

• Therapeutic foster care 

• Legal advocacy 

• Psychiatric emergency walk-in services 

• Suicide prevention services 

• Consumer-run (peer support) services 

• Screening for tobacco use 

• Smoking/tobacco cessation counseling 

• Nicotine replacement therapy 

• Non-nicotine smoking/tobacco cessation medications (by 

prescription) 

• Other (Specify: ____) 

• None of these services and practices are 

From N-SSATS (2020) 

Which of the following services are offered by this facility at this location, 

that is, the location listed on the front cover? MARK ALL THAT APPLY 

Assessment and Pre-Treatment Services 

• Screening for substance abuse 

• Screening for mental disorders 

• Comprehensive substance abuse assessment or diagnosis 

• Comprehensive mental health assessment or diagnosis (for 

example, psychological or 

• psychiatric evaluation and testing) 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 138 
► 

GOAL AREA 4 

OUTCOME 3 

• Screening for tobacco use 

• Outreach to persons in the community who may need treatment 

• Interim services for clients when immediate admission is not 

possible 

• Professional interventionist/educational consultant 

• We do not offer any of these assessment and pre-treatment 

services 

Education and Counseling Services 

• HIV or AIDS education, counseling, or support 

• Hepatitis education, counseling, or support 

• Health education other than HIV/AIDS or Hepatitis 

• Substance abuse education 

• Smoking/tobacco cessation counseling 

• Individual counseling 

• Group counseling 

• Family counseling 

• Marital/couples counseling 

• Vocational training or educational support (for example, high school 

coursework, GED preparation, etc.) 

• We do not offer any of these education and counseling services 

Pharmacotherapies 

• Disulfiram (Antabuse®) 

• Naltrexone (oral) 

• Naltrexone (extended-release, injectable, for example, Vivitrol®) 

• Acamprosate (Campral®) 

• Nicotine replacement 

• Non-nicotine smoking/tobacco cessation medications (for 

example, bupropion, varenicline) 

• Medications for psychiatric disorders 

• Methadone 

• Buprenorphine with naloxone 

• Buprenorphine without naloxone 

• Buprenorphine sub-dermal implant (Probuphine®) 

• Buprenorphine (extended-release, injectable, for example, 

Sublocade®) 

• Medications for HIV treatment 

• Medications for Hepatitis C (HCV) treatment 

• Lofexidine 

• Clonidine 

• We do not offer any of these pharmacotherapy services 

CHAPTER 4 - OUTCOME INDICATORS 139 
 

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GOAL AREA 4 

OUTCOME 3 

Comments Tobacco control programs may want to assess this indicator by facility type 

(i.e., inpatient outpatient, residential). 

Rating Not rated. 

References 1. Prochaska JJ, Das S, Young-Wolff KC. Smoking, mental illness, and 

public health. Annu Rev Public Health 2017;38:165–85. 

2. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco 

Product Use Among Adults — United States, 2019. MMWR Morb 

Mortal Wkly Rep 2020;69:1736–1742. 

3. Centers for Disease Control and Prevention. Vital signs: current 

cigarette smoking among adults aged ≥18 years with mental illness—

United States, 2009–2011. MMWR Morb Mortal Wkly Rep. 

2013;62:81–7. 

4. Compton W. The need to incorporate smoking cessation into 

behavioral health treatment. Am J Addict 2018;27:42–3. 

5. Marynak K, VanFrank B, Tetlow S, et al. Tobacco Cessation 

Interventions and Smoke-Free Policies in Mental Health and Substance 

Abuse Treatment Facilities — United States, 2016. MMWR Morb Mortal 

Wkly Rep. 2018;67:519–523. 

6. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

7. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: 

U.S. Department of Health and Human Services, Public Health Service; 

May 2008. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 140 
 

 

 

 

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GOAL AREA 4 

OUTCOME 3 

Behavioral Health Treatment Facilities with Tobacco-Free Policies 

Indicator 

number 

4.3.f 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 3. Increased health systems changes and coverage that promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of mental health facilities that prohibit smoking in all indoor and 

outdoor locations 

Proportion of substance use disorder treatment facilities that prohibit 

smoking in all indoor and outdoor locations 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Tobacco-free policies prohibiting tobacco use on all grounds of healthcare 

facilities can provide a supportive environment for quitting, prevent 

relapses, and reduce exposure to secondhand smoke.1-3 

Applying Persons with mental health conditions and/or substance use disorders are 

health more than twice as likely to smoke cigarettes as persons without such 

disparities disorders. 

3-4 Creating a supportive, tobacco-free environment in facilities 

framing that serve these population groups can promote and support quitting. 

However, less than half of mental health and substance use disorder 

treatment facilities in the U.S. prohibit smoking in all indoor and outdoor 

locations.5 

Example data National Mental Health Services Survey (N-MHSS), 2020 

source(s) National Survey of Substance Abuse Treatment Services (N-SSATS), 2020 

American Nonsmokers’ Rights (ANR) Foundation, 100% Smokefree U.S.

Hospital Campuses and Psychiatric Facilities, 2019 

Example From N-MHSS (2020) and N-SSATS (2020) 

survey Which of the following statements BEST describes this facility’s smoking question(s) policy for clients? 

• Not permitted to smoke anywhere outside or within any building

• Permitted in designated outdoor area(s) 

• Permitted anywhere outside 

• Permitted in designated indoor area(s) 

• Permitted anywhere inside 

• Permitted anywhere without restriction 

CHAPTER 4 - OUTCOME INDICATORS 141 
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OUTCOME 3 

Comments Tobacco control programs can consider assessing this indicator in other 

healthcare facilities that serve population groups disproportionately 

affected by tobacco use in their state and/or community. Moreover, tobacco 

control programs can consider examining provider support for tobacco 

cessation in behavioral health facilities when assessing this indicator. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Fee E, Brown TM. Hospital smoking bans and their impact. Am J Public 

Health. 2004;94(2):185. 

2. Williams SC, Hafner JM, Morton DJ, Holm AL, Milberger SM, Koss RG, 

et al. The adoption of smoke-free hospital campuses in the United 

States. Tob Control. 2009;18(6):451-8. 

3. Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and 

Public Health. Annu Rev Public Health. 2017;38:165–185. 

4. CDC. Vital signs: current cigarette smoking among adults aged ≥18

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

Mortal Wkly Rep. 2013;62:81–7. 

5. Marynak K, VanFrank B, Tetlow S, Mahoney M, Phillips E, Jamal A, et 

al. Tobacco cessation interventions and smoke-free policies in mental 

health and substance abuse treatment facilities—United States, 2016. 

MMWR Morb Mortal Wkly Rep. 2018;67(18):519-23. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 142 
 

 

 

 

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GOAL AREA 4 

OUTCOME 3 

Disparities in Access to Comprehensive Evidence-Based Cessation Services HP 

Indicator 

number 

4.3.g 

Goal Area 4. Identify and eliminate tobacco-related disparities 

Outcome 3. Increased health systems changes and coverage that promote and 

support cessation in populations experiencing tobacco-related disparities 

What to 

measure 

Proportion of insured population whose public and/or private insurance 

covers all recommended evidence-based cessation treatments, overall, 

and among population groups experiencing tobacco-related disparities 

Differences in insured population whose public and/or private insurance 

covers all recommended evidence-based cessation treatments by 

population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015), 3.2.a “Proportion of the insured population with access to 

comprehensive cessation services.”

Rationale Comprehensive coverage of evidence-based cessation treatments, 

including counseling and medications, increases access to and utilization 

of effective cessation treatment services, as well as successful quit 

attempts.1-3 

Applying Studies have found that certain populations are less likely to have access 

health to comprehensive coverage, including persons with low educational 

disparities attainment, persons with low income, Medicaid enrollees, and persons 

framing who are underemployed or unemployed.4-8 

Example 

data 

source(s) 

National Health Interview Survey (NHIS), 2017 

American Lung Association (ALA), State Cessation Coverage 

Example Adapted from NHIS Access to Health Care and Utilization Questions 

survey (2017) 

question(s) During the PAST 12 MONTHS, was there any time when you needed to 

get any of the following, but didn’t get it because you couldn’t afford it:

(for each, select: Yes, No, Don’t know, or Refused) 

• A nicotine patch? 

• A prescription pill, such as Zyban, Buproprion, or Wellbutrin? 

• A prescription pill called Chantix or Varenicline? 

• A telephone help line or quit line? 

• A stop smoking clinic, class, or support group? 

• One-on-one counseling? 

CHAPTER 4 - OUTCOME INDICATORS 143 
 

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GOAL AREA 4 

OUTCOME 3 

• A nicotine gum or lozenge? 

• A nicotine containing nasal spray or inhaler? 

During the PAST 12 MONTHS, were any of the following true for tobacco 

cessation treatments or prescriptions: (for each, select: Yes, No, Don’t

know, or Refused) 

• You skipped medication doses to save money 

• You took less medicine to save money 

• You delayed filling a prescription to save money 

• You asked your doctor for a lower cost medication to save money 

• You bought prescription drugs from another country to save 

money 

• You used alternative therapies to save money 

Comments Comprehensive cessation services are currently defined as coverage of 

all evidence-based treatments, which includes all FDA-approved 

cessation medications (nicotine replacement therapy (NRT) gum, NRT 

patch, NRT nasal spray, NRT lozenge, NRT inhaler, varenicline, and 

bupropion), group counseling, and individual counseling. Telephone 

counseling is evidence-based as well, but coverage of telephone 

counseling can be more difficult to define. This definition may change 

over time as evidence emerges on new treatments. 

To increase use, coverage of cessation services should be without 

barriers. Health insurance-related barriers include: provisions in coverage 

that pose barriers to accessing cessation treatments, such as copayments, requirements for prior authorization, and limitations on the 

number and duration of treatments, which may reduce use of these 

treatments and therefore reduce cessation.1-2 For additional guidance on 

assessing barriers to cessation coverage, refer to Promoting Quitting 

among Adults and Young People: Outcome Indicators for Comprehensive 

Tobacco Control Programs— 2015, 

6 Indicator 3.2.b, “Proportion of the

insured population without health insurance barriers to accessing 

evidence-based cessation treatments.” 

This indicator is related to Healthy People 2030 objective TU-16: 

Increase Medicaid coverage of evidence-based treatment to help people 

quit using tobacco. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 144 
► 

- I -

-

~ -

I -

$$ ● ◕ ◕ ●

GOAL AREA 4 

OUTCOME 3 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Smoking cessation. 

a report of the Surgeon General. Atlanta, GA: 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, 2020. 

2. Kahende J, Malarcher A, England L, et al. Utilization of smoking 

cessation medication benefits among medicaid fee-for-service 

enrollees 1999-2008. PLoS One. 2017;12(2):e0170381. Published 

2017 Feb 16. doi:10.1371/journal.pone.0170381 

3. Ku L, Brantley E, Bysshe T, Steinmetz E, Bruen BK. How Medicaid 

and Other Public Policies Affect Use of Tobacco Cessation Therapy, 

United States, 2010–2014. Prev Chronic Dis 2016;13:160234 

4. DiGiulio A, Jump Z, Babb S, et al. State Medicaid coverage for 

tobacco cessation treatments and barriers to accessing treatments —

United States, 2008–2018. MMWR Morb Mortal Wkly Rep. 

2020;69:155–160. 

5. Zhang L, Babb S, Schauer G, Asman K, Xu X, Malarcher A. 

Cessation behaviors and treatment use among US smokers by 

insurance status, 2000–2015. Am J Prev Med. 2019 Oct 1;57(4):478-

86. 

6. Land T, Warner D, Paskowsky M, et al. Medicaid coverage for 

tobacco dependence treatments in Massachusetts and associated 

decreases in smoking prevalence. PLoS One. 2010 Mar 

18;5(3):e9770. 

7. Duffy SA, Kilbourne AM, Austin KL, et al. Risk of smoking and receipt 

of cessation services among veterans with mental disorders. 

Psychiatr Serv. 2012 Apr 1;63(4):325-32. 

8. Centers for Disease Control and Prevention. Promoting quitting 

among adults and young people: outcome indicators for 

comprehensive tobacco control programs—2015. Atlanta, GA: 

Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2015. 

CHAPTER 4 - OUTCOME INDICATORS 145 
 

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GOAL AREA 4 

OUTCOME 4 

Outcome 4: Decreased tobacco industry and environmental 

influences that contribute to tobacco-related disparities 

Environmental and community factors have a strong influence on tobacco-related attitudes, 

beliefs, and behaviors.1-7 Features in the environment, such as a high concentration of tobacco 

retailers and exposure to tobacco marketing, promote tobacco use, increase the likelihood of 

initiation and sustained use, and reduce cessation.

1-7 Studies have shown that tobacco retailers 

are often more concentrated in urban, racial/ethnic minority, and low-income communities.1,2,8-10 

Increased density of tobacco retailer stores increases availability and accessibility of tobacco 

products and exposure to point-of-sale marketing and promotions. Moreover, evidence 

demonstrates that the greater the number of tobacco retailers surrounding schools, the more 

likely youth who smoke are to purchase their own cigarettes.5,11 Because of their effect on 

tobacco use, reducing retail tobacco outlets in communities can foster social norms that 

discourage and reduce tobacco use. 

Numerous studies have documented the tobacco industry’s marketing strategies in target

communities with a high proportion of racial/ethnic minorities, persons with low educational 

attainment, and persons with low income.2,6,8-19 These industry marketing tactics have 

contributed to tobacco-related disparities in many populations disproportionally affected by 

tobacco use, including youth, African Americans or Black persons, American Indian/Alaska 

Native persons, and LGBTQ+ persons.2,6,8-19 Point-of-sale tobacco advertising is often more 

prevalent in stores near schools and in minority and low-income neighborhoods.2,4,14,16,20 

Moreover, research has shown that the tobacco industry uses strategic, tailored approaches to 

reach their target audiences through a variety of channels, including through tobacco imagery 

on television, print media (e.g., magazines), point-of-sale advertising, and sponsorship.2,6 For 

example, the tobacco industry advertises in publications and sponsors community events of 

target population groups.2 Evidence also indicates tailored strategies are used to market 

menthol products to urban, low income, and predominantly African American or Black 

communities.17-19 

The tobacco industry also spends billions of dollars each year on marketing, much of which is 

spent on price discounts.21 The industry offers retailers volume discounts, price promotions, instore branded displays, and payment for prime shelf spaces to promote use of tobacco products 

in the retail environment. In return for financial incentives, retailers enter into contractual 

agreements with tobacco companies to ensure high visibility and accessibility of their products 

to stimulate impulse purchases.2,22,23 The tobacco industry also engages in a variety of pricerelated marketing strategies to control prices that are charged to consumers. These strategies 

include distributing coupons via print ads, at the point of sale, and via direct mail, as well as 

offering multipack discounts.2 Strategies to reduce prices are especially appealing to youth and 

persons with low income.2,24 Research has shown that exposure to tobacco product promotions, 

such as tobacco product discounts and promotions, are higher in communities with a high 

proportion of racial/ethnic minorities and persons with low income.

2,16 

Policies and environmental changes that reduce the tobacco industry’s influence can have a 

strong impact on reducing on tobacco use overall, and among populations experiencing 

tobacco-related disparities. Monitoring indicators under this outcome can help determine the 

extent to which tobacco control policies and interventions effect community and environmental 

factors that are known to have a strong influence on tobacco-related disparities. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 146 
► 

GOAL AREA 4 

OUTCOME 4 

While not included in this guide, tobacco control programs may want to assess indicators 

related to social influences (e.g., tobacco product use among peers, living with someone who 

uses a tobacco product) as they have shown to influence tobacco use and affect exposure to 

secondhand smoke.2 Some research has shown that these factors can influence tobaccorelated disparities; however, the evidence is conflicting and seems to vary by population group 

characteristics.2 

The following indicators are associated with this outcome: 

4.4.a: Disparities in density of stores selling tobacco 

4.4.b: Disparities in tobacco product sales to minors 

4.4.c: Disparities in youth and young adult access to tobacco products 

4.4.d: Disparities in the amount and type of retail tobacco advertising 

4.4.e: Disparities in exposure to tobacco marketing HP 

4.4.f: Consumer-focused industry promotions 

4.4.g: Disparities in exposure to tobacco discounts and promotions 

References 

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: 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. 

2. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

3. McCarthy W, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of tobacco retailers near 

schools: effects on tobacco use among students. Am J Public Health. 2009;99(11):2006–13. 

4. Henriksen L, Feighery E, Schleicher N, Cowling D, Kline R, Fortmann S. Is adolescent 

smoking related to the density and proximity of tobacco outlets and retail cigarette 

advertising near schools? Prev Med. 2008;47(2):210–4. 

5. McCarthy W, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of tobacco retailers near 

schools: effects on tobacco use among students. Am J Public Health. 2009;99(11):2006–13. 

6. U.S. National Cancer Institute. The role of the media in promoting and reducing tobacco 

use. Tobacco Control Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. 

Department of Health and Human Services, National Institutes of Health, National Cancer 

Institute; June 2008. 

7. Cantrell J, Anesetti-Rothermel A, Pearson JL, Xiao H, Vallone D, Kirchner TR. The impact of 

the tobacco retail outlet environment on adult cessation and differences by neighborhood 

poverty. Addiction. 2015 Jan;110(1):152-61. 

8. Lee JGL, Sun DL, Schleicher NM, et al. Inequalities in tobacco outlet density by race, 

ethnicity and socioeconomic status, 2012, USA: results from the ASPiRE Study. J Epidemiol 

Community Health 2017;71:487-492. 

CHAPTER 4 - OUTCOME INDICATORS 147 
 

 

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GOAL AREA 4 

OUTCOME 4 

9. Chuang Y, Cubbin C, Ahn D, Winkleby M. Effects of neighbourhood socioeconomic status 

and convenience store concentration on individual level smoking. J Epidemiology 

Community Health. 2005;59(7):568–73. 

10. Fakunle D, Morton CM, Peterson NA. The importance of income in the link between tobacco 

outlet density and demographics at the tract level of analysis in New Jersey. Journal Ethn 

Subst Abuse. 2010;9(4):249–59. 

11. Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail 

cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc Med. 

2007;161(5):440–5. 

12. D’Silva J, O’Gara E, Villaluz NT. Tobacco industry misappropriation of American Indian 

culture and traditional tobacco. Tob Control 2018;27:e57-e64. 

13. Stevens P, Carlson LM, Hinman JM. An analysis of tobacco industry marketing to lesbian, 

gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco 

control and prevention. Health Promot Pract. 2004;5(3)(suppl):129S-134S.ic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 1998. 

14. Cantrell J, Kreslake JM, Ganz O, Pearson JL, Vallone D, Anesetti-Rothermel A, Xiao H, 

Kirchner TR. Marketing little cigars and cigarillos: advertising, price, and associations with 

neighborhood demographics. Am J Public Health. 2013 Oct;103(10):1902-9. 

15. Lempert LK, Glantz SA.Tobacco industry promotional strategies targeting American 

Indians/Alaska Natives and exploiting Tribal sovereignty. Nicotine Tob Res. 2019;21(7):940-8. 

16. Widome R, Brock B, Noble P, Forster JL. The relationship of neighborhood demographic 

characteristics to point-of-sale tobacco advertising and marketing. Ethn Health. 

2013;18(2):136-51. 

17. Cruz TB, Wright LT, Crawford G. The menthol marketing mix: targeted promotions for focus 

communities in the United States. Nicotine Tob Res. 2010;12(Suppl 2):S147-53. 

18. Seidenberg AB, Caughey RW, Rees VW, Connolly GN. Storefront cigarette advertising 

differs by community demographic profile. Am J Health Promot. 2010;24(6):e26-31. 

19. Anderson SJ. Marketing of menthol cigarettes and consumer perceptions: a review of 

tobacco industry documents. Tob Control. 2011;20(Suppl 2):ii20-8. 

20. Henriksen L, Feighery E, Schleicher N, Cowling D, Kline R, Fortmann S. Is adolescent 

smoking related to the density and proximity of tobacco outlets and retail cigarette 

advertising near schools? Prev Med. 2008;47(2):210–4. 

21. Federal Trade Commission. Cigarette Report for 2018. Accessed March 26, 2020. 

https://www.ftc.gov/reports/federal-trade-commission-cigarette-report-2018-smokelesstobacco-report-2018 

22. Loomis BR, Farrelly MC, Mann NH. The association of retail promotions for cigarettes with 

the Master Settlement Agreement, tobacco control programmes and cigarette excise taxes. 

Tob Control. 2006;15(6):458–63. 

23. Robertson L, Cameron C, McGee R, Marsh L, Hoek J. Point-of-sale tobacco promotion and 

youth smoking: a meta-analysis. Tob Control. 2016 Dec;25(e2):e83–9. 

24. White VM, White MM, Freeman K, Gilpin EA, Pierce JP. Cigarette promotional offers who 

takes advantage? Am J Prev Med. 2006;30:225-31. 

Identifying and Eliminating Tobacco-Related Disparities: 

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-I 

-

-

-

GOAL AREA 4 

OUTCOME 4 

Decreased Tobacco Industry and Environmental Influences That Contribute to 

Tobacco-Related Disparities 

Indicator Rating 

←○ ◕ ●→ better 

Number Indicator 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

4.4.a Disparities in density of 

stores selling tobacco $$ ● ● ● ●

4.4.b Disparities in tobacco 

product sales to minors $$ ● ● ● ●

4.4.c Disparities in youth and 

young adult access to 

tobacco products 

$$ ● ● ● ●

4.4.d Disparities in the amount 

and type of retail tobacco 

advertising 

$$ ● ● ● ●

4.4.e Disparities in exposure to 

tobacco marketing HP $$ ● ◕ ● ●

4.4.f Consumer-focused 

industry promotions $$ ● ◕ ◕ ◕

4.4.g Disparities in exposure to 

tobacco discounts and 

promotions 

$$ ● ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data

to measure the indicator. 

CHAPTER 4 - OUTCOME INDICATORS 149 
 

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OUTCOME 4 

Disparities in Density of Stores Selling Tobacco 

Indicator 

number 

4.4.a 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

The number of retailers selling tobacco products within a given geographic 

area or population size, and in jurisdictions and/or communities 

disproportionately burdened by tobacco product use 

Differences in the number of retailers selling tobacco products within a 

given geographic area or population size by community population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.6.a, “Density of stores selling tobacco”

Rationale Research has shown that the density of tobacco retailers influences 

smoking behaviors for youth and adults.1-5 Persons who live in areas with a 

high density of tobacco retailers are at an increased risk for smoking 

initiation, tobacco use, and reduced abstinence.1-6 

Applying 

health 

disparities 

framing 

Studies have found that stores selling tobacco products are more 

concentrated in communities with a high proportion of racial/ethnic 

minorities, including African American or Black persons and 

Latino/Hispanic persons, persons with low educational attainment, and 

1,5-8 persons with low income, as well as in urban communities. 

Example data 

source(s) 

North American Industry Classification Systems (NAICS) 

Example 

survey 

question(s) 

Not applicable. 

Comments Density may be determined by calculating the number of tobacco retailers 

per population or the number of retailers per land area/street segment. The 

most appropriate method should be determined based on the specific 

geographic circumstances. 

This measure is best measured by reviewing tobacco retail licensing data 

and tracking location (e.g., geographic information system information) of 

retail outlets in geographic areas, including which types of tobacco 

Identifying and Eliminating Tobacco-Related Disparities: 

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OUTCOME 4 

products are being sold at the retail outlets and the characteristics of those 

geographic areas. 

The NAICS codes for all businesses likely to sell tobacco products based 

on their primary classification code, including supermarkets and other 

grocery stores, convenience stores, beer/wine/liquor stores, pharmacies 

and drug stores, gas stations with convenience stores, and other gasoline 

stations and tobacco stores. Ideally, this indicator should be based on 

license data rather than NAICS codes and business rights. 

Tobacco control programs may want to assess this indicator across 

jurisdictions and/or communities and among communities 

disproportionately affected by tobacco use to examine the extent to which 

these differences may contribute to tobacco-related disparities. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

2. Henriksen L, Feighery E, Schleicher N, Cowling D, Kline R, Fortmann 

S. Is adolescent smoking related to the density and proximity of 

tobacco outlets and retail cigarette advertising near schools? Prev Med. 

2008;47(2):210–4. 

3. Chuang Y, Cubbin C, Ahn D, Winkleby M. Effects of neighbourhood 

socioeconomic status and convenience store concentration on 

individual level smoking. Journal Epidemiology Community Health. 

2005;59(7):568–73. 

4. McCarthy W, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of 

tobacco retailers near schools: effects on tobacco use among students. 

American J Public Health. 2009;99(11):2006–13. 

5. Cantrell J, Anesetti-Rothermel A, Pearson JL, Xiao H, Vallone D, 

Kirchner TR. The impact of the tobacco retail outlet environment on 

adult cessation and differences by neighborhood poverty. Addiction. 

2015 Jan;110(1):152-61. 

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GOAL AREA 4 

OUTCOME 4 

6. Novak S, Reardon S, Raudenbush S, Buka S. Retail tobacco outlet 

density and youth cigarette smoking: a propensity-modeling approach. 

Am J Public Health 2006;96(4):670–6. 

7. D. Yu, N.A. Peterson, M.A. Sheffer, R.J. Reid, J.E. Schnieder. Tobacco 

outlet density and demographics: analysing the relationships with a 

spatial regression approach. Public Health, 124 (7) (2010), pp. 412-6. 

8. Lee JGL, Sun DL, Schleicher NM, et al. Inequalities in tobacco outlet 

density by race, ethnicity and socioeconomic status, 2012, USA: results 

from the ASPiRE Study. J Epidemiol Community Health 2017;71:487-

92. 

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Disparities in Tobacco Product Sales to Youth and Young Adults 

Indicator 

number 

4.4.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

Proportion of tobacco product retailers who are not in compliance with 

policies prohibiting sales to persons under 21 years of age, overall, and 

among jurisdictions and/or communities with disproportionately high youth 

and young adult tobacco product use and with heavily concentrated youthoriented facilities (e.g., schools) 

Differences in the proportion of tobacco product retailers who are not in 

compliance with policies prohibiting sales to persons under 21 years of age 

by community population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Reducing young people’s ability to purchase tobacco products is an

important component of a comprehensive approach to prevent youth 

smoking.1 The recent increases in youth tobacco use underscores the 

importance of preventing youth access to tobacco products to reduce youth 

experimentation and initiation.2 In 2018, only one in four U.S. youth who 

attempted to buy were refused sale. 

3 Research suggests that pockets of 

retailer noncompliance may contribute to inequities in tobacco retailer 

sales.4 

Applying 

health 

disparities 

framing 

Some evidence suggests that tobacco retailers in communities that share 

certain demographic characteristics, including but not limited to, those with 

high proportions of racial/ethnic minorities, including American 

Indian/Alaska Native persons, Latino/Hispanic persons, and African 

American or Black persons, as well as persons with low income, are more 

likely to sell tobacco products to minors.4-8 

Example data 

source(s) 

FDA, Compliance Check Inspection of Tobacco Product Retailers 

Example 

survey 

question(s) 

Not applicable. This indicator is best measured by tracking and monitoring 

national, state, and local agencies’ inspection and violation reports. 

Comments This indicator may be best measured by examining tobacco retailer 

inspections/compliance data. Tobacco control programs may want to 

CHAPTER 4 - OUTCOME INDICATORS 153 
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OUTCOME 4 

consider assessing the proportion of tobacco retailer inspections resulting 

in underage buy violations by geographic area, demographic 

characteristics, tobacco product type, and retailer type when measuring 

this indicator. 

Programs should distinguish between characteristics of the communities 

where the store is located (e.g., a low income, predominantly African 

American neighborhood) and characteristics of the underage purchaser 

(e.g., an African American or Black teenager). 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Centers for Disease Control and Prevention. Best practices for 

comprehensive tobacco control programs—2014. Atlanta: Centers for 

Disease Control and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 2014. 

2. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product 

use among middle and high school students - United States, 2011-

2018. MMWR Morb Mortal Wkly Rep. 2019;68(6):157–164. 

3. Brown T, Platt S, Amos A. Equity impact of interventions and policies to 

reduce smoking in youth: Systematic review. Tob Control, 2014 23(S1), 

e98–e105. 

4. Liu ST, Snyder K, Tynan MA, Wang TW. Youth access to tobacco 

products in the United States, 2016-2018. Tobacco Regul Sci. 2019 

Nov 1;5(6):491-501. 

5. Lee JG, Landrine H, Torres E, Gregory KR. Inequities in tobacco 

retailer sales to minors by neighbourhood racial/ethnic composition, 

poverty and segregation, USA, 2015. Tob Control. 2016 

Dec;25(e2):e142-e145. 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

7. Lipperman-Kreda, S, Grube JW, Friend KB. Contextual and community 

factors associated with youth access to cigarettes through commercial 

sources. Tob Control. 2014;23(1):39-44. 

8. Widome R, Brock B, Noble P, Forster JL. The relationship of point-ofsale tobacco advertising and neighborhood characteristics to underage 

sales of tobacco. Eval Health Prof. 2012;35(3):331-45. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 154 
 

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GOAL AREA 4 

OUTCOME 4 

Disparities in Youth and Young Adult Access to Tobacco Products 

Indicator 

number 

4.4.c 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

c. Proportion of youth and young adults reporting that they have purchased 

tobacco products from a retailer, overall, and among population groups 

experiencing tobacco-related disparities 

Differences in the proportion of youth and young adults reporting that they 

have purchased tobacco products from a retailer by population group 

characteristics and retailer type 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.6.d, “Proportion of young people reporting that they have

purchased tobacco products from a retailer.”

Rationale Reducing youth access to tobacco products can reduce opportunities for 

experimentation and initiation of tobacco use.1,2 In 2018, only one in four 

U.S. youth who attempted to buy were refused sale.3 Data on access to 

tobacco products by underage persons can provide an indication of retailer 

compliance that can help inform interventions to reduce youth and young 

adult access. 

Applying 

health 

disparities 

framing 

Studies have shown that youth that live in communities with a high 

proportion of racial/ethnic minorities, including American Indian/Alaska 

Native persons, Latino/Hispanic persons, and African American or Black 

persons, were more likely to purchase a tobacco product from a retailer.4-7 

However, one national study found that a higher proportion of non-Hispanic 

White youth reported purchasing their own product at a retailer,3 which 

underscores the need to collect state and community level data to better 

identify state- and community-specific disparities.3 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

CHAPTER 4 - OUTCOME INDICATORS 155 
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GOAL AREA 4 

OUTCOME 4 

Example 

survey 

question(s) 

From NYTS (2020) 

During the past 30 days, where did you get or buy the e-cigarettes that you 

have used? (Select one or more) 

• A gas station or convenience store 

• A grocery store 

• A drugstore 

• A mall or shopping center kiosk/stand 

• On the Internet 

• A vape shop or other store that only sells e-cigarettes 

• Some other place not listed here (specify: _________) 

• From a family member 

• From a friend 

• From some other person that is not a family member or a friend 

During the past 30 days, where did you buy your [tobacco name]? (Select 

one or more) 

• I did not buy this tobacco product during the past 30 days 

• A gas station or convenience store 

• A grocery store 

• A drugstore 

• A vending machine 

• On the Internet 

• Through the mail 

• A vape shop or tobacco shop 

• Some other place not listed here 

(specify):___________________________________ 

During the past 30 days, did anyone ever refuse to sell you cigarettes 

because of your age? 

• I did not try to buy cigarettes in a store during the past 30 days 

• Yes 

• No 

Comments Tobacco control programs may want to assess this indicator by geographic 

area, retailer type, and by type of tobacco product. Moreover, programs 

should consider evaluating youth and young adult purchasing of tobacco 

products from online retailers. 

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OUTCOME 4 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

2. Brown T, Platt S, Amos A. Equity impact of interventions and policies to 

reduce smoking in youth: systematic review. Tob Control, 2014 23(S1), 

e98–e105. 

3. Liu ST, Snyder K, Tynan MA, Wang TW. Youth access to tobacco 

products in the United States, 2016-2018. Tob Regul Sci. 2019 Nov 

1;5(6):491-501. 

4. Landrine H, Corral I, Klonoff EA, et al. Ethnic disparities in youth access 

to tobacco: California statewide results, 1999-2003. Health Promot 

Pract. 2010;11(1):132-9. 

5. Lee JG, Landrine H, Torres E, Gregory KR. Inequities in tobacco 

retailer sales to minors by neighbourhood racial/ethnic composition, 

poverty and segregation, USA, 2015. Tob Control. 2016;25(e2):e142–

e145. 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

7. Lipperman-Kreda, S, Grube JW, Friend KB. Contextual and community 

factors associated with youth access to cigarettes through commercial 

sources. Tob Control. 2014;23(1):39-44. 

CHAPTER 4 - OUTCOME INDICATORS 157 
 

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OUTCOME 4 

Disparities in the Amount and Type of Retail Tobacco Advertising 

Indicator 

number 

4.4.d 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

Amount and type of advertising in retail stores including in store 

promotions, product placement, and product power wall displays across 

jurisdictions and/or communities, and among jurisdictions and/or 

communities disproportionately affected by tobacco use 

Differences in the amount and type of advertising in retail stores including 

in store promotions, product placement, and product power wall displays by 

community population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.7.a, “Extent and type of retail tobacco advertising.”

Rationale There is a causal relationship between exposure to retail tobacco 

advertising and promotion and tobacco initiation, continued use, and fewer 

successful quit attempts.1-4 

Applying 

health 

disparities 

framing 

Numerous studies have shown that communities with a high proportion of 

racial/ethnic minorities, including African American or Black persons and 

Latino/Hispanic persons, and persons with low income, as well as urban 

communities, have a higher concentration of retail stores with tobacco 

advertising and promotions.5-12 Additionally, evidence demonstrates that 

the tobacco industry targets youth through increased advertising in stores 

located near schools.12-15 

Example data 

source(s) 

Environmental scan of tobacco advertising in retail outlets 

Kantar Media database 

Example 

survey 

question(s) 

Not applicable. 

Comments Tobacco control programs may want to consider assessing this indicator by 

retailer type and geographic area. Evaluators may want to consider utilizing 

the standardized tobacco assessments for retail settings (STARS). 

Identifying and Eliminating Tobacco-Related Disparities: 

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Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

2. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal 

study of exposure to retail cigarette advertising and smoking initiation. 

Pediatrics. 2010 Aug;126(2):232–8. 

3. U.S. National Cancer Institute. The role of the media in promoting and 

reducing tobacco use. Tobacco Control Monograph No. 19. NIH 

Publication No. 07-6242. Bethesda, MD: U.S. Department of Health 

and Human Services, National Institutes of Health, National Cancer 

Institute; June 2008. 

4. Pierce JP. Tobacco industry marketing, population-based tobacco 

control and smoking behavior. Am J Prev Med. 2007;33(6 

Suppl):S327–34. 

5. Ribisl KM, D'Angelo H, Feld AL, et al. Disparities in tobacco marketing 

and product availability at the point of sale: Results of a national study. 

Prev Med. 2017 Dec;105:381-388. 

6. Roberts ME, Berman ML, Slater MD, Hinton A, Ferketich AK. Point-ofsale tobacco marketing in rural and urban Ohio: Could the new 

landscape of Tobacco products widen inequalities? Prev Med. 2015 

Dec;81:232-5. 

7. Cantrell J, Kreslake JM, Ganz O, Pearson JL, Vallone D, AnesettiRothermel A, Xiao H, Kirchner TR. Marketing little cigars and cigarillos: 

advertising, price, and associations with neighborhood demographics. 

Am J Public Health. 2013 Oct;103(10):1902-9. 

8. Hosler AS, Done DH, Michaels IH, Guarasi DC, Kammer JR. 

Longitudinal trends in tobacco availability, tobacco advertising, and 

ownership changes of food stores, Albany, New York, 2003-2015. Prev 

Chronic Dis. 2016 May 12;13:E62. 

9. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of 

trends in amount and type of cigarette advertising and sales promotions 

in California stores, 2002–2005. Tob Control. 2008;17(2):93–8. 

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GOAL AREA 4 

OUTCOME 4 

10. Siahpush M, Jones PR, Singh GK, Timsina LR, Martin J. The 

association of tobacco marketing with median income and racial/ethnic 

characteristics of neighbourhoods in Omaha, Nebraska. Tob Control. 

2010;19(3):256-8. 

11. Widome R, Brock B, Noble P, Forster JL. The relationship of 

neighborhood demographic characteristics to point-of-sale tobacco 

advertising and marketing. Ethn Health. 2013;18(2):136-51. 

12. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

13. Barnoya J, Colditz G, Moreland-Russell S, Cyr J, Snider D, Schootman 

M. Prevalence of cigarette advertising and other promotional strategies 

at the point of sale in St Louis, Missouri: analysis by store type and 

distance from a school. Prev Chronic Dis. 2014 Apr 17;11:E61. 

14. Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted 

advertising, promotion, and price for menthol cigarettes in California 

high school neighborhoods. Nicotine Tob Res. 2012 Jan;14(1):116–21. 

15. McCarthy WJ, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of 

tobacco retailers near schools: effects on tobacco use among students. 

Am J Public Health. 2009;99(11):2006-13. 

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OUTCOME 4 

Disparities in Exposure to Tobacco Marketing 

Indicator 

number 

4.4.e 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

Proportion of the population who report exposure to pro-tobacco marketing, 

overall, and among population groups experiencing tobacco-related 

disparities 

Differences in the proportion of the population who report exposure to protobacco marketing by population group characteristics 

\Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale The tobacco industry spends billions of dollars on marketing and promotion 

of tobacco products each year.1-2 Exposure to tobacco product marketing 

increases the likelihood of tobacco use initiation, continued use, and 

3-9 increased consumption, and reduces successful quit attempts. 

Applying The tobacco industry has a history of targeting marketing practices, 

health including advertising, promotions, sponsorships, and contributions to 

disparities elected officials, that have contributed to tobacco-related disparities, 

framing including among youth, African American or Black persons, American 

Indian/Alaska Native persons, Latino/Hispanic persons, LGBTQ+ persons, 

persons with low income, and persons residing in urban communities.10-22 

Example data National Youth Tobacco Survey (NYTS), 2020 

source(s) Population Assessment of Tobacco and Health- Youth Survey (PATH-Y) 

Study, 2016-2017 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A) 

Study, 2016-2017 

Example From NYTS (2020) 

survey When you are using the Internet, how often do you see ads or promotions question(s) for cigarettes, or other tobacco products? 

• I do not use the Internet 

• Never 

• Rarely 

• Sometimes 

• Most of the time 

CHAPTER 4 - OUTCOME INDICATORS 161 
 

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GOAL AREA 4 

OUTCOME 4 

• Always 

When you read newspapers or magazines, how often do you see ads or 

promotions for cigarettes, or other tobacco products? 

• I do not read newspapers or magazines 

• Never 

• Rarely 

• Sometimes 

• Most of the time 

• Always 

When you go to a convenience store, supermarket, or gas station, how 

often do you see ads or promotions for cigarettes, or other tobacco 

products? 

• I never go to a convenience store, supermarket, or gas station 

• Never 

• Rarely 

• Sometimes 

• Most of the time 

• Always 

When you watch TV or streaming services (such as Netflix, Hulu, or 

Amazon Prime), or go to the movies, how often do you see ads or 

promotions for cigarettes or other tobacco products? 

• I do not watch TV or streaming services, or go to the movies 

• Never 

• Rarely 

• Sometimes 

• Most of the time 

• Always 

From PATH-Y (2016-2017) 

In the past 30 days, when you visited convenience stores, small markets, 

or liquor stores, how often did you see ads for cigarettes or other tobacco 

products (not including e-cigarettes or electronic nicotine products)? 

• Never 

• Rarely 

• Sometimes 

• Often 

• Don’t know

• Refused 

From PATH-Y and PATH-A (2016-2017) 

Identifying and Eliminating Tobacco-Related Disparities: 

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GOAL AREA 4 

OUTCOME 4 

In the past 30 days, have you noticed cigarettes or other tobacco products 

(not including e-cigarettes or electronic nicotine products) being advertised 

in any of the following places? Choose all that apply. 

• I haven't seen any advertisements in the past 30 days 

• At gas stations, convenience stores, or other retail stores 

• On billboards 

• In newspapers or magazines 

• On radio 

• On television 

• At events such as fairs, festivals, or sporting events 

• At nightclubs, bars, or music concerts 

• On websites or social media sites 

• Somewhere else (SPECIFY) 

• Don’t know

• Refused 

Comments Tobacco control programs may want to assess the amount and frequency 

of exposure to pro-tobacco marketing when assessing this indicator. 

This indicator supports the Healthy People 2030 objective TU-22: Reduce 

the proportion of adolescents exposed to tobacco marketing. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Federal Trade Commission. Cigarette report for 2018. Accessed March 

26, 2020.https://www.ftc.gov/reports/federal-trade-commissioncigarette-report-2018-smokeless-tobacco-report-2018 

2. Federal Trade Commission. Smokeless tobacco report for 2018. 

Accessed March 26, 2020. https://www.ftc.gov/reports/federal-tradecommission-cigarette-report-2018-smokeless-tobacco-report-2018 

3. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

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GOAL AREA 4 

OUTCOME 4 

4. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal 

study of exposure to retail cigarette advertising and smoking initiation. 

Pediatrics. 2010 Aug;126(2):232–8. 

5. U.S. National Cancer Institute. The role of the media in promoting and 

reducing tobacco use. Tobacco Control Monograph No. 19. NIH 

Publication No. 07-6242. Bethesda, MD: U.S. Department of Health 

and Human Services, National Institutes of Health, National Cancer 

Institute; June 2008. 

6. Pierce JP, Sargent JD, Portnoy DB, et al. Association between 

receptivity to tobacco advertising and progression to tobacco use in 

youth and young adults in the PATH Study. JAMA Pediatr. 2018 

May;172(5):444-451. 

7. Pierce JP. Tobacco industry marketing, population-based tobacco 

control and smoking behavior. Am J Prev Med. 2007;33(6 

Suppl):S327–34. 

8. Robertson L, McGee R, Marsh L, Hoek J. A systematic review on the 

impact of point-of-sale tobacco promotion on smoking. Nicotine Tob 

Res. 2015 Jan;17(1):2-17. 

9. Soneji S, Pierce JP, Choi K, et al. Engagement with online tobacco 

marketing and associations with tobacco product use among U.S. 

youth. J Adolesc Health. 2017 Jul;61(1):61-69. 

10. Moran MB, Heley K, Pierce JP, et al. Ethnic and socioeconomic 

disparities in recalled exposure to and self-reported impact of tobacco 

marketing and promotions. Health Commun. 2019 Mar;34(3):280–9. 

11. D’Silva J, O’Gara E, Villaluz NT. Tobacco industry misappropriation of 

American Indian culture and traditional tobacco. Tob Control. 

2018;27:e57-e64. 

12. Stevens P, Carlson LM, Hinman JM. An analysis of tobacco industry 

marketing to lesbian, gay, bisexual, and transgender (LGBT) 

populations: strategies for mainstream tobacco control and prevention. 

Health Promot Pract. 2004;5(3)(suppl):129S-134S.ic Disease 

Prevention and Health Promotion, Office on Smoking and Health; 1998. 

13. Kong AY, Queen TL, Golden SD, Ribisl KM. Neighborhood disparities 

in the availability, advertising, promotion, and youth appeal of little 

cigars and cigarillos, United States, 2015. Nicotine Tob Res. 2020 Dec 

12;22(12):2170-2177. 

14. Roberts ME, Berman ML, Slater MD, Hinton A, Ferketich AK. Point-ofsale tobacco marketing in rural and urban Ohio: Could the new 

landscape of Tobacco products widen inequalities? Prev Med. 2015 

Dec;81:232-5. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 164 
► 

GOAL AREA 4 

OUTCOME 4 

15. Cantrell J, Kreslake JM, Ganz O, et al. Marketing little cigars and 

cigarillos: advertising, price, and associations with neighborhood 

demographics. Am J Public Health. 2013 Oct;103(10):1902-9. 

16. Hosler AS, Done DH, Michaels IH, Guarasi DC, Kammer JR. 

Longitudinal trends in tobacco availability, tobacco advertising, and 

ownership changes of food stores, Albany, New York, 2003-2015. Prev 

Chronic Dis. 2016 May 12;13:E62. 

17. Lempert LK, Glantz SA. Tobacco industry promotional strategies 

targeting American Indians/Alaska Natives and exploiting Tribal 

sovereignty. Nicotine Tob Res. 2019;21(7):940-8. 

18. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of 

trends in amount and type of cigarette advertising and sales promotions 

in California stores, 2002–2005. Tob Control. 2008;17(2):93–8. 

19. Siahpush M, Jones PR, Singh GK, Timsina LR, Martin J. The 

association of tobacco marketing with median income and racial/ethnic 

characteristics of neighbourhoods in Omaha, Nebraska. Tob Control. 

2010;19(3):256-8. 

20. Widome R, Brock B, Noble P, Forster JL. The relationship of 

neighborhood demographic characteristics to point-of-sale tobacco 

advertising and marketing. Ethn Health. 2013;18(2):136-51. 

21. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

22. 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, 

Hispanics: 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, 1998. 

CHAPTER 4 - OUTCOME INDICATORS 165 
 

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GOAL AREA 4 

OUTCOME 4 

Consumer-Focused Industry Promotions 

Indicator 

number 

4.4.f 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

Level and type of consumer-focused tobacco industry promotions within a 

defined geographic area and among jurisdictions and/or communities 

disproportionately burdened by tobacco use. Consumer-focused 

promotions can include sale price, rebates, coupons, and buy one get one 

free offers. 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.8.c, “Extent and type of consumer-focused industry 

promotions.”

Rationale The tobacco industry uses promotions to counteract the impact of 

advertising restrictions.1-7 Greater availability of promotions lowers the price 

of tobacco and incentivizes increased consumption and sustained use of 

tobacco products.1,7 Discounts and promotions are also associated with 

increased initiation and uptake among youth and decreased quit attempts 

1,7-9 among people who smoke.

Applying 

health 

disparities 

framing 

Price discounts can disproportionately affect racial/ethnic minorities and 

persons with low income, who are more sensitive to price and more likely 

to take advantage of promotional offers.1,7,10 Research shows that price 

promotions contribute to tobacco-related disparities because price-related 

promotions are disproportionately higher at retailers in communities with a 

higher proportion of racial/ethnic minorities, persons with low educational 

attainment, and persons with low income.7,11-14 The tobacco industry has 

used price discounts to increase the menthol cigarette market in 

communities with a high proportion of African American or Black persons 

and persons with low income, as well as in urban communities.7,12,13 

Example data 

source(s) 

Nielsen Store Scanner Tobacco Product Pricing Data 

Example 

survey 

question(s) 

Not applicable. 

Comments Tobacco control programs can track the price of tobacco products using 

retail scanner data that provide information on volume, price, brand, 

product type, package type, and promotions; however, scanner data are 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 166 
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OUTCOME 4 

generally only available for designated market areas that may not 

correspond with state borders. Additionally, scanner data can be costly to 

obtain and complex to analyze. Scanner data are not available for all store 

types. 

States may also use retail observation to capture price information with the 

benefits of flexibility in obtaining unique price data (e.g., advertised prices), 

specific price-promotional strategies, and compliance with certain policies 

such as minimum price law. Suggested variables for retail observation 

include: 

• Tobacco product prices and promotions (sale price, rebates, 

coupons, buy one get one free, bundles, gifts with purchase) 

• Average number of tobacco promotions 

• Percentage of tobacco retailers with promotions 

Evaluators may want to consider utilizing the standardized tobacco 

assessments for retail settings (STARS). 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

2. Loomis BR, Farrelly MC, Mann NH. The association of retail 

promotions for cigarettes with the master settlement agreement, 

tobacco control programs, and cigarette excise taxes. Tob Control. 

2006;15(6):458– 63. 

3. Loomis BR, Farrelly MC, Nonnemaker JM, Mann NH. Point-ofpurchase cigarette promotions before and after the Master Settlement 

Agreement: exploring retail scanner data. Tob Control. 2006;15(2):140–

2. 

4. Bloom PN. Role of slotting fees and trade promotions in shaping how 

tobacco is marketed in retail stores. Tob Control. 2001 Dec;10(4):340–

4. 

5. Feighery EC, Ribisl KM, Schleicher NC, Clark PI. Retailer participation 

in cigarette company incentive programs is related to increased levels 

CHAPTER 4 - OUTCOME INDICATORS 167 
 

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GOAL AREA 4 

OUTCOME 4 

of cigarette advertising and cheaper cigarette prices in stores. Prev 

Med. 2004;38(6):876–84. 

6. Lavack AM, Toth G. Tobacco point-of-purchase promotion: examining 

tobacco industry documents. Tob Control. 2006;15(5):377–84. 

7. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

8. Pierce J. Tobacco industry marketing, population-based tobacco 

control, and smoking behavior. Am J Prev Med. 2007;33(6 

Suppl):S327–4 

9. Slater S, Chaloupka F, Wakefield M, Johnston L, O’Malley P. The 

impact of retail cigarette marketing practices on youth smoking uptake. 

Archives of Pediatrics & Adolescent Medicine. 2007;161(5):440–5. 

10. White VM, White MM, Freeman K, Gilpin EA, Pierce JP. Cigarette 

promotional offers who takes advantage? Am J Prev Med. 

2006;30:225-31. 

11. Roberts ME, Berman ML, Slater MD, Hinton A, Ferketich AK. Point-ofsale tobacco marketing in rural and urban Ohio: Could the new 

landscape of Tobacco products widen inequalities? Prev Med. 2015 

Dec;81:232-5. 

12. Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted 

advertising, promotion, and price for menthol cigarettes in California 

high school neighborhoods. Nicotine Tob Res. 2011;14(1):116-21. 

13. Cruz TB, Wright LT, Crawford G. The menthol marketing mix: targeted 

promotions for focus communities in the United States. Nicotine Tob 

Res. 2010;12(Suppl 2):S147-53.. 

14. Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A 

Systematic review of neighborhood disparities in point-of-sale tobacco 

marketing. Am J Public Health. 2015 Sep;105(9):e8-18. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 168 
 

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GOAL AREA 4 

OUTCOME 4 

Disparities in Exposure to Tobacco Discounts and Promotions 

Indicator 

number 

4.4.g 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 4. Decreased tobacco industry and environmental influences that 

contribute to tobacco-related disparities 

What to 

measure 

Proportion of the population reporting exposure to tobacco discounts and 

promotions, overall, and among population groups experiencing tobaccorelated disparities 

Differences in the proportion of the population reporting exposure to 

tobacco discounts and promotions by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Exposure to tobacco product discounts and promotions can increase the 

likelihood of youth experimentation and promotes increased consumption 

1,2 and sustained use among youth and adults who use tobacco. 

Applying Studies have shown that certain populations, including but not limited to, 

Health youth (<18 years old), non-Hispanic White persons, African American or 

Disparities Black persons, American Indian/Alaska Native persons, LGBTQ+ persons, 

Framing persons with low educational attainment, persons with low income, and 

persons who reside in urban communities experience higher risk of 

exposure to tobacco discounts and promotions.3-11 

Example data 

source(s) 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A), 

2016-2017 

Example From PATH-A (2016-2017) 

survey In the past 12 months, have you received discounts or coupons for any of question(s) the following products? Choose all that apply. 

• Cigarettes 

• E-cigarettes or other electronic nicotine products (including e-liquid) 

• Cigars 

• Shisha or hookah tobacco 

• Snus 

• Other types of smokeless tobacco (such as dip, spit or chew) 

• Some other type of tobacco product 

• None of the above 

• Don’t know

CHAPTER 4 - OUTCOME INDICATORS 169 
 

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OUTCOME 4 

• Refused 

Comments In addition to assessing exposure, tobacco control programs may want to 

expand on this indicator by also examining use of tobacco discounts and 

promotion. Example question from Tobacco Use Supplement to the 

Current Population Survey (2018-2019) is listed below. 

Did you use coupons, rebates, or any other special promotions when you 

bought your LAST (“PACK” or “CARTON”) of cigarettes?

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

2. Siahpush M, Shaikh RA, Hyland A, et al. Point-of-sale cigarette 

marketing, urge to buy cigarettes, and impulse purchases of cigarettes: 

results from a population-based survey. Nicotine Tob Res. 2016 

May;18(5):1357-62. 

3. Moran MB, Heley K, Pierce JP, et al. Ethnic and socioeconomic 

disparities in recalled exposure to and self-reported impact of tobacco 

marketing and promotions. Health Commun. 2019 Mar;34(3):280–9. 

4. Osman A, Queen T, Choi K, Goldstein AO. Receipt of direct tobacco 

mail/email coupons and coupon redemption: demographic and 

socioeconomic disparities among adult smokers in the United States. 

Prev Med. 2019 Sep;126:105778. 

5. White VM, White MM, Freeman K, Gilpin EA, Pierce JP. Cigarette 

promotional offers who takes advantage? Am J Prev Med. 

2006;30:225-31. 

6. Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted 

advertising, promotion, and price for menthol cigarettes in California 

high school neighborhoods. Nicotine & Tobacco Research. 2012 

Jan;14(1):116–21. 

7. Lempert LK, Glantz SA. Tobacco industry promotional strategies 

targeting American Indians/Alaska Natives and exploiting Tribal 

sovereignty. Nicotine Tob Res. 2019;21(7):940-8.. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 170 
► 

GOAL AREA 4 

OUTCOME 4 

8. Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A 

systematic review of neighborhood disparities in point-of-sale tobacco 

marketing. Am J Public Health. 2015 Sep;105(9):e8-18. 

9. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

10. Choi K, Soneji S, Tan ASL. Receipt of tobacco direct mail coupons and 

changes in smoking status in a nationally representative sample of US 

adults. Nicotine Tob Res. 2018;20(9):1095–1100. 

11. Jane Lewis M, Bover Manderski MT, Delnevo CD. Tobacco industry 

direct mail receipt and coupon use among young adult smokers. Prev 

Med. 2015;71:37–39. 

CHAPTER 4 - OUTCOME INDICATORS 171 
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GOAL AREA 4 

OUTCOME 5 

Outcome 5: Increased quit attempts, quit attempts using 

evidence-based cessation services, and successful cessation 

among populations experiencing tobacco-related disparities 

Increasing quit rates among tobacco users decreases tobacco-related diseases and deaths and 

increases healthcare savings.1 While the benefits of quitting are greater the earlier in life that an 

individual quits, quitting smoking benefits people who smoke at any age.2,3 Research has shown 

that most people who smoke want to quit but often need to make several quit attempts before 

successfully quitting.4 While some people can quit smoking without the use of cessation 

services, evidence demonstrates that people who smoke who use evidence-based cessation 

pharmacotherapy with behavioral support are more likely to successfully quit than those quitting 

without these treatments.3,5 Use of individual, group, and telephone counseling, as well as FDAapproved medications, increase quit rates.2-3,5 However, only about a third of people who smoke 

who try to quit use evidence-based cessation services.5 

Disparities exist both in general quit attempts and in quit attempts using evidence-based 

services.3,6-9 Studies have found that older adults, racial/ethnic minorities, persons with low 

income, persons with low educational attainment, persons who are uninsured, and those living 

in rural communities are less likely to make a quit attempt.3,6-9 Similar disparities have been 

documented in the use of evidence-based cessation services to quit smoking.3,6-7,10 These 

disparities may be partly explained by differences in tobacco use behaviors, healthcare access 

and utilization, access to evidence-based cessation treatment, and knowledge of and beliefs 

about available cessation treatment.1-3,11 Moreover, studies have shown that successful 

cessation is lower among racial/ethnic minorities, persons with low educational attainment, 

Medicaid enrollees and persons who are uninsured, and those living in rural communities.3,6-7 

Population groups and characteristics listed under the indicators in this outcome reflect those 

that emerged as having significant disparities in the literature review conducted. Because 

cessation behaviors and factors influencing these behaviors can vary across states and 

communities, tobacco control programs should consider using their state and community-level 

data to identify populations experiencing disparities in this outcome. Additionally, as new 

products enter the market, it is important to monitor whether tobacco users are quitting 

altogether or substituting one type of product for another. 

The following indicators are associated with this outcome: 

4.5.a: Disparities in the intention to quit 

4.5.b: Disparities in quit attempts HP 

4.5.c: Disparities in quit attempts using evidence-based cessation treatment(s) 

4.5.d: Use of quitline services among populations experiencing disparities NR 

4.5.e: Disparities in recent cessation success HP 

4.5.f: Disparities in sustained abstinence from tobacco use 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. NR Denotes an indicator that is not rated. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 172 
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GOAL AREA 4 

OUTCOME 5 

References 

1. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco 

control programs— 2014. Atlanta, GA: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, 2014. 

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, 2014. 

3. U.S. Department of Health and Human Services. Smoking cessation. A report of the 

Surgeon General. Atlanta, GA: 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, 2020. 

4. Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to 

quit smoking successfully in a longitudinal cohort of smokers. BMJ Open 2016;6:e011045. 

5. Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, Whitlock EP. 

Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, 

including pregnant women: a review of reviews for the U.S. Preventive Services Task Force. 

Ann Intern Med. 2015;163(8):608–621. 

6. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults —

United States, 2000–2015. MMWR Morb Mortal Wkly Rep. 2017;65:1457–1464. 

7. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

8. Walton K, Wang TW, Schauer GL, et al. State-specific prevalence of quit attempts among 

adult cigarette smokers — United States, 2011–2017. MMWR Morb Mortal Wkly Rep. 

2019;68:621–626. 

9. Naavaal S, Malarcher A, Xu X, Zhang L, Babb S. Variations in cigarette smoking and quit 

attempts by health insurance among US adults in 41 states and 2 jurisdictions, 2014. Public 

Health Rep. 2018;133(2):191–199. 

10. Babb S, Malarcher A, Asman K, et al. Disparities in cessation behaviors between Hispanic 

and non-Hispanic White adult cigarette smokers in the United States, 2000–2015. Prev 

Chronic Dis 2020;17:190279. 

11. Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. 

Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, 

Public Health Service; May 2008. 

CHAPTER 4 - OUTCOME INDICATORS 173 
 

Indicator Rating 

←○ ◕ ●→ better 

► 

GOAL AREA 4 

OUTCOME 5 

Increased Quit Attempts, Quit Attempts using Evidence-Based Cessation Services, and 

Successful Cessation among Populations Experiencing Tobacco-Related Disparities 

Number Indicator 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

4.5.a Disparities in the intention 

to quit $$ ● ● ● ●

4.5.b Disparities in quit attempts 

HP $$ ● ● ● ●

4.5.c 

Disparities in quit attempts 

using evidence-based 

cessation treatment(s) 

$$ ● ● ● ●

4.5.d 

Use of quitline services 

among populations 

experiencing disparities NR 

NR NR NR NR NR NR 

4.5.e Disparities in recent 

HP cessation success $$ ● ● ● ●

4.5.f 

Disparities in sustained 

abstinence from tobacco 

use 

$$ ● ● ◕ ●

$$ ● ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data

to measure the indicator. 

NR Denotes an indicator that is not rated. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 174 
Indicator 

number 

4.5.a 

Goal area 4. Identify and eliminate disparities 

Outcome 5. Increased quit attempts, quit attempts using evidence-based cessation 

services, and successful cessation among populations experiencing 

tobacco-related disparities 

What to 

measure 

Proportion of tobacco users who intend to stop using tobacco products, 

overall, and among population groups experiencing tobacco-related 

disparities 

Differences in the proportion of tobacco users who intend to stop using 

tobacco products by population group characteristics 

Similar 

existing 

indicator(s) 

Goal 3 (2015) 3.1.d, “Proportion of tobacco users who intend to quit.”

Rationale Intention to quit smoking is an important step in tobacco use cessation; 

research has shown that intention to quit is a predictor of quit attempts and 

1-4 successful quitting.

Applying 

Health 

Disparities 

Framing 

Studies have shown that certain population groups, including older adults, 

certain racial/ethnic groups including American Indian/Alaska Native 

persons, LGBTQ+ persons, persons with low educational attainment, 

persons with low income, persons who are uninsured, and persons residing 

1,5-8 in rural areas are less likely to report interest in quitting smoking.

One study in California found that African American or Black persons were 

less interested in quitting as compared to other racial/ethnic groups; 

conversely, a national study found there was more interest among this 

group as compared to other racial/ethnic groups.6,9 These findings 

underscore the importance of collecting and using state- and communitylevel data to identify and monitor tobacco-related disparities. 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

National Quitline Data Warehouse (NQDW) Intake Survey, 2020 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

2018-2019 

Example 

survey 

question(s) 

From NYTS (2020) 

Are you seriously thinking about quitting the use of all tobacco products? 

• I do not use tobacco products 

• Yes, during the next 30 days 

► 

GOAL AREA 4 

OUTCOME 5 

Disparities in the Intention to Quit 

CHAPTER 4 - OUTCOME INDICATORS 175 
 

 

 

 

 

 

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$$$$ ●● ●● ●● ●●

GOAL AREA 4 

OUTCOME 5 

• Yes, during the next 6 months 

• Yes, during the next 12 months 

• Yes, but not during the next 12 months 

• No, I am not thinking about quitting the use of all tobacco products 

From NQDW Intake Survey (2020) 

Do you intend to quit using [NAME OF TOBACCO PRODUCT] within the 

next 30 days? 

• Yes 

• No 

• Don’t Know

• Refused 

From TUS-CPS (2018-2019) 

Are you seriously considering quitting smoking within the next 6 months? 

• Yes 

• No 

• Don’t know

• Refused 

Are you planning to quit within the next 30 days? 

• Yes 

• No 

• Don’t know

• Refused 

Comments For polytobacco users, it is important to measure quit intentions for all 

tobacco products used because intentions may vary across products. 

Tobacco users may quit one product but continue to use others. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 176 
References 1. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

2. Emery JL, Sutton S, Naughton F. Cognitive and Behavioral Predictors 

of Quit Attempts and Biochemically-Validated Abstinence During 

Pregnancy. Nicotine Tob Res. 2017 May 1;19(5):547-554. 

3. Vangeli E, Stapleton J, Smit ES, Borland R, West R. Predictors of 

attempts to stop smoking and their success in adult general population 

samples: a systematic review. Addiction. 2011;106:2110–2121. 

4. Smit ES, Fidler JA, West R. The role of desire, duty and intention in 

predicting attempts to quit smoking. Addiction. 2011;106(4):844–851. 

5. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

6. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking 

among adults — United States, 2000–2015. MMWR Morb Mortal Wkly 

Rep. 2017;65:1457–1464. 

7. Bennett K, McElroy JA, Johnson AO, Munk N, Everett KD. A persistent 

disparity: smoking in rural sexual and gender minorities. LGBT Health. 

2015 Mar;2(1):62-70. 

8. Reid JL, Hammond D, Boudreau C, Fong GT, Siahpush M; ITC 

Collaboration. Socioeconomic disparities in quit intentions, quit 

attempts, and smoking abstinence among smokers in four western 

countries: findings from the International Tobacco Control Four Country 

Survey. Nicotine Tob Res. 2010;12 Suppl(Suppl 1):S20–S33. 

9. Trinidad DR, Xie B, Fagan P, et al. Disparities in the population 

distribution of African American and non-Hispanic White smokers along 

the quitting continuum. Health Educ Behav. 2015 Dec;42(6):742-51. 

► 

GOAL AREA 4 

OUTCOME 5 

CHAPTER 4 - OUTCOME INDICATORS 177 
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GOAL AREA 4 

OUTCOME 5 

Disparities in Quit Attempts HP 

Indicator 

number 

4.5.b 

Goal area 4. Identify and eliminate disparities 

Outcome 5. Increased quit attempts, quit attempts using evidence-based cessation 

services, and successful cessation among populations experiencing 

tobacco-related disparities 

What to 

measure 

Proportion of tobacco users who have stopped using tobacco for more than 

one day during the previous 12 months in an attempt to quit, overall, and 

among population groups experiencing tobacco-related disparities 

Differences in the proportion of tobacco users who have stopped using 

tobacco for more than one day during the previous 12 months in an attempt 

to quit by population group characteristics 

Similar 

existing 

indicator(s) 

Goal 3 (2015) 3.6.a, “Proportion of tobacco users who have made a quit 

attempt.”

Rationale Attempting to quit is an essential step in tobacco use cessation.1,2 

Increased numbers of quit attempts are associated with increased 

cessation and reduced overall smoking prevalence.1,2 Research has found 

that people who smoke often need to make several quit attempts before 

successfully quitting.2,3 

Applying Studies have shown that certain population groups, including older adults, 

Health non-Hispanic White persons, American Indian/Alaska Native persons, 

Disparities persons with low educational attainment, persons who have public 

Framing insurance, persons who are uninsured, persons with low income, blue 

collar and service workers, and persons residing in rural areas are less 

likely to report a quit attempt.2,4-10 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Behavioral Risk Factor Surveillance System (BRFSS), 2019 

Example 

survey 

question(s) 

From NYTS (2020) 

During the past 12 months, how many times have you stopped smoking 

cigarettes for one day or longer because you were trying to quit smoking 

cigarettes for good? 

• I did not smoke cigarettes during the past 12 months 

• I did not try to quit during the past 12 months 

• 1 time 

• 2 times 

• 3 to 5 times 

• 6 to 9 times 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 178 
 

 

 

 

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GOAL AREA 4 

OUTCOME 5 

• 10 or more times 

During the past 12 months, how many times have you stopped using all 

tobacco products for one day or longer because you were trying to quit all 

tobacco products for good? 

• I did not use tobacco products during the past 12 months 

• I did not try to quit all tobacco products during the past 12 months 

• 1 time 

• 2 times 

• 3 to 5 times 

• 6 to 9 times 

• 10 or more times 

NHIS (2020) 

During the PAST 12 MONTHS, have you stopped smoking for more than 

one day BECAUSE YOU WERE TRYING TO QUIT SMOKING? 

• Yes 

• No 

• Refused 

• Don’t know

(Note: Asked of current smokers) 

How long has it been since you quit smoking cigarettes? 

* Enter number for time since quit smoking, and time period for time since 

quitting (day(s), week(s), month(s), year(s)) 

(Note: Asked of former smokers, include former smokers who quit in the 

past year in measure) 

From BRFSS (2019) 

During the past 12 months, have you stopped smoking for one day or 

longer because you were trying to quit smoking? 

• Yes 

• No 

• Don’t know / Not sure

• Refused 

Comments When considering population quit rates, it is important to understand both 

the number of tobacco users who made a quit attempt and the number of 

times they made a quit attempt. Tobacco control programs can also 

consider the population quit rate, which is driven by two factors: prevalence 

of quit attempts, and prevalence of successful quitting among people who 

smoke who make a quit attempt. 

CHAPTER 4 - OUTCOME INDICATORS 179 
► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 5 

This indicator is related to Healthy People 2030 objective TU-11: Increase 

past-year attempts to quit smoking in adults. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. 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, 2014. 

2. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

3. Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit 

attempts it takes to quit smoking successfully in a longitudinal cohort of 

smokers. BMJ Open. 2016;6(6):e011045. 

4. Alexander LA, Crawford T, Mendiondo MS. Occupational status, worksite cessation programs and policies and menthol smoking on quitting 

behaviors of US smokers. Addiction. 2010;105 Suppl 1:95-104. 

5. Reid JL, Hammond D, Boudreau C, Fong GT, Siahpush M; ITC 

Collaboration. Socioeconomic disparities in quit intentions, quit 

attempts, and smoking abstinence among smokers in four western 

countries: findings from the International Tobacco Control Four Country 

Survey. Nicotine Tob Res. 2010;12 Suppl(Suppl 1):S20–S33. 

6. Naavaal S, Malarcher A, Xu X, Zhang L, Babb S. Variations in cigarette 

smoking and quit attempts by health insurance among US adults in 41 

states and 2 jurisdictions, 2014. Public Health Rep. 

2018;Mar/Apr;133(2):191-9. 

7. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

8. Babb S, Malarcher A, Asman K, et al. Disparities in cessation behaviors 

between Hispanic and non-Hispanic White adult cigarette smokers in 

the United States, 2000-2015. Prev Chronic Dis. 2020;17:E10. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 180 
► 

GOAL AREA 4 

OUTCOME 5 

9. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking 

Among Adults — United States, 2000–2015. MMWR Morb Mortal Wkly 

Rep 2017;65:1457–1464. 

10. Trinidad DR, Pérez-Stable EJ, White MM, Emery SL, Messer K. A 

nationwide analysis of US racial/ethnic disparities in smoking 

behaviors, smoking cessation, and cessation-related factors. Am J 

Public Health. 2011;101(4):699–706. 

CHAPTER 4 - OUTCOME INDICATORS 181 
 

► 

GOAL AREA 4 

OUTCOME 5 

Disparities in Quit Attempts Using Evidence-Based Cessation Treatment(s) 

Indicator 

number 

4.5.c 

Goal area 4. Identify and eliminate disparities 

Outcome 5. Increased quit attempts, quit attempts using evidence-based cessation 

services, and successful cessation among populations experiencing 

tobacco-related disparities 

What to 

measure 

Proportion of tobacco users who have stopped using tobacco for more than 

one day during the previous 12 months using an evidence-based method* 

for their quit attempt, overall, and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of tobacco users who have stopped using 

tobacco for more than one day during the previous 12 months using an 

evidence-based method* for their quit attempt by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.5.b, “Proportion of tobacco users who have made a quit

attempt using evidence-based strategies.”

Rationale Research demonstrates that people who smoke who use evidence-based 

cessation pharmacotherapy with behavioral support are more likely to 

successfully quit than those attempting to quit without these treatments.1,2 

Use of individual, group, and telephone counseling, as well as FDAapproved medications, increases quit rates.1-3 However, only about a third 

of people who try to quit use evidence-based cessation services.4 

Applying Studies have found that using evidence-based cessation services is 

health particularly low among certain population groups, including young adults, 

disparities racial/ethnic minorities, including Latino/Hispanic persons and Asian 

framing American/Pacific Islander persons, LGBTQ+ persons, persons with low 

educational attainment, persons with low income, persons who are 

uninsured, persons who are unemployed, and persons residing in rural 

1,4-8 areas. 

Example data Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

source(s) 2018-2019 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A), 

2016-2017 

National Health Interview Survey Cancer Control Supplement (NHIS-CCS), 

2015 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 182 
 

 

 

 

 

 

► 

GOAL AREA 4 

OUTCOME 5 

Example 

survey 

question(s) 

From TUS-CPS (2018-2019) 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the 

past 12 months: Did you use ANY of the following PRODUCTS: Yes/No 

• A NICOTINE.... patch, gum, lozenge, nasal spray or inhaler

• A prescription pill, called Chantix, Varenicline, Zyban, Bupropion,or 

Wellbutrin? 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the 

past 12 months: Did you use ANY of the following: Yes/No 

• A telephone help line or quit line? 

• One-on-one IN-PERSON counseling by a health professional? 

• A stop smoking clinic, class, or support group? 

• Internet or web-based program or tool including smartphone apps 

and text messaging programs? 

From PATH-A (2016-2017) 

Thinking back to [the time you tried to quit/the last time you tried to 

quit/when you quit] [tobacco product] in the past 12 months, did you use 

any of the following to help you: counseling, a telephone help line or quit 

line, books, pamphlets, videos, a quit tobacco clinic, class, or support 

group, or an internet or web-based program? 

• Yes 

• No 

• Don’t know 

• Refused 

Thinking back to [the time you tried to quit/the last time you tried to 

quit/when you quit] [tobacco product] in the past 12 months, did you use a 

nicotine patch, gum, inhaler, nasal spray, lozenge or pill? 

• Yes 

• No 

• Don’t know

• Refused 

Thinking back to [the time you tried to quit/the last time you tried to 

quit/when you quit] [tobacco product] in the past 12 months, did you use 

Chantix, varenicline, Wellbutrin, Zyban, or bupropion? 

• Yes 

• No 

• Don’t know

• Refused 

CHAPTER 4 - OUTCOME INDICATORS 183 
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$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 5 

From NHIS-CCS (2015) 

Thinking back to when you tried to QUIT smoking in the PAST 12 

MONTHS, did you use ANY of the following PRODUCTS: (for each, select: 

Yes, No, Don’t know, or Refused) 

• A nicotine patch? 

• A prescription pill, such as Zyban, Buproprion, or Wellbutrin? 

• A prescription pill called Chantix or Varenicline? 

• A telephone help line or quit line? 

• A stop smoking clinic, class, or support group? 

• One-on-one counseling? 

• A nicotine gum or lozenge? 

• A nicotine containing nasal spray or inhaler? 

(Note: asked of current smokers who tried to quit for more than one day 

during the past 12 months) 

Thinking back to when you stopped smoking completely, did you use ANY 

of the following PRODUCTS: (for each, select: Yes, No, Don’t know, or 

Refused) 

• A nicotine patch? 

• A prescription pill, such as Zyban, Buproprion, or Wellbutrin? 

• A prescription pill called Chantix or Varenicline? 

• A telephone help line or quit line? 

• A stop smoking clinic, class, or support group? 

• One-on-one counseling? 

• A nicotine gum or lozenge? 

• A nicotine containing nasal spray or inhaler? 

(Note: asked of former smokers who quit in the last two years) 

Comments *Evidence-based treatment includes use of FDA-approved cessation 

medications (nicotine replacement therapy (NRT) gum, NRT patch, NRT 

nasal spray, NRT lozenge, NRT inhaler, varenicline, bupropion), and/or 

counseling (group, individual, and telephone-based). This definition may 

change over time as evidence emerges on new treatments. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 184 
► 

GOAL AREA 4 

OUTCOME 5 

References 1. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

2. Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, 

Whitlock EP. Behavioral counseling and pharmacotherapy interventions 

for tobacco cessation in adults, including pregnant women: a review of 

reviews for the U.S. Preventive Services Task Force. Ann Intern Med. 

2015;163(8):608–621. 

3. 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, 2014. 

4. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking 

among adults — United States, 2000–2015. MMWR Morb Mortal Wkly 

Rep. 2017;65:1457–1464. 

5. Babb S, Malarcher A, Asman K, et al. Disparities in cessation behaviors 

between Hispanic and non-Hispanic White adult cigarette smokers in 

the United States, 2000–2015. Prev Chronic Dis 2020;17:190279. 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

7. Margerison-Zilko C, Cubbin C. Socioeconomic disparities in tobaccorelated health outcomes across racial/ethnic groups in the United 

States: National Health Interview Survey 2010. Nicotine Tob Res. 2013 

Jun;15(6):1161-5. 

8. Levinson AH, Hood N, Mahajan R, Russ R. Smoking cessation 

treatment preferences, intentions, and behaviors among a large sample 

of Colorado gay, lesbian, bisexual, and transgendered smokers. 

Nicotine Tob Res. 2012;14(8):910–918. 

CHAPTER 4 - OUTCOME INDICATORS 185 
► 

GOAL AREA 4 

OUTCOME 5 

Use of Quitline Services among Populations Experiencing Disparities NR 

Indicator 

number 

4.5.d 

Goal area 4. Identify and eliminate disparities 

Outcome 5. Increased quit attempts, quit attempts using evidence-based cessation 

services, and successful cessation among populations experiencing 

tobacco-related disparities 

What to 

measure 

Proportion of tobacco users who received a quitline service, overall, and 

among population groups experiencing tobacco-related disparities 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Quitlines are an important resource for linking tobacco users with evidencebased cessation services. Quitlines increase quit rates, have broad reach, 

and are effective with diverse populations.1,2 Residents in all 50 U.S. states, 

the District of Columbia, the commonwealth of Puerto Rico, and the territory 

of Guam have access to Quitline services.1,2 Moreover, because quitlines 

connect tobacco users to free evidence-based cessation services, they can 

be beneficial in supporting cessation among low income, uninsured, and 

1,2 underinsured tobacco users. 

Applying 

health 

disparities 

framing 

While quitlines are reaching populations experiencing tobacco-related 

disparities, overall reach remains low and differences by population 

characteristics. 

3 For example, some studies have found that quitline use is 

particularly lower among younger and older adults, American Indian/Alaska 

1,2,4 Native persons and Asian American/Pacific Islander persons 

Example data 

source(s) 

National Quitline Data Warehouse (NQDW), Quitline Intake Survey, 2020 

CDC State Tobacco Activities Tracking and Evaluation (STATE) System 

Example 

survey 

question(s) 

Not applicable. 

Comments When calculating the proportion or reach ratio of tobacco users receiving 

quitline services, tobacco control programs should assess the unique 

number of tobacco users receiving quitline services divided by the total 

estimated number of tobacco users in the state. Tobacco control programs 

should consider examining the reach of quitline services overall and by 

population group characteristics. 

Rating Not rated. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 186 
► 

GOAL AREA 4 

OUTCOME 5 

References 1. Baezconde-Garbanati L, Guy MC, Soto C; North American Quitline 

Consortium. The use of quitlines among priority populations in the U.S.: 

lessons from the scientific evidence. 2011. Accessed March 23, 2020. 

http://c.ymcdn.com/sites/www.naquitline.org/resource/resmgr/Issue_Pap 

ers/IssuePaperTheUseofQuitlinesA.pdf 

2. U.S. Department of Health and Human Services. Smoking cessation. a 

report of the Surgeon General. Atlanta, GA: 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, 2020. 

3. Schauer GL, Malarcher AM, Zhang L, Engstrom MC, Zhu SH. 

Prevalence and correlates of quitline awareness and utilization in the 

United States: an update from the 2009–2010 National Adult Tobacco 

Survey. Nicotine Tob Res. 2014 May 1;16(5):544-53. 

4. Marshall LL, Zhang L, Malarcher AM, Mann NH, King BA, Alexander RL. 

Race/ethnic variations in quitline use among US adult tobacco users in 

45 states, 2011-2013. Nicotine Tob Res. 2017;19(12):1473-81. 

CHAPTER 4 - OUTCOME INDICATORS 187 
 

 

► 

GOAL AREA 4 

OUTCOME 5 

Disparities in Recent Cessation Success HP 

Indicator 

number 

4.5.e 

Goal area 4. Identify and eliminate disparities 

Outcome 5. Increased quit attempts, quit attempts using evidence-based cessation 

services, and successful cessation among populations experiencing 

tobacco-related disparities 

What to 

measure 

Proportion of former tobacco users who last used tobacco 6 months to one 

year ago among those who quit in the past year, overall, and among 

population groups experiencing tobacco-related disparities 

Differences in the proportion of former tobacco users who last used 

tobacco 6 months to one year ago among those who quit in the past year 

by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.7.a, “Proportion of tobacco users who have sustained 

abstinence from tobacco use.”

Rationale Increasing tobacco quit rates will decrease tobacco-related morbidity and 

mortality.1 Recent cessation can help assess progress toward permanent 

tobacco cessation and can serve as a more proximate measures of the 

impact of public health interventions. 

Applying 

health 

disparities 

framing 

Although the frequency of quit attempts is greater among African American 

or Black persons than non-Hispanic White persons, they experience less 

success in cessation. Moreover, older adults, persons with low income, 

persons with low educational attainment, and persons with mental health 

2-6 conditions are also less likely to report recent cessation success. 

Example data 

source(s) 

National Health Interview Survey (NHIS), 2020 

Behavioral Risk Factor Surveillance System (BRFSS), 2019 

Example 

survey 

question(s) 

From NHIS (2020) 

How long has it been since you quit smoking cigarettes? 

* Enter number for time since quit smoking, and time period for time since 

quitting (day(s), week(s), month(s), year(s)) 

(Note: Asked of former smokers, include former smokers who quit in the 

past year in measure) 

From BRFSS (2019) 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 188 
 

► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 5 

How long has it been since you last smoked a cigarette, even one or two 

puffs? 

• Within the past month (less than 1 month ago) 

• Within the past 3 months (1 month but less than 3 months ago) 

• Within the past 6 months (3 months but less than 6 months ago) 

• Within the past year (6 months but less than 1 year ago) 

• Within the past 5 years (1 year but less than 5 years ago) 

• Within the past 10 years (5 years but less than 10 years ago) 

• 10 years or more 

• Never smoked regularly 

• DON’T KNOW/NOT SURE

• REFUSED 

Comments Evaluators could modify the example questions to measure sustained 

abstinence from all tobacco products and ask current people who use a 

tobacco product about their last quit attempt or longest quit. 

This indicator is related to the follow Healthy People 2030 objective TU14: Increase successful quit attempts in adults who smoke 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Institute of Medicine. 2007. Ending the tobacco problem: A blueprint for 

the nation. Washington, DC: The National Academies Press. 

2. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking 

Among Adults - United States, 2000-2015. MMWR Morb Mortal Wkly 

Rep. 2017 Jan 6;65(52):1457-1464. 

3. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the 

US population. Tob Control. 2014;23(e2):e147-e53. 

4. Fagan P, Shavers VL, Lawrence D, Gibson JT, O'Connell ME. 

Employment characteristics and socioeconomic factors associated with 

disparities in smoking abstinence and former smoking among US 

workers. J Health Care Poor Underserved. 2007 Nov;18(4 Suppl):52-

72. 

5. Varghese M, Sheffer C, Stitzer M, Landes R, Brackman SL, Munn T. 

Socioeconomic disparities in telephone-based treatment of tobacco 

dependence. Am J Public Health. 2014;104(8):e76-e84. 

CHAPTER 4 - OUTCOME INDICATORS 189 
► 

GOAL AREA 4 

OUTCOME 5 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 190 
 

 

 

 

► 

GOAL AREA 4 

OUTCOME 5 

Disparities in Sustained Abstinence from Tobacco Use 

Indicator 

number 

4.5.f 

Goal area 4. Identify and eliminate disparities

Outcome 5. Increased quit attempts, quit attempts using evidence-based cessation

services, and successful cessation among populations experiencing

tobacco-related disparities

What to 

measure 

Proportion of former tobacco users who have sustained abstinence from 

tobacco use for 6 months or longer, overall, and among population groups 

experiencing tobacco-related disparities 

Differences in the proportion of former tobacco users who have sustained 

abstinence from tobacco use for 6 months or longer by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 3 (2015) 3.7.b, “Proportion of tobacco users who have sustained 

abstinence from tobacco use.”

Rationale The longer a person has gone without using a tobacco product, the more 

likely they are to remain abstinent.1 Sustained abstinence is an important 

measure to assess progress toward permanent tobacco cessation and 

reducing tobacco use. 

Applying Studies have found that certain population groups, including non-Hispanic 

health African American or Black persons, persons with low educational 

disparities attainment, persons with low income, Medicaid enrollees, persons with 

framing mental health conditions, and persons who are unemployed are less likely 

to report sustained abstinence from tobacco.2-6 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Behavioral Risk Factor Surveillance System (BRFSS), 2019 

Example 

survey 

question(s) 

From NYTS (2020) 

When was the last time you smoked a cigarette, even one or two puffs? 

• I have never smoked cigarettes, even one or two puffs

• Earlier today

• Not today but sometime during the past 7 days

• Not during the past 7 days but sometime during the past 30 days

• Not during the past 30 days but sometime during the past 6 months

• Not during the past 6 months but sometime during the past year

• 1 to 4 years ago

• 5 or more years ago

CHAPTER 4 - OUTCOME INDICATORS 191 
 

$$ ● ● ● ●

► 

GOAL AREA 4 

OUTCOME 5 

When was the last time you used an e-cigarette, even one or two times? 

• I have never smoked cigarettes, even one or two puffs

• Earlier today

• Not today but sometime during the past 7 days

• Not during the past 7 days but sometime during the past 30 days

• Not during the past 30 days but sometime during the past 6 months

• Not during the past 6 months but sometime during the past year

• 1 to 4 years ago

• 5 or more years ago

From BRFSS (2019) 

How long has it been since you last smoked a cigarette, even one or two 

puffs? 

• Within the past month (less than 1 month ago)

• Within the past 3 months (1 month but less than 3 months ago)

• Within the past 6 months (3 months but less than 6 months ago)

• Within the past year (6 months but less than 1 year ago)

• Within the past 5 years (1 year but less than 5 years ago)

• Within the past 10 years (5 years but less than 10 years ago)

• 10 years or more

• Never smoked regularly

• DON’T KNOW/NOT SURE

• REFUSED

Comments Evaluators could modify the example questions to measure sustained 

abstinence from all tobacco products and ask current people who use a 

tobacco product about their last quit attempt or longest quit. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better

References 1. U.S. Department of Health and Human Services. Smoking cessation. a

report of the Surgeon General. Atlanta, GA: 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, 2020.

2. U.S. National Cancer Institute. A socioecological approach to

addressing tobacco-related health disparities. National Cancer Institute

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 192 
► 

GOAL AREA 4 

OUTCOME 5 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

3. Kendzor DE, Reitzel LR, Mazas CA, et al. Individual-and area-level

unemployment influence smoking cessation among African Americans

participating in a randomized clinical trial. Soc Sci Med. 2012

May;74(9):1394-401.

4. Fagan P, Shavers VL, Lawrence D, Gibson JT, O'Connell ME.

Employment characteristics and socioeconomic factors associated with

disparities in smoking abstinence and former smoking among US

workers. J Health Care Poor Underserved. 2007 Nov;18(4 Suppl):52-

72.

5. Varghese M, Sheffer C, Stitzer M, Landes R, Brackman SL, Munn T.

Socioeconomic disparities in telephone-based treatment of tobacco

dependence. Am J Public Health. 2014 Aug;104(8):e76-84.

6. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the

US population. Tob Control. 2014;23(e2):e147-e53.

CHAPTER 4 - OUTCOME INDICATORS 193 
► 

GOAL AREA 4 

OUTCOME 6 

Outcome 6: Eliminate disparities in tobacco use initiation 

Tobacco use and nicotine dependence begins primarily in adolescence and young adulthood.1 

Nearly 90 percent of adults who smoke daily begin smoking cigarettes before the age of 18.1 

Research has linked earlier age of initiation to greater nicotine dependence, longer duration of 

smoking, and sustained use.1 The tobacco industry is known to market tobacco products, 

including flavored tobacco products, to appeal to youth and young adults.1,2 This has in part 

contributed to the significant increase in the use of tobacco products among young and young 

adults in recent years, and the disproportionate use of e-cigarettes among youth and young 

adults.3-5 Reducing and delaying initiation can prevent adverse health outcomes related to 

tobacco initiation in adolescence and young adulthood and decrease the likelihood of continued, 

sustained use in adulthood.

1-6 

Tobacco use initiation mostly begins with flavored products.2,7 Federal law prohibits cigarettes 

from containing characterizing flavors other than tobacco or menthol. Non-cigarette tobacco 

products, such as cigars, smokeless tobacco products, hookah, and e-cigarettes are available in 

a variety of fruit, candy, and other flavors. Federal law also requires manufacturers of products 

entering the market after 2007 to get FDA authorization before selling their products. FDA 

announced that, beginning on February 7, 2020, it would prioritize its enforcement activities to 

remove from the market any flavored cartridge-based e-cigarette product other than tobacco- or 

menthol-flavored cartridge-based products, unless and until it authorized any of those types of 

products for sale. FDA has said that it will make enforcement decisions on a case-by-case basis 

with respect to other products that need to come off the market while it continues to review the 

remaining marketing applications filed by e-cigarette companies. In addition, in April 2021, FDA 

said that it intends to issue a rule, prohibiting menthol as a characterizing flavor in cigarettes, 

and banning all characterizing flavors (including menthol) in cigars. 

Studies have shown significant increases in recent years in the use of e-cigarettes among U.S. 

middle and high school students, the vast majority of whom reported using flavored products.3-5 

Research has also shown that some youth populations at higher risk for initiation 

disproportionately use flavored tobacco products.10 Jurisdictions at the local, state, and federal 

levels have proposed and enacted bans on flavored tobacco products, including e-cigarettes, to 

discourage use and initiation among youth and young adults.10 However, bans that include 

exemptions, such as for menthol, could mitigate the equitable reach and effectiveness of the 

policies among all populations.10 

Additionally, disparities in initiation behaviors exist among subgroups of youth and young adults by 

race/ethnicity, gender identity and sexual orientation, income, and geographic location.2,12-18 Factors 

that contribute to differences and increases in risk of initiation among these groups include social 

and environmental factors, including interaction with peers who engage in tobacco use, as well as 

living in environments where tobacco use is prominent and heavily marketed.1,2,13 

Monitoring the indicators under this outcome can help assess progress in preventing and 

reducing initiation of tobacco use among youth and young adults and can help examine the 

extent to which tobacco control efforts are reducing tobacco-related disparities related to 

initiation. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 194 
► 

GOAL AREA 4 

OUTCOME 6 

The following indicators are associated with this outcome: 

4.6.a: Disparities in the average age at which young people first tried a tobacco product 

4.6.b: Disparities in the initiation of tobacco use through flavored tobacco products 

4.6.c: Disparities in the proportion of youth and young adults who report never having tried a 

tobacco product 

References 

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: 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. 

2. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

3. Cullen KA, Gentzke AS, Sawdey MD, et al. E-Cigarette use among youth in the United 

States, 2019. JAMA. 2019 Dec 3;322(21):2095-103. 

4. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product use among middle 

and high school students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 

2019;68:157–164. 

5. Villanti AC, Johnson AL, Glasser AM, et al. Association of flavored tobacco use with tobacco 

initiation and subsequent use among US youth and adults, 2013-2015. JAMA Netw Open. 

2019;2(10):e1913804. 

6. Institute of Medicine, Board on Population Health and Public Health Practice, Committee on 

the Public Health. Implications of raising the minimum age for purchasing tobacco products. 

Public health implications of raising the minimum age of legal access to tobacco products. 

Washington (DC: National Academies Press (US), 2015. 

7. Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use among US youth 

aged 12-17 years, 2013-2014. JAMA. 2015;214:1871-2. 

8. U.S. Food and Drug Administration. Menthol and Other Flavors in Tobacco Products. 

Accessed March 30, 2020. https://www.fda.gov/tobacco-products/products-ingredientscomponents/menthol-and-other-flavors-tobacco-products 

9. U.S. Food and Drug Administration. FDA finalizes enforcement policy on unauthorized 

flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint. 

Available at: https://www.fda.gov/news-events/press-announcements/fda-finalizesenforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children 

10. Rose SW, Amato MS, Anesetti-Rothermel A, et al. Characteristics and reach equity of 

policies restricting flavored tobacco product sales in the United States. Health Promot Pract. 

2020 Jan;21(1_suppl):44S-53S. 

11. Campaign for Tobacco-Free Kids. States & localities that have restricted the sale of flavored 

tobacco products. Accessed March 18, 2020. 

https://www.tobaccofreekids.org/assets/factsheets/0398.pdf 

CHAPTER 4 - OUTCOME INDICATORS 195 
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GOAL AREA 4 

OUTCOME 6 

12. Margerison-Zilko C, Cubbin C. Socioeconomic disparities in tobacco-related health 

outcomes across racial/ethnic groups in the United States: National Health Interview Survey 

2010. Nicotine Tob Res. 2013 Jun;15(6):1161-5. 

13. Corliss HL, Rosario M, Birkett MA, Newcomb ME, Buchting FO, Matthews AK. Sexual 

orientation disparities in adolescent cigarette smoking: intersections with race/ethnicity, 

gender, and age. Am J Public Health. 2014;104(6):1137-47. 

14. Andersson MA, Maralani V. Early-life characteristics and educational disparities in smoking. 

Soc Sci Med. 2015;144:138-47. 

15. Sharapova S, Reyes-Guzman C, Singh T, et al. Age of tobacco use initiation and 

association with current use and nicotine dependence among US middle and high school 

students, 2014–2016. Tob Control. 2020;29:49-54. 

16. Centers for Disease Control and Prevention. 1991-2017 High school Youth Risk Behavior 

Survey data. Accessed April 17, 2020. http://nccd.cdc.gov/youthonline/ 

17. Fagan P, Moolchan ET, Lawrence D, Fernander A, Ponder PK. Identifying health disparities 

across the tobacco continuum. Addiction. 2007;102:5-29. 

18. Odani S, Armour BS, Agaku IT. Racial/ethnic disparities in tobacco product use among 

middle and high school students — United States, 2014–2017. MMWR Morb Mortal Wkly 

Rep. 2018;67:952-57. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 196 
 

Indicator Rating 

←○ ◕ ●→ better 

► 

1-I 

1-I 

1- I 

GOAL AREA 4 

OUTCOME 6 

Eliminate Disparities in Tobacco Use Initiation 

Number Indicator 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

4.6.a 

Disparities in the average 

age at which young people 

first tried a tobacco product 

$$ ● ● ● ●

4.6.b 

Disparities in the initiation 

of tobacco use using a 

flavored tobacco product 

$$ ● ● ● ●

4.6.c 

Disparities in the 

proportion youth and 

young adults who report 

never having tried a 

tobacco product 

$$ ◕ ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data

to measure the indicator. 

CHAPTER 4 - OUTCOME INDICATORS 197 
 

 

 

 

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GOAL AREA 4 

OUTCOME 6 

Disparities in the Average Age at Which Young People First Tried a 

Tobacco Product 

Indicator 

number 

4.6.a 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 6. Eliminate disparities in tobacco use initiation 

What to 

measure 

Average age at which youth under age 18 years and young adults aged 18-

24 years first tried a tobacco product, overall, and among population 

groups experiencing tobacco-related disparities 

Differences in the average age at which youth under age 18 years and 

young adults aged 18-24 years first tried a tobacco product by population 

group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.9.b, “Average age at which young people first tried a 

commercial tobacco product other than cigarettes.”

Rationale Research has linked earlier age of initiation to greater nicotine dependence 

and longer duration of smoking.1 Most people who smoke daily report 

having initiated tobacco use before the age of 18 years. 

1 Reducing or 

delaying initiation can have an impact on overall tobacco use prevalence 

and reduce adverse tobacco-related outcomes.1,2 

Applying Studies have found that certain youth and young adult subgroups, including 

health American Indian/Alaska Native persons, Native Hawaiian/Other Pacific 

disparities Islander persons, African American or Black persons, Latino/Hispanic 

framing persons, LGBTQ+ persons, persons with low educational attainment, and 

persons with low income are more likely to initiate tobacco use at a 

3-8 younger age. 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 

2018-2019 

Example From NYTS (2020) 

survey How old were you when you first tried [cigarette smoking/ smoking a cigar, question(s) cigarillo, or little cigar/ smoking tobacco in a hookah or waterpipe], even 

one or two puffs? 

• 8 years old or younger 

• ____ [whole years between ages 9 and 18] 

• 19 years old or older 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 198 
► 

1-I 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 6 

How old were you when you first used chewing tobacco, snuff, or dip for 

the first time? 

• 8 years old or younger 

• ____ [whole years between ages 9 and 18] 

• 19 years old or older 

How old were you when you first tried using an e-cigarette, even once or 

twice? 

• 8 years old or younger 

• ____ [whole years between ages 9 and 18] 

• 19 years old or older 

From TUS-CPS (2018-2019) 

How old (were/was) (you/name) the first time (you/he/she) smoked part or 

all of a cigarette? 

ENTER (0) IF NEVER SMOKED REGULARLY 

ENTER AGE (01 – AGE) 

|__|__| 

Comments Tobacco products include e-cigarettes, cigarettes, cigars (cigars, little 

cigars, and cigarillos), smokeless tobacco (chewing tobacco, snuff, dip, 

snus), pouches, heated tobacco products, and dissolvable tobacco [e.g., 

sticks, strips, orbs, tablets, lozenges]), hookahs, pipe tobacco, and bidis 

(small brown cigarettes wrapped in a leaf). 

Tobacco control programs may want to assess this indicator by tobacco 

product, as age of initiation may vary by tobacco product. Programs may 

want to capture and report on commercially available tobacco products 

most pertinent to their unique state and/or local market. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

CHAPTER 4 - OUTCOME INDICATORS 199 
► 

GOAL AREA 4 

OUTCOME 6 

2. Institute of Medicine. 2015. Public Health Implications of Raising the 

Minimum Age of Legal Access to Tobacco Products. Washington, DC: 

The National Academies Press. 

3. Margerison-Zilko C, Cubbin C. Socioeconomic disparities in tobaccorelated health outcomes across racial/ethnic groups in the United 

States: national health interview survey 2010. Nicotine Tob Res. 

2012;15(6):1161-5. 

4. Corliss HL, Rosario M, Birkett MA, Newcomb ME, Buchting FO, 

Matthews AK. Sexual orientation disparities in adolescent cigarette 

smoking: intersections with race/ethnicity, gender, and age. Am J 

Public Health. 2014;104(6):1137-47. 

5. Andersson MA, Maralani V. Early-life characteristics and educational 

disparities in smoking. Soc Sci Med. 2015;144:138-47. 

6. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

7. Sharapova S, Reyes-Guzman C, Singh T, et al. Age of tobacco use 

initiation and association with current use and nicotine dependence 

among US middle and high school students, 2014–2016. Tob Control. 

2020;29:49-54. 

8. Centers for Disease Control and Prevention. 1991-2017 High school 

Youth Risk Behavior Survey data. Accessed on April 17, 2020. 

http://nccd.cdc.gov/youthonline/ 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 200 
 

► 

GOAL AREA 4 

OUTCOME 6 

Disparities in the Initiation of Tobacco Use Using a Flavored Tobacco Products 

Indicator 

number 

4.6.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 6. Eliminate disparities in tobacco use initiation 

What to 

measure 

Proportion of tobacco users who initiated tobacco product use with a 

flavored tobacco product, overall, and among population groups 

experiencing tobacco-related disparities 

Differences in the proportion of tobacco users who initiated tobacco 

product use with a flavored tobacco product by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Studies have found that flavored tobacco products are especially appealing 

to youth and young adults and are associated with experimentation among 

these age groups. 

1-6 Most youth who have ever used a tobacco product 

report that their first tobacco product was flavored.2-4 Initiating tobacco with 

flavored tobacco products is associated with subsequent sustained and 

regular tobacco use and consequently, higher risk of adverse health 

outcomes.2,4 Flavored tobacco products, including e-cigarettes, have 

contributed to significant increases in the prevalence of tobacco use among 

5,6 youth and young adults in recent years. 

Applying The tobacco industry has marketed flavored tobacco products to appeal to 

health certain population groups, including youth and young adults, women, and 

disparities certain racial/ethnic groups.1,2,6 Research indicates that while non-Hispanic 

framing White persons report higher use of flavored tobacco products, African 

American or Black persons and Latino/Hispanic persons report 

disproportionately higher use of menthol cigarettes.2,6 

Example data Population Assessment of Tobacco and Health- Youth Survey (PATH-Y), 

source(s) 2016-2017 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A), 

2016-2017 

Example 

survey 

question(s) 

From PATH-Y (2016-2017) 

Was the first cigarette you smoked flavored to taste like menthol or mint? 

• Yes 

• No 

• I don’t know

CHAPTER 4 - OUTCOME INDICATORS 201 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

► 

GOAL AREA 4 

OUTCOME 6 

• Don’t know

• Refused 

Was the first shisha or hookah tobacco product you smoked flavored to 

taste like clove, spice, candy, fruit, chocolate, alcohol (such as wine or 

cognac), or other sweets? 

• Yes 

• No 

• I don’t know

• Don’t know

• Refused 

When you first used an electronic nicotine product, which flavor did you 

use? Choose all that apply. 

• Tobacco-flavored 

• Menthol or mint 

• Clove or spice 

• Fruit 

• Chocolate 

• An alcoholic drink (such as wine or cognac, margarita or other 

cocktails) 

• A non-alcoholic drink (such as coffee, soda, energy drinks, or other 

beverages) 

• Candy, desserts, or other sweets? 

• Some other flavor 

• Don’t know

• Refused 

From PATH-A (2016-2017) 

When you first started smoking cigarettes, did you start with cigarettes 

flavored to taste like menthol or mint? 

• Yes 

• No 

• I don’t know

• Don’t know

• Refused 

When you first started smoking hookah, did you smoke shisha or hookah 

tobacco flavored to taste like menthol, mint, clove, spice, fruit, chocolate, 

alcoholic drinks, candy or other sweets? 

• Yes 

• No 

• I don’t know

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 202 
 

 

 

 

► 

1-I 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 6 

• Don’t know

• Refused 

When you first used an electronic nicotine product, which flavor did you 

use? Choose all that apply. 

• Tobacco-flavored 

• Menthol or mint 

• Clove or spice 

• Fruit 

• Chocolate 

• An alcoholic drink (such as wine or cognac, margarita or other 

cocktails) 

• A non-alcoholic drink (such as coffee, soda, energy drinks, or other 

beverages) 

• Candy, desserts, or other sweets? 

• Some other flavor 

• Don’t know

• Refused 

Comments Tobacco products include e-cigarettes, cigarettes, cigars (cigars, little 

cigars, and cigarillos), smokeless tobacco (chewing tobacco, snuff, dip, 

snus, pouches, heated tobacco products, and dissolvable tobacco [e.g., 

sticks, strips, orbs, tablets, lozenges]), hookahs, pipe tobacco, and bidis 

(small brown cigarettes wrapped in a leaf). 

Tobacco control programs may want to assess this indicator by tobacco 

product, as initiation with flavored tobacco products may vary by product. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

← ○ ◕ ●→ better

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

Atlanta, GA: 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. 

CHAPTER 4 - OUTCOME INDICATORS 203 
► 

GOAL AREA 4 

OUTCOME 6 

2. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

3. Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use 

among US youth aged 12-17 years, 2013-2014. JAMA. 2015;214:1871-

2. 

4. Villanti AC, Johnson AL, Glasser AM, et al. Association of flavored 

tobacco use with tobacco initiation and subsequent use among US 

youth and adults, 2013-2015. JAMA Netw Open. 2019;2(10):e1913804. 

5. Cullen KA, Gentzke AS, Sawdey MD, et al. E-Cigarette use among 

youth in the United States, 2019. JAMA. 2019 Dec 3;322(21):2095-103. 

6. Cullen KA, Liu ST, Bernat JK, et al. Flavored Tobacco product use 

among middle and high school students — United States, 2014–2018. 

MMWR Morb Mortal Wkly Rep. 2019;68:839–844. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 204 
 

 

 

 

 

 

 

 

► 

GOAL AREA 4 

OUTCOME 6 

Disparities in the Proportion of Youth and Young Adults Who Report Never Having Tried 

a Tobacco Product 

Indicator 

number 

4.6.c 

Goal area 4. Identify and Eliminate Disparities 

Outcome 6. Eliminate disparities in tobacco use initiation 

What to 

measure 

Proportion of youth under age 18 years and young adults aged 18-24 years 

who report never having tried a tobacco product, overall, and among 

population groups experiencing tobacco-related disparities 

Differences in the proportion of youth under age 18 years and young adults 

aged 18-24 years who report never having tried a tobacco product by 

population group characteristics 

Similar Goal 1 (2014) 1.9.c, “Proportion of young people who report never having

existing tried a tobacco product.”

indicator(s) Goal 2 (2017) 2.5.d, “Proportion of young people who have never tried a 

from other tobacco product.”

goal areas 

Rationale Nearly 9 out of 10 adults who smoke cigarettes first try cigarette smoking 

by age 18 years, and 98% first try smoking by age 26 years. 

1 Reducing the 

number of youth and young adults who experiment with tobacco will 

decrease the number who become established tobacco users.1,2 

Applying Certain youth and young adult subgroups, including men, non-Hispanic 

health White persons, Latino/Hispanic persons, LGBTQ+ persons, and persons 

disparities living in the Southern and Midwestern geographic areas of the U.S., have a 

framing disproportionately higher prevalence of ever use.1,3,4 While overall ever use 

of a tobacco product is highest among non-Hispanic White persons, ever 

use of a combustible product is highest among African American or Black 

persons.4 Moreover, one national study assessing racial/ethnic disparities 

found that ever use of a tobacco product was disproportionally higher 

among American Indian/Alaska Native persons and Native 

Hawaiians/Other Pacific Islander 5 persons. 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Youth Risk Behavior Surveillance System (YRBSS), 2019 

National Health and Nutrition Examination Survey, (NHANES), 2015-2016 

Example 

survey 

question(s) 

From NYTS (2020) 

Have you ever tried cigarette smoking, even one or two puffs? 

• Yes 

• No 

CHAPTER 4 - OUTCOME INDICATORS 205 
► 

GOAL AREA 4 

OUTCOME 6 

Have you ever tried smoking cigars, cigarillos, or little cigars, such as Black 

and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies Blunts, 

even one or two puffs? 

• Yes 

• No 

Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi 

Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small 

amount? 

• Yes 

• No 

Have you ever used an e-cigarette, even once or twice? 

• Yes 

• No 

Have you ever tried smoking tobacco in a hookah or waterpipe, even one 

or two puffs? 

• Yes 

• No 

Which of the following tobacco products have you ever tried, even just one 

time? 

• Roll-your-own cigarettes 

• Pipes filled with tobacco (not waterpipe) 

• Snus, such as Camel, Marlboro, or General Snus 

• Dissolvable tobacco products such as Ariva, Stonewall, Camel 

orbs, Camel sticks, Marlboro sticks, or Camel strips 

• Bidis (small brown cigarettes wrapped in a leaf) 

• I have never tried any of the products listed above 

From YRBSS (2019) 

Have you ever tried cigarette smoking, even one or two puffs? 

• Yes 

• No 

Have you ever used an electronic vapor product? 

• Yes 

• No 

Identifying and Eliminating Tobacco-Related Disparities: 

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► 

1- I 

$$ ◕ ● ● ●

GOAL AREA 4 

OUTCOME 6 

From NHANES (2015-2016) 

Have you ever smoked a cigarette, even one time? 

• Yes 

• No 

• Don’t know/Not sure

• Refused 

Have you ever smoked a regular cigar, cigarillo or little filtered cigar even 

one time? 

• No 

• Don’t know/Not sure

• Refused 

. Have you ever used an e-cigarette even one time? 

• Yes 

• No 

• Don’t know/Not sure

• Refused 

Have you ever used smokeless tobacco even one time? 

• Yes 

• No 

• Don’t know/Not sure

• Refused 

Comments Tobacco products include e-cigarettes, cigarettes, cigars (cigars, little 

cigars, and cigarillos), smokeless tobacco (chewing tobacco, snuff, dip, 

snus, pouches, heated tobacco products, and dissolvable tobacco [e.g., 

sticks, strips, orbs, tablets, lozenges]), hookahs, pipe tobacco, and bidis 

(small brown cigarettes wrapped in a leaf). 

Tobacco control programs may want to assess this indicator by tobacco 

product, as ever use of a tobacco product may vary by product. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults: a report of the Surgeon General. 

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

for Disease Control and Prevention, National Center for Chronic 

CHAPTER 4 - OUTCOME INDICATORS 207 
► 

GOAL AREA 4 

OUTCOME 6 

Disease Prevention and Health Promotion, Office on Smoking and 

Health, 2012. 

2. Paul SL, Blizzard L, Patton GC, Dwyer T, Venn A. Parental smoking 

and smoking experimentation in childhood increase the risk of being a 

smoker 20 years later: the Childhood Determinants of Adult Health 

Study. Addiction. 2008 May;103(5):846–53. 

3. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

4. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and 

associated factors among middle and high school students — United 

States, 2019. MMWR Surveill Summ. 2019;68(No. SS-12):1–22. 

5. Odani S, Armour BS, Agaku IT. Racial/ethnic disparities in tobacco 

product use among middle and high school students — United States, 

2014–2017. MMWR Morb Mortal Wkly Rep. 2018;67:952–957. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 208 
► 

GOAL AREA 4 

OUTCOME 7 

Outcome 7: Eliminate disparities in tobacco use 

Tobacco use remains the leading cause of preventable morbidity and mortality in the United 

States, resulting in more than 480,000 deaths each year.1 Despite progress in reducing cigarette 

smoking and related morbidity and mortality in the past few decades, these reductions have not 

been equally distributed across population groups.1-3 Significant disparities in tobacco use 

persist by certain population characteristics, including age, race/ethnicity, gender identity and 

sexual orientation, educational attainment, income, mental health and substance use conditions, 

occupation, and geographic location. Studies indicate that certain population groups, including 

racial/ethnic minorities, LGBTQ+ persons, persons with low educational attainment, persons 

with low income, persons with mental health and substance use disorders, and persons living in 

the Southern and Midwestern geographic areas of the United States have experienced less 

progress in reducing tobacco use.1-8 These disparities are present across and vary by patterns 

of tobacco use, including type of product used, number of products used, frequency of use, and 

use of flavored products.1,2,4-8 

Multiple individual and community-level factors that are often interrelated, including educational 

attainment, income level, social, cultural and environmental characteristics, targeted tobacco 

sales and marketing practices, and variation both in tobacco control strategies and policies and 

in local policymaking authority, contribute to tobacco-related disparities among these population 

groups.2,9-11 The introduction of new tobacco products (e.g., e-cigarettes) has also contributed to 

significant increases in tobacco use in some population groups, including youth.1,6 Moreover, 

population groups experiencing disparities often lack access to evidence-based, culturally 

appropriate cessation interventions; this, in part, contributes to sustained tobacco use, nicotine 

dependences, and reduced likelihood of quitting.2,10,12 

Population groups listed under the indicators in this outcome reflect those that emerged in the 

literature, many of which are based on national-level studies and do not assess within-group 

disparities. Tobacco control programs should consider using their state- and community-level 

data to identify populations experiencing disparities within this outcome. 

The following indicators are associated with this outcome: 

4.7.a: Disparities in tobacco use prevalence HP 

4.7.b: E-cigarette use among youth and young adults NR, HP 

4.7.c: Disparities in the use of flavored tobacco products HP 

NR, HP 4.7.d: Menthol flavored cigarette use 

4.7.e: Disparities in polytobacco use 

4.7.f: Disparities in the daily use of tobacco products 

4.7.g: Disparities in nicotine dependence 

NR Denotes an indicator that is not rated. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

CHAPTER 4 - OUTCOME INDICATORS 209 
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GOAL AREA 4 

OUTCOME 7 

References 

1. 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, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 

2. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

3. Centers for Disease Control and Prevention. Best practices user guide: health equity in 

tobacco 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, 2015. 

4. Creamer MR, Wang TW, Babb S, et al. Tobacco product use and cessation indicators 

among adults — United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68:1013–1019. 

5. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and associated factors 

among middle and high school students — United States, 2019. MMWR Surveill Summ. 

2019;68(No. SS-12):1–22. 

6. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product use among middle 

and high school students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 

2019;68:157–164. 

7. Trinidad DR, Pérez-Stable EJ, White MM, Emery SL, Messer K. A nationwide analysis of US 

racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related 

factors. Am J Public Health. 2011;101(4):699-706. 

8. Martell BN, Garrett BE, Caraballo RS. Disparities in Adult Cigarette Smoking — United 

States, 2002–2005 and 2010–2013. MMWR Morb Mortal Wkly Rep 2016;65:753–758. 

9. Garrett BE, Dube SR, Babb S, McAfee T. Addressing the social determinants of health to 

reduce tobacco-related disparities. Nicotine Tob Res. 2014;17(8):892-7. 

10. Sheffer CE, Stitzer M, Landes R, Brackman SL, Munn T, Moore P. Socioeconomic 

disparities in community-based treatment of tobacco dependence. Am J Public Health. 

2012;102(3):e8-e16. 

11. Blosnich J, Lee JG, Horn K. A systematic review of the aetiology of tobacco disparities for 

sexual minorities. Tob Control. 2013;22(2):66-73. 

12. U.S. Department of Health and Human Services. Smoking cessation. a report of the 

Surgeon General. Atlanta, GA: 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, 2020. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 210 
► 

-

-

GOAL AREA 4 

OUTCOME 7 

Eliminate Disparities in Tobacco Use 

Indicator Rating 

←○ ◕ ●→ better 

Number Indicator 

Overall Quality 

low ↔ high

Resources 

Needed 

Strength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

4.7.a Disparities in tobacco use 

prevalence HP $$ ● ● ● ●

4.7.b 

E-cigarette use among 

youth and young adults NR,

HP 

NR NR NR NR NR NR 

4.7.c 

Disparities in the use of 

flavored tobacco products 

HP 

$$ ● ● ● ●

4.7.d Use of menthol flavored 

cigarettes NR, HP NR NR NR NR NR NR 

4.7.e Disparities in polytobacco 

use 

$$ ● ● ● ●

4.7.f Disparities in the daily use

of tobacco products $ ● ● ● ●

4.7.g Disparities in nicotine 

dependence $$ ● ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to collect and 

analyze data using the most commonly available data source. The more dollar signs (maximum four), the 

more resources needed. Dollar signs do not represent a specific amount or range of costs but are instead 

a relative measure of expert reviewers’ ratings regarding resources required to collect and analyze data

to measure the indicator. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

NR Denotes an indicator that is not rated. 

CHAPTER 4 - OUTCOME INDICATORS 211 
 

 

 

 

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GOAL AREA 4 

OUTCOME 7 

Disparities in Tobacco Use Prevalence HP 

Indicator 

number 

4.7.a 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Cigarettes 

Proportion of youth under age 18 years who report smoking cigarettes on 

at least one day of the past 30 days and the proportion of adults aged 18 

years or older who have smoked at least 100 cigarettes in their lifetime* 

and who now report smoking cigarettes every day or some days, overall, 

and among population groups experiencing tobacco-related disparities 

Differences in the proportion of youth under age 18 years who report 

smoking cigarettes on at least one day of the past 30 days and the 

proportion of adults aged 18 years or older who have smoked at least 100 

cigarettes in their lifetime* and who now report smoking cigarettes every 

day or some days by population group characteristics 

All other tobacco products 

Proportion of youth under age 18 years who report using a tobacco product 

at least one day of the past 30 days and the proportion of adults aged 18 

years or older who have ever used a tobacco product and who now report 

using the product every day or some days, overall, and among population 

groups experiencing tobacco-related disparities 

Differences in the proportion of youth under age 18 years who report using 

a tobacco product at least one day and in the proportion of adults aged 18 

years or older who have ever used a tobacco product and who now report 

using the product every day or some days by population group 

characteristics 

Similar existing Goal 1 (2014) 1.10.a, “Prevalence of tobacco use among young people.”

indicator(s) Goal 2 (2017) 2.5.c “Tobacco use prevalence.”

from other goal Goal 3 (2015) 3.8.a, “Tobacco use prevalence.” areas 

Rationale Tobacco use remains the leading cause of preventable morbidity and 

mortality in the United States, resulting in more than 480,000 deaths each 

year.1 Preventing and reducing the use of all forms of tobacco products as 

early in life as possible is the best strategy for decreasing preventable 

tobacco-related disease and premature death attributed to tobacco.1 While 

prevalence of tobacco use has decreased in recent decades, progress has 

not been equally distributed across population groups. 

2-5 Moreover, there 

has been a substantial increase in youth tobacco use in recent years, 

erasing much of the progress in preventing and reducing tobacco use 

4,5 among this population group. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 212 
► 

GOAL AREA 4 

OUTCOME 7 

Applying Males, American Indian/Alaska Native persons, Native Hawaiian/Other 

health Pacific Islander persons, non-Hispanic White persons, multi-racial persons, 

disparities LGBTQ+ persons, persons with low educational attainment, persons with 

framing low income, persons with mental health and substance use conditions, 

persons with disabilities, veterans and active military personnel, blue collar 

and service workers, persons who are unemployed or underemployed, and 

persons who live in the Southern and Midwestern geographic areas of the 

U.S. experience disproportionately high prevalence of tobacco use.2-15 

Rural and urban differences have also been noted, but these have varied 

16 by geographic areas of the U.S. 

Example data National Youth Tobacco Survey (NYTS), 2020 

source(s) Youth Risk Behavioral Surveillance System (YRBSS), 2019 

National Health Interview Survey (NHIS), 2020 

Behavioral Risk Factor Surveillance System (BRFSS), 2019 

Example 

survey 

question(s) 

From NYTS (2020) 

During the past 30 days, on how many days did you smoke/use [ecigarettes/cigarettes/cigar, cigarillo, or little cigar/chewing tobacco, snuff, or 

dip/hookah or waterpipe]? 

Specify |_|_| (Range 0-30) 

During the past 30 days, which of the following products have you used on 

at least one day (Select one or more)? 

• Roll-your-own cigarettes 

• Pipes filled with tobacco (not hookah or waterpipe) 

• Snus, such as Camel, Marlboro, or General Snus 

• Dissolvable tobacco products such as Ariva, Stonewall, Camel 

orbs, Camel sticks, Marlboro sticks, or Camel strips 

• Bidis (small brown cigarettes wrapped in a leaf) 

• I have not used any of the products listed above in the past 30 days 

From YRBSS (2019) 

During the past 30 days, on how many days did you smoke/use [electronic 

vapor product/ cigarettes/ cigars, cigarillos, or little cigars/ chewing 

tobacco, snuff, dip, snus, or dissolvable tobacco products]? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

From NHIS (2020) 

CHAPTER 4 - OUTCOME INDICATORS 213 
 

 

 

 

 

 

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GOAL AREA 4 

OUTCOME 7 

Have you smoked at least 100 cigarettes in your entire life? 

• Yes 

• No 

• Refused 

• Don’t Know

Do you now smoke cigarettes every day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• Refused 

• Don’t know 

Have you ever smoked a regular cigar, cigarillo, or a little filtered cigar even 

one time? 

• Yes 

• No 

• Refused 

• Don’t Know

Do you now smoke regular cigars, cigarillos, or little filtered cigars every 

day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• Refused 

• Don’t know

From BRFSS (2019) 

Have you smoked at least 100 cigarettes in your entire life? 

• Yes 

• No 

• Don’t know/Not sure 

• Refused 

Do you now smoke cigarettes every day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• Don’t know/Not sure

• Refused 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 214 
► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 7 

Comments Tobacco products include e-cigarettes, cigarettes, cigars (cigars, little 

cigars, and cigarillos), smokeless tobacco (chewing tobacco, snuff, dip, 

snus, pouches, heated tobacco products, and dissolvable tobacco [e.g., 

sticks, strips, orbs, tablets, lozenges]), hookahs, pipe tobacco, and bidis 

(small brown cigarettes wrapped in a leaf). 

Tobacco control programs may want to assess this indicator by tobacco 

product as disparities can vary by tobacco product.2-5 Moreover, withingroup disparities can be identified when disaggregating tobacco use 

estimates within broad population categories, including racial/ethnic 

categories.2,6,14 

*To maintain consistency with some previously published studies, the use 

of lifetime thresholds for cigarette and non-cigarette tobacco products could 

also be considered in the calculation of current use of these products. 

This indicator is related to Healthy People 2030 objectives: 

• TU-01 Reduce current tobacco use in adults 

• TU-02-Reduce current cigarette smoking in adults 

• TU-03 Reduce current cigarette, cigar, and pipe smoking in adults 

• TU-04 Reduce current tobacco use in adolescents 

• TU-05 Reduce current e-cigarette use in adolescents 

• TU-06 Reduce current cigarette smoking in adolescents 

• TU-07 Reduce current cigar smoking in adolescents 

• TU-08 Reduce current use of smokeless tobacco products among 

adolescents 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

2. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

CHAPTER 4 - OUTCOME INDICATORS 215 
► 

GOAL AREA 4 

OUTCOME 7 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

3. Creamer MR, Wang TW, Babb S, et al. Tobacco product use and 

cessation indicators among adults — United States, 2018. MMWR 

Morb Mortal Wkly Rep. 2019;68:1013–1019. 

4. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and 

associated factors among middle and high school students — United 

States, 2019. MMWR Surveill Summ. 2019;68(No. SS-12):1–22. 

5. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product 

use among middle and high school students — United States, 2011–

2018. MMWR Morb Mortal Wkly Rep. 2019;68:157–164. 

6. Martell BN, Garrett BE, Caraballo RS. Disparities in adult cigarette 

smoking — United States, 2002–2005 and 2010–2013. MMWR Morb 

Mortal Wkly Rep 2016;65:753–758.. 

7. Fagan P, Shavers VL, Lawrence D, Gibson JT, O'Connell ME. 

Employment characteristics and socioeconomic factors associated with 

disparities in smoking abstinence and former smoking among US 

workers. J Health Care Poor Underserved. 2007 Nov;18(4 Suppl):52-

72. 

8. Trinidad DR, Pérez-Stable EJ, White MM, Emery SL, Messer K. A 

nationwide analysis of US racial/ethnic disparities in smoking 

behaviors, smoking cessation, and cessation-related factors. Am J 

Public Health. 2011;101(4):699-706. 

9. Weaver KE, Palmer N, Lu L, Case LD, Geiger AM. Rural–urban 

differences in health behaviors and implications for health status 

among US cancer survivors. Cancer Causes & Control. 

2013;24(8):1481-90. 

10. Pampel FC, Mollborn S, Lawrence EM. Life course transitions in early 

adulthood and SES disparities in tobacco use. Social Science 

Research. 2014;43:45-59. 

11. Bennett K, McElroy JA, Johnson AO, Munk N, Everett KD. A persistent 

disparity: smoking in rural sexual and gender minorities. LGBT health. 

2015;2(1):62-70. 

12. Max WB, Stark B, Sung H-Y, Offen N. Sexual identity disparities in 

smoking and secondhand smoke exposure in California: 2003–2013. 

Am J Public Health. 2016;106(6):1136-42. 

13. Kasza KA, Ambrose BK, Conway KP, et al. Tobacco product use by 

adults and youths in the United States in 2013 and 2014. N Engl J Med. 

2017 Jan 26;376(4):342-353. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 216 
► 

GOAL AREA 4 

OUTCOME 7 

14. Odani S, Armour BS, Agaku IT. Racial/ethnic disparities in tobacco 

product use among middle and high school students - United States, 

2014-2017. MMWR Morb Mortal Wkly Rep. 2018;67(34):952–957. 

15. U.S. Department of Defense. 2015 Health Related Behaviors Survey of 

Active Duty Military Personnel. Fairfax, VA: US Department of Defense; 

2018. 

16. Roberts ME, Doogan NJ, Kurti AN, et al. Rural tobacco use across the 

United States: How rural and urban areas differ, broken down by 

census regions and divisions. Health & Place. 2016;39:153-9. 

CHAPTER 4 - OUTCOME INDICATORS 217 
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GOAL AREA 4 

OUTCOME 7 

E-cigarette Use Among Youth and Young Adults NR, HP 

Indicator 

number 

4.7.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Proportion of youth under 18 years who report using an e-cigarette product 

at least one day of the past 30 days and differences by population group 

characteristics 

Proportion of young adults 18-24 years who have ever used an e-cigarette 

and who report using an e-cigarette every day or some days and 

differences by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale E-cigarette use is a key driver of tobacco product use among youth.1 Ecigarettes are the most commonly used tobacco product among youth and 

the second most commonly used product among young adults. 

1-2 During 

2017-2018, e-cigarette use among youth reached epidemic levels, erasing 

passed progress in reducing tobacco product use among youth.1 Some 

youth who use e-cigarettes transition to use of combustible tobacco 

products.3-4 No form of tobacco product use among youth is safe.5 

Applying 

health 

disparities 

framing 

E-cigarette use is highest among youth and young adults, in particular nonHispanic White and Hispanic youth.1-2,6 The availability of flavored ecigarettes and marketing of e-cigarette products has contributed to use of 

e-cigarettes in youth and young adults.5-7 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Youth Risk Behavioral Surveillance System (YRBSS), 2019 

Behavioral Risk Factor Surveillance System (BRFSS), 2019 

Example 

survey 

question(s) 

From NYTS (2020) 

During the past 30 days, on how many days did you use e-cigarettes? 

Specify |_|_| (Range 0-30) 

From YRBSS (2019) 

During the past 30 days, on how many days did you use an electronic 

vapor product? 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 218 
 

 

 

 

► 

GOAL AREA 4 

OUTCOME 7 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

From BRFSS (2018), Optional Module 

Have you ever used an e-cigarette or other electronic vaping product, even 

just once, in your entire life? 

• Yes 

• No 

• Don’t know/Not sure

• Refused 

Do you know use e-cigarettes or other electronic vaping products every 

day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• Don’t know/Not sure

• Refused 

Comments This indicator is related to Healthy People 2030 objective TU-05: Reduce 

current e-cigarette use in adolescents. 

Rating Not rated. 

References 1. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product 

use among middle and high school students — United States, 2011–

2018. MMWR Morb Mortal Wkly Rep. 2019;68:157–164. 

2. Creamer MR, Wang TW, Babb S, et al. Tobacco product use and 

cessation indicators among adults — United States, 2018. MMWR 

Morb Mortal Wkly Rep. 2019;68:1013–1019. 

3. Vogel EA, Prochaska JJ, Ramo DE, et al. Adolescents' e-cigarette use: 

increases in frequency, dependence, and nicotine exposure over 12 

months. J Adolesc Health 2019;64(6):770-75. 

4. Berry KM, Fetterman JL, Benjamin EJ, et al. Association of electronic 

cigarette use with subsequent initiation of tobacco cigarettes in US 

youths. JAMA Netw Open 2019;2(2):e18771. 

CHAPTER 4 - OUTCOME INDICATORS 219 
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GOAL AREA 4 

OUTCOME 7 

5. U.S. Department of Health and Human Services. E-Cigarette use 

among youth and young adults. a report of the Surgeon General. 

Atlanta, GA: 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, 2016. 

6. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and 

associated factors among middle and high school students —United 

States, 2019. MMWR Surveill Summ. 2019;68(No. SS-12):1–22. 

7. Cullen KA, Gentzke AS, Sawdey MD, et al. E-cigarette use among 

youth in the United States, 2019. JAMA. 2019 Nov 5;322(21):2095–

103. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 220 
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GOAL AREA 4 

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Disparities in the Use of Flavored Tobacco Products HP 

Indicator 

number 

4.7.c 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Proportion of youth under age 18 years who used a flavored tobacco 

product at least 1 day in the previous 30 days and the proportion of adults 

aged 18 years or older who report using a flavored tobacco product every 

day or some days, overall, and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of youth under age 18 years who used a 

flavored tobacco product at least 1 day in the previous 30 days and in the 

proportion of adults aged 18 years or older who report using a flavored 

tobacco product every day or some days by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Flavors play a key role in smoking initiation and continued tobacco use 

among youth and young adults. 

1,2 Research has shown that sweet-tasting 

flavors are particularly appealing to youth and young adults.2-7 About 7 out 

of 10 youth who use tobacco use a flavored product.8 Menthol flavored 

products, which have multiple sensory effects, have been heavily marketed 

by the tobacco industry.7,9-11 Some studies show that people who smoke 

menthol cigarettes have a harder time quitting smoking than those who 

smoke non-menthol cigarettes.12 

Applying The tobacco industry has targeted marketing of flavored tobacco products 

health to youth, racial/ethnic minorities, low income communities, and urban 

disparities areas.7,9-11 Youth and young adults have the highest use of flavored 

framing tobacco products.6-8 Additional population groups, including LGBTQ+ 

persons, persons with low educational attainment, and persons with low 

income also have disproportionately higher prevalence of use of flavored 

tobacco products.3,6-7,13 Menthol flavored tobacco products contribute to 

significant tobacco-related health disparities, including among youth and 

young adults, women, African American or Black persons, LGBTQ+ 

persons, and persons with mental health conditions.6-7,13-15 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Population Assessment of Tobacco and Health- Adult (PATH-A), 2016-

2017 

CHAPTER 4 - OUTCOME INDICATORS 221 
 

 

 

 

 

 

 

 

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GOAL AREA 4 

OUTCOME 7 

Example 

survey 

question(s) 

From NYTS (2020) 

During the past 30 days, were the cigarettes that you usually smoked 

menthol? 

• Yes 

• No 

• Not sure 

Were any of the [tobacco product] that you used in the past 30 days 

flavored to taste like menthol, mint, clove or spice, alcohol (wine, cognac), 

candy, fruit, chocolate, or any other flavor? 

• Yes 

• No 

• Don’t Know

What flavors were the [tobacco product] that you have used in the past 30 

days? (Select one or more) 

• Menthol 

• Mint 

• Clove or spice 

• Fruit 

• Chocolate 

• Alcoholic drinks (such as wine, cognac, margarita, or other cocktails) 

• Candy, desserts, or other sweets 

• Some other flavor not listed here (Specify: _____) 

From PATH-A (2016-2017) 

In the past 30 days, [were any of the cigarettes/was any of the roll-yourown cigarette tobacco] you smoked flavored to taste like menthol or mint? 

• Yes 

• No 

• I don’t know

• Don’t know

• Refuse 

In the past 30 days, [were/was] any of the [traditional cigar/cigarillo/filtered 

cigar/pipe tobacco/shisha or hookah tobacco]s that you smoked flavored to 

taste like menthol, mint, clove, spice, fruit, chocolate, alcoholic drinks, 

candy or other sweets? 

• Yes 

• No 

• I don’t know

• Don’t know

• Refuse 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 222 
 

 

 

 

► 

- I 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 7 

In the past 30 days, was any of the [snus /smokeless tobacco] you used 

flavored to taste like menthol, mint, wintergreen, spearmint or frost, clove, 

spice, fruit, chocolate, alcoholic drinks, candy or other sweets? 

• Yes 

• No 

• I don’t know

• Don’t know

• Refuse 

In the past 30 days, which flavors of [electronic nicotine products/electronic 

nicotine cartridges/e-liquid], have you used? Chose all that apply. 

• Tobacco-flavored 

• Menthol or mint 

• Clove or spice 

• Fruit 

• Chocolate 

• An alcoholic drink (such as wine, cognac, margarita or other 

cocktails) 

• A non-alcoholic drink (such as coffee, soda, energy drinks, or other 

beverages) 

• Candy, desserts or other sweets 

• Some other flavor (SPECIFY) 

• DON'T KNOW 

• REFUSED 

Comments Tobacco control programs may want to assess this indicator by tobacco 

product as disparities can vary by tobacco product. Moreover, because of 

its impact on tobacco-related disparities, it’s important to assess 

differences in menthol-flavored tobacco products across and within 

population groups, including race/ethnicity. 

This indicator is related to a Healthy People 2030 objective TU-09: 

Reduce current use of flavored tobacco products in adolescents who use 

tobacco. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

CHAPTER 4 - OUTCOME INDICATORS 223 
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GOAL AREA 4 

OUTCOME 7 

References 1. Villanti AC, Johnson AL, Glasser AM, et al. Association of flavored 

tobacco use with tobacco initiation and subsequent use among US 

youth and adults, 2013-2015. JAMA Netw Open. 2019;2(10):e1913804. 

2. Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use 

among US youth aged 12-17 years, 2013-2014. JAMA. 

2015;314(17):1871-3. 

3. Huang L-L, Baker HM, Meernik C, Ranney LM, Richardson A, 

Goldstein AO. Impact of non-menthol flavours in tobacco products on 

perceptions and use among youth, young adults and adults: a 

systematic review. Tob Control. 2017;26(6):709-19. 

4. Mennella JA, Pepino MY, Reed DR. Genetic and environmental 

determinants of bitter perception and sweet preferences. Pediatrics. 

2005;115(2):e216-222. 

5. De Graaf C, Zandstra EH. Sweetness intensity and pleasantness in 

children, adolescents, and adults. Physiol Behav.1999;67(4):513-520. 

6. Cullen KA, Liu ST, Bernat JK, et al. Flavored tobacco product use 

among middle and high school students — United States, 2014–2018. 

MMWR Morb Mortal Wkly Rep. 2019;68:839–844. 

7. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

8. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and 

associated factors among middle and high school students — United 

States, 2019. MMWR Surveill Summ. 2019;68(No. SS-12):1–22. 

9. Carpenter CM, Wayne GF, Pauly JL, Koh HK, Connolly GN. New 

cigarette brands with flavors that appeal to youth: tobacco marketing 

strategies. Health Aff (Millwood). 2005 Nov-Dec;24(6):1601-10. 

10. Cummings KM, Morley CP, Horan JK, Steger C, Leavell NR. Marketing 

to America's youth: evidence from corporate documents. Tob Control. 

2002 Mar;11 Suppl 1(Suppl 1):I5-17. 

11. Kreslake JM, Wayne GF, Connolly GN. The menthol smoker: tobacco 

industry research on consumer sensory perception of menthol 

cigarettes and its role in smoking behavior. Nicotine Tob Res. 2008 

Apr;10(4):705-15. 

12. Villanti AC, Collins LK, Niaura RS, Gagosian SY, Abrams DB. Menthol 

cigarettes and the public health standard: a systematic review. BMC 

Public Health. 2017;17:983. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 224 
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GOAL AREA 4 

OUTCOME 7 

13. Villanti AC, Mowery PD, Delnevo CD, Niaura RS, Abrams DB, Giovino 

GA. Changes in the prevalence and correlates of menthol cigarette use 

in the USA, 2004-2014. Tob Control. 2016;25:ii14-ii20. 

14. Sterling K, Fryer C, Pagano I, Jones D, Fagan P. Association between 

menthol-flavoured cigarette smoking and flavoured little cigar and 

cigarillo use among African-American, Hispanic, and White young and 

middle-aged adult smokers. Tob Control. 2016;25(Suppl 2):ii21–ii31. 

15. Young-Wolff KC, Hickman NJ III, Kim R, Gali K, Prochaska JJ. 

Correlates and prevalence of menthol cigarette use among adults with 

serious mental illness. Nicotine Tob Res. 2015;17(3):285–291. 

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OUTCOME 7 

Use of Menthol Flavored Cigarettes NR, HP 

Indicator 

number 

4.7.d 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Proportion of youth under age 18 years who smoked a menthol flavored cigarette 

at least 1 day in the previous 30 days and the proportion of adults aged 18 years 

or older who smoked a menthol flavored cigarette every day or some days, 

overall, and among population groups experiencing tobacco-related disparities 

Differences in the proportion of youth under age 18 years who smoked a menthol 

flavored cigarette at least 1 day in the previous 30 days and in the proportion of 

adults aged 18 years or older who smoked a menthol flavored cigarette product 

every day or some days by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Flavors play a key role in smoking initiation and sustained use.1,2 Menthol 

flavored products, which have multiple sensory effects, have been heavily 

marketed by the tobacco industry.3-6 Some studies show that people who smoke 

menthol cigarettes have a harder time quitting smoking than those who smoke 

7 non-menthol cigarettes. 

Applying Menthol flavored tobacco products, particularly menthol cigarettes, contribute to 

health significant tobacco-related health disparities in the U.S.3,8-11 African American or 

disparities Black persons have the highest percentage of menthol cigarette use of all 

framing racial/ethnic groups, and menthol cigarettes are a key contributor to tobaccorelated disparities among this population group. More than 7 in 10 African 

American or Black persons who smoke use menthol cigarettes. 8-9 Other 

population groups that have a high prevalence of menthol cigarette use include 

youth and young adults, women, LGBTQ+ persons, and persons with mental 

health conditions.3,8-11 

Example 

data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Population Assessment of Tobacco and Health- Adult (PATH-A), 2016-2017 

Example From NYTS (2020) 

survey During the past 30 days, were the cigarettes that you usually smoked menthol? question(s) • Yes 

• No 

• Not Sure 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 226 
 

 

 

 

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GOAL AREA 4 

OUTCOME 7 

From PATH-A (2016-2017) 

In the past 30 days, [were any of the cigarettes/was any of the roll-your-own 

cigarette tobacco] you smoked flavored to taste like menthol or mint? 

• Yes 

• No 

• I don’t know

• Don’t know

• Refuse 

Comments Tobacco control programs may want to assess this indicator by tobacco product 

as disparities can vary by tobacco product. Moreover, because of its strong 

influence on tobacco-related disparities, it’s important to assess differences in

menthol-flavored tobacco products across and within population groups, 

including race/ethnicity. 

This indicator is related to a Healthy People 2030 objective TU-09: Reduce 

current use of flavored tobacco products in adolescents who use tobacco. 

Rating Not rated. 

References 1. Villanti AC, Johnson AL, Glasser AM, et al. Association of flavored 

tobacco use with tobacco initiation and subsequent use among US youth 

and adults, 2013-2015. JAMA Netw Open. 2019;2(10):e1913804. 

2. Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use 

among US youth aged 12-17 years, 2013-2014. JAMA. 2015;314(17): 

1871-3. 

3. U.S. National Cancer Institute. A socioecological approach to addressing 

tobacco-related health disparities. National Cancer Institute Tobacco 

Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: 

U.S. Department of Health and Human Services, National Institutes of 

Health, National Cancer Institute; 2017. 

4. Carpenter CM, Wayne GF, Pauly JL, Koh HK, Connolly GN. New 

cigarette brands with flavors that appeal to youth: tobacco marketing 

strategies. Health Aff (Millwood). 2005 Nov-Dec;24(6):1601-10. 

5. Cummings KM, Morley CP, Horan JK, Steger C, Leavell NR. Marketing to 

America's youth: evidence from corporate documents. Tob Control. 2002 

Mar;11 Suppl 1(Suppl 1):I5-17. 

6. Kreslake J, Ferris Wayne G, Connolly G. The menthol smoker: tobacco 

industry research on consumer sensory perception of menthol cigarettes 

and its role in smoking behavior. Nicotine Tob Res. 2008;10(8):705-16. 

7. Villanti AC, Collins LK, Niaura RS, Gagosian SY, Abrams DB. Menthol 

cigarettes and the public health standard: a systematic review. BMC 

Public Health. 2017;17:983. 

CHAPTER 4 - OUTCOME INDICATORS 227 
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GOAL AREA 4 

OUTCOME 7 

8. Centers for Disease Control and Prevention. Menthol and cigarettes. 

Accessed April 7, 2020. 

https://www.cdc.gov/tobacco/basic_information/tobacco_industry/mentholcigarettes/index.html. 

9. Villanti AC, Mowery PD, Delnevo CD, Niaura RS, Abrams DB, Giovino 

GA. Changes in the prevalence and correlates of menthol cigarette use in 

the USA, 2004-2014. Tob Control. 2016;25:ii14-ii20. 

10. Sterling K, Fryer C, Pagano I, Jones D, Fagan P. Association between 

menthol-flavoured cigarette smoking and flavoured little cigar and cigarillo 

use among African-American, Hispanic, and White young and middleaged adult smokers. Tob Control. 2016;25(Suppl 2):ii21–ii31. 

11. Young-Wolff KC, Hickman NJ III, Kim R, Gali K, Prochaska JJ. Correlates 

and prevalence of menthol cigarette use among adults with serious 

mental illness. Nicotine Tob Res. 2015;17(3):285–291. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 228 
 

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GOAL AREA 4 

OUTCOME 7 

Disparities in Polytobacco Use 

Indicator 

number 

4.7.e 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Proportion of youth under age 18 years who report having used two or 

more tobacco products in the past 30 days and the proportion of adults 

aged 18 years or older who report using two or more tobacco products 

every day or some days, overall, and among populations experiencing 

tobacco-related disparities 

Differences in the proportion of youth under age 18 years who report 

having used two or more tobacco products in the past 30 days and in the 

proportion of adults aged 18 years or older who report using two or more 

tobacco products every day or some days by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 1 (2014) 1.10.d, “Proportion of polytobacco product use among young 

people.”

Rationale Use of multiple products increases exposure to higher levels of nicotine 

and other harmful constituents and increases the risk of nicotine 

dependence and adverse health effects.1,2 Patterns of multiple product use 

have shifted over time, in part, because of new products that have entered 

the market.3-7 

Applying Studies indicate that certain population groups, including youth and young 

health adults, men, American Indian/Alaska Native persons, non-Hispanic White 

disparities persons, Latino/Hispanic persons, persons with low educational attainment, 

framing persons with low income, persons with mental health and substance use 

conditions, persons with disabilities, and persons living in the Southern and 

Midwestern geographic areas of the U.S. are more likely to be polytobacco 

3,4,6,8-11 users. 

Example data National Youth Tobacco Survey (NYTS), 2020 

source(s) Youth Risk Behavioral Surveillance System (YRBSS), 2019 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A), 

2016-2017 

Example From NYTS (2020) 

survey During the past 30 days, on how many days did you [smoke/use] [any question(s) tobacco product(s)/ e-cigarettes/ cigarettes/ cigars, cigarillos, or little cigars 

/chewing tobacco, snuff, or dip/ tobacco in a hookah or waterpipe]? 

CHAPTER 4 - OUTCOME INDICATORS 229 
 

 

 

 

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GOAL AREA 4 

OUTCOME 7 

Specify |_|_| (Range 0-30) 

During the past 30 days, which of the following products have you used on 

at least one day (Select one or more)? 

• Roll-your-own cigarettes 

• Pipes filled with tobacco (not hookah or waterpipe) 

• Snus, such as Camel, Marlboro, or General Snus 

• Dissolvable tobacco products such as Ariva, Stonewall, Camel 

orbs, Camel sticks, Marlboro sticks, or Camel strips 

• Bidis (small brown cigarettes wrapped in a leaf) 

• I have not used any of the products listed above in the past 30 days 

From YRBSS (2019) 

During the past 30 days, on how many days did you smoke/use [electronic 

vapor products/cigarettes/cigars, cigarillos, or little cigars/chewing tobacco, 

snuff, dip, snus, or dissolvable tobacco products]? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

From PATH-A (2016-2017) 

In the past 30 days, have you smoked a [cigarette/traditional cigar/cigarillo 

or filtered cigar/pipe filled with tobacco/smoked tobacco in a hookah], even 

one or two puffs? 

• Yes 

• No 

• Don’t know/Not sure 

• Refused 

In the past 30 days, have you used [a/an] [electronic nicotine product/snus 

pouches/other smokeless tobacco products, such as loose snus, moist 

snuff, dip, spit, or chewing tobacco], even one or two times? 

• Yes 

• No 

• Don’t know/Not sure 

• Refused 

Comments Not applicable. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 230 
► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 7 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. Preventing tobacco 

use among youth and young adults : a report of the Surgeon General. 

Atlanta: US Department of Health and Human Services. Centers for 

Disease Control and Prevention; 2012. 

2. Ali M, Gray TR, Martinez DJ, Curry LE, Horn KA. Risk profiles of youth 

single, dual, and poly tobacco users. Nicotine Tob Res. 

2016;18(7):1614-21. 

3. Creamer MR, Wang TW, Babb S, et al. Tobacco product use and 

cessation indicators among adults — United States, 2018. MMWR 

Morb Mortal Wkly Rep. 2019;68:1013–1019. 

4. Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product 

use among middle and high school students — United States, 2011–

2018. MMWR Morb Mortal Wkly Rep. 2019;68:157–164. 

5. Johnson AL, Collins LK, Villanti AC, Pearson JL, Niaura RS. Patterns of 

nicotine and tobacco product use in youth and young adults in the 

United States, 2011-2015. Nicotine Tob Res. 2018;20(suppl_1):S48–

S54. 

6. Gilreath TD, Leventhal A, Barrington-Trimis JL, Unger JB, Cruz TB, 

Berhane K, et al. Patterns of alternative tobacco product use: 

emergence of hookah and e-cigarettes as preferred products amongst 

youth. J Adolesc Health. 2016;58(2):181-5. 

7. Huh J, Leventhal AM. Progression of poly-tobacco product use patterns 

in adolescents. Am J Prev Med. 2016;51(4):513-7. 

8. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

9. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

CHAPTER 4 - OUTCOME INDICATORS 231 
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GOAL AREA 4 

OUTCOME 7 

10. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and 

associated factors among middle and high school students — United 

States, 2019. MMWR Surveill Summ. 2019;68(No. SS-12):1–22. 

11. Osman A, Kowitt SD, Ranney LM, Heck C, Goldstein AO. Trends and 

racial disparities in mono, dual, and poly use of tobacco products 

among youth. Nicotine Tob Res. 2018;20(suppl_1):S22–S30. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 232 
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GOAL AREA 4 

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Disparities in the Daily Use of Tobacco Products 

Indicator 

number 

4.7.f 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Proportion of youth under age 18 years and adults aged 18 years or older 

who report daily use of at least one tobacco product, overall, and among 

population groups experiencing tobacco-related disparities 

Differences in the proportion of youth under age 18 years and adults aged 

18 years or older that report daily use of at least one tobacco product by 

population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Daily use of tobacco products increases the risk of nicotine dependence, 

sustained use, and tobacco-related adverse health effects.1-2 Moreover, 

daily users are less likely to make a quit attempt and successfully quit.2 

Applying 

health 

disparities 

framing 

Studies indicate that adults, men, American Indian/Alaska Native persons, 

non-Hispanic White persons, LGBTQ+ persons, persons with low income, 

persons with mental health conditions, blue collar and service workers, and 

persons residing in the Midwestern geographic areas of the U.S. and in 

3-11 rural areas are more likely to be daily tobacco users. 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Youth Risk Behavioral Surveillance System (YRBSS), 2019 

Behavioral Risk Factor Surveillance System (BRFSS), 2019 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A), 

2016-2017 

Example 

survey 

question(s) 

From NYTS (2020) 

During the past 30 days, on how many days did you [smoke/use] [any 

tobacco product(s)/ e-cigarettes/ cigarettes/ cigars, cigarillos, or little cigars 

/chewing tobacco, snuff, or dip/ tobacco in a hookah or waterpipe]? 

Specify |_|_| (Range 0-30) 

From YRBSS (2019) 

During the past 30 days, on how many days did you smoke/use [electronic 

vapor product/cigarettes/cigars, cigarillos, or little cigars/chewing tobacco, 

snuff, dip, snus, or dissolvable tobacco products]? 

CHAPTER 4 - OUTCOME INDICATORS 233 
 

 

 

 

► 

$ ● ● ● ●

GOAL AREA 4 

OUTCOME 7 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

From BRFSS (2019) 

Do you now smoke/use [cigarettes/ chewing tobacco, snuff, or snus] every 

day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• Don’t know / Not sure 

• Refused 

From PATH-A (2016-2017) 

Do you now [smoke cigarettes/use electronic nicotine products/smoke 

traditional cigars/cigarillos/filtered cigars as blunts/smoke a pipe filled with 

tobacco/smoke tobacco in a hookah/use snus/use smokeless tobacco] 

• Every day 

• Some days 

• Not at all 

• Don’t know / Not sure 

• Refused 

Comments Tobacco control programs may want to consider examining this indicator 

by tobacco product and intensity of use to help interpret the results of this 

indicator. 

Rating Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. Schane RE, Ling PM, Glantz SA. Health effects of light and intermittent 

smoking: a review. Circulation. 2010;121(13):1518–1522. 

2. Tindle HA, Shiffman S. Smoking cessation behavior among intermittent 

smokers versus daily smokers. Am J Public Health. 2011;101(7):e1–e3. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 234 
► 

GOAL AREA 4 

OUTCOME 7 

3. Corliss HL, Wadler BM, Jun H-J, et al. Sexual-orientation disparities in 

cigarette smoking in a longitudinal cohort study of adolescents. Nicotine 

Tob Res. 2012;15(1):213-22. 

4. Roberts ME, Doogan NJ, Kurti AN, et al. Rural tobacco use across the 

United States: how rural and urban areas differ, broken down by 

census regions and divisions. Health Place. 2016;39:153-9. 

5. Sutfin EL, McCoy TP, Berg CJ, et al. Tobacco use by college students: 

a comparison of daily and nondaily smokers. Am J Health Behav. 

2012;36(2):218-29. 

6. Sharapova SR, Singh T, Agaku IT, Kennedy SM, King BA. Patterns of 

e-cigarette use frequency—National Adult Tobacco Survey, 2012–

2014. Am J Prev Med. 2018;54(2):284-8. 

7. Max WB, Stark B, Sung H-Y, Offen N. Sexual identity disparities in 

smoking and secondhand smoke exposure in California: 2003–2013. 

Am J Public Health. 2016;106(6):1136-42. 

8. 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, National Center 

for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health; 2014. 

9. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

10. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the 

U.S. population. Tob Control. 2014 Nov;23(e2):e147-53. 

11. Forman-Hoffman VL, Hedden SL, Miller GK, Brown K, Teich J, Gfroerer 

J. Trends in cigarette use, by serious psychological distress status in 

the United States, 1998-2013. Addict Behav. 2017 Jan;64:223-228. 

CHAPTER 4 - OUTCOME INDICATORS 235 
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GOAL AREA 4 

OUTCOME 7 

Disparities in Nicotine Dependence 

Indicator 

number 

4.7.g 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 7. Eliminate disparities in tobacco use 

What to 

measure 

Proportion of youth under age 18 years and adults aged 18 years or older 

that report nicotine dependence, overall, and among population groups 

experiencing tobacco-related disparities 

Differences in the proportion of youth under age 18 years and adults aged 

18 years or older that report nicotine dependence by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Not applicable. 

Rationale Nicotine is the addictive drug in tobacco.1 Tobacco companies are known 

to design products with enough nicotine to create and sustain addiction.1 

For example, cigarettes were designed to increase the likelihood that 

initiation would lead to dependence and difficulty quitting.1 This indicator 

can help examine the extent to which interventions to decrease tobacco, 

multiple product use, and daily use are having an effect on nicotine 

dependence.1 

Applying Studies show that certain population groups including non-Hispanic White 

health persons, LGBTQ+ persons, persons with low educational attainment, and 

disparities persons with low income are more likely to experience nicotine 

framing dependence.2-4 Because youth and pregnant persons are especially 

vulnerable to the harmful effects of nicotine, programs may want to monitor 

nicotine dependence among these population groups.1 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

Population Assessment of Tobacco and Health- Adult Survey (PATH-A), 

2016-2017 

Example From NYTS (2020) 

survey During the past 30 days, have you had a strong craving or felt like you question(s) really needed to use a tobacco product of any kind? 

• Yes 

• No 

How soon after you wake up do you want to use a tobacco product? 

• I do not want to use tobacco 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 236 
 

 

 

 

 

 

 

 

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GOAL AREA 4 

OUTCOME 7 

• Within 5 minutes 

• From 6 to 30 minutes 

• From more than 30 minute to 1 hour 

• After more than 1 hour but less than 24 hours 

• I rarely want to use tobacco 

From PATH-A (2016-2017) 

Do you ever have strong cravings to [smoke/use] [tobacco product]? 

• Yes 

• No 

• Don’t know

Have you ever felt like you really needed to [smoke/use] [tobacco product]? 

• Yes 

• No 

• Don’t know

Please rate your level of agreement for each statement using the following 

scale: 1=not true of me at all to 5=extremely true of me 

• I find myself reaching for [tobacco product] without thinking about it. 

[My urges keep getting stronger if I don’t/I still have urges to]

[smoke/use] [tobacco product]. 

• [Tobacco product] [control/controls] me. 

• My [tobacco product][smoking/use] is out of control. 

• My urge to [smoke/use] [tobacco product] is out of control. 

• I usually want to [smoke/use] [tobacco product] right after I wake 

up. 

• I can only go a couple of hours without [smoking/using]/wanting to 

[smoke/use] [tobacco product]. 

• [I frequently [smoke/use]]/I find myself almost [smoking/using] 

[tobacco product] without thinking about it. 

• [Smoking/Using] [tobacco product] [really helps/would really help] 

me feel better if I’ve been feeling down. 

• [Smoking/Using] [tobacco product] helps me think better. 

• I would find it really hard to stop [smoking/using] [tobacco product]. 

• [I would find it hard to stop [smoking/using] [tobacco product] for a 

week./ I would find it hard to not [smoke/use] [tobacco product] for 

another week.] 

• After not [smoking/using] [tobacco product] for a while, [I need/I 

would like] to [smoke/use] [tobacco product] in order to feel less 

restless and irritable. 

CHAPTER 4 - OUTCOME INDICATORS 237 
I $$ ● ● ● ●

Strength 

Overall of 

quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

► 

-

GOAL AREA 4 

OUTCOME 7 

• [After not [smoking/using] [tobacco product] for a while, [I need/I

feel like I need] to [smoke/use] [tobacco product] in order to keep

myself from experiencing any discomfort.

Comments Because frequency, intensity of use, and polytobacco use are strongly 

associated with nicotine dependence, population groups with high and 

frequent consumption of tobacco products and those who use multiple 

products are at increased risk of nicotine dependence.5,6 For this reason, 

disparities across these indicators should be monitored and considered 

when measuring this indicator and interpreting results. 

There are several known tests for nicotine dependence, including 

Fagerstrom Test for Nicotine Dependence7 and the Hooked on Nicotine 

Checklist. 

8-9 Tobacco control programs may want to remain consistent with 

the scale used to compare this indicator over time. Moreover, programs 

may want to assess this indicator by product type, as nicotine levels can 

vary by tobacco product. 

Rating 

←○ ◕ ●→ better

References 1. 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, National Center

for Chronic Disease Prevention and Health Promotion, Office on

Smoking and Health; 2014.

2. Corliss HL, Wadler BM, Jun H-J, et al. Sexual-orientation disparities in

cigarette smoking in a longitudinal cohort study of adolescents. Nicotine

Tob Res. 2012;15(1):213-22.

3. Nighbor TD, Doogan NJ, Roberts ME, et al. Smoking prevalence and

trends among a U.S. national sample of women of reproductive age in

rural versus urban settings. PLoS One. 2018 Nov 28;13(11):e0207818.

4. Apelberg BJ, Corey CG, Hoffman AC, et al. Symptoms of tobacco

dependence among middle and high school tobacco users: results from

the 2012 National Youth Tobacco Survey. Am J Prev Med 2014;47(2

Suppl 1):S4-14.

5. Etter JF, Eissenberg T. Dependence levels in users of electronic

cigarettes, nicotine gums and tobacco cigarettes. Drug Alcohol

Depend. 2015;147:68–75.

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 238 
► 

GOAL AREA 4 

OUTCOME 7 

6. Sung HY, Wang Y, Yao T, Lightwood J, Max W. Polytobacco use and 

nicotine dependence symptoms among US adults, 2012-2014. Nicotine 

Tob Res. 2018;20(suppl_1):S88–S98. 

7. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The 

Fagerström Test for Nicotine Dependence: a revision of the Fagerström 

Tolerance Questionnaire. Br J Addict. 1991 Sep;86(9):1119-27. 

8. DiFranza JR, Rigotti NA, McNeill AD, et al. Initial symptoms of nicotine 

dependence in adolescents. Tob Control. 2000 Sep;9(3):313-9. 

9. DiFranza JR, Savageau JA, Fletcher K, et al. Measuring the loss of 

autonomy over nicotine use in adolescents: the DANDY (Development 

and Assessment of Nicotine Dependence in Youths) study. Arch 

Pediatr Adolesc Med. 2002 Apr;156(4):397-403. 

CHAPTER 4 - OUTCOME INDICATORS 239 
 

 

► 

GOAL AREA 4 

OUTCOME 8 

Outcome 8: Eliminate disparities in secondhand smoke exposure 

Secondhand smoke (SHS) exposure contributes to approximately 41,000 deaths among 

nonsmoking adults each year in the U.S.1 The 2006 Surgeon General’s report, The Health 

Consequences of Involuntary Exposure to Secondhand Smoke, concluded that there is no riskfree level of SHS exposure.2 Exposure to SHS can lead to lung cancer, heart disease, and 

stroke in adults and to increased risk of acute respiratory infections, ear problems, and sudden 

infant death syndrome in children.1,2 Exposure to SHS has decreased substantially in the past 

three decades, in large part because of the significant declines in smoking and the growing 

number of states and communities with comprehensive smokefree laws that do not allow 

smoking in indoor areas of work and public places, including restaurants, and bars.3 

Although substantial progress toward protecting people who do not smoke from SHS exposure 

has been made, disparities in SHS exposure exist by age, race/ethnicity, gender identity and 

sexual orientation, educational attainment, income, housing type, occupation, and geographic 

location.3 Many studies have found that children, youth, African American or Black persons, 

LGBTQ+ persons, persons with low educational attainment, persons with low income, persons 

who work in blue collar and service occupations, persons living in rental and multiunit 

properties, and persons who live in states without comprehensive smokefree policies continue 

to be disproportionately exposed to SHS.1-16 These disparities may partly exist because these 

population groups are less likely to be protected by smokefree policies in workplaces and by 

voluntary smokefree rules in private settings.1,2,10,12,17 Gaps in coverage may reflect policy 

exemptions, which are common for hospitality venues; casinos; tobacco-oriented businesses, 

such as smoke shops; and outdoor workplaces.17,18 

Moreover, as indoor public spaces and workplaces are covered by comprehensive smokefree 

policies, private settings remain a major source of SHS for people who do not smoke and the 

main source for SHS exposure for children.1-2 Persons living in multiunit housing, such as 

apartment buildings and condominiums, are particularly at risk of exposure in the home, where 

secondhand smoke can transfer between neighboring living units and common areas.4-16 

Multiunit housing properties are home to a high proportion of children, racial/ethnic minorities, 

and individuals of low socioeconomic status.15,19 

The following indicators are associated with this outcome: 

4.8.a: Disparities in nonsmokers exposed to secondhand smoke 

4.8.b: Disparities in exposure to secondhand smoke in the workplace 

4.8.c: Disparities in exposure to secondhand smoke in indoor public spaces 

4.8.d: Disparities in exposure to secondhand smoke in homes and vehicles 

4.8.e: Disparities in multiunit housing residents’ exposure to secondhand smoke

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 240 
► 

GOAL AREA 4 

OUTCOME 8 

References 

1. 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, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 

2. U.S. Department of Health and Human Services. The health consequences of involuntary 

exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: 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. 

3. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to 

secondhand smoke—United States, 1999–2012. MMWR Morb Mortal Wkly Rep. 

2015;64(4):103-108. 

4. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

5. Max WB, Stark B, Sung H-Y, Offen N. Sexual identity disparities in smoking and 

secondhand smoke exposure in California: 2003–2013. Am J Public Health. 

2016;106(6):1136-42. 

6. Wang TW, Marynak KL, Agaku IT, King BA. Secondhand Exposure to Electronic Cigarette 

Aerosol Among US Youths. JAMA Pediatr. 2017 May 1;171(5):490-492. 

7. Nguyen KH, Gomez Y, Homa DM, King BA. Tobacco Use, Secondhand smoke, and smokefree home rules in multiunit housing. Am J Prev Med. 2016;51(5):682–692. 

8. Gan WQ, Mannino DM, Jemal A. Socioeconomic disparities in secondhand smoke exposure 

among US never-smoking adults: the National Health and Nutrition Examination Survey 

1988–2010. Tob Control. 2015;24(6):568-73. 

9. Su C, Syamlal G, Tamers S, Li J, Luckhaupt SE. Workplace secondhand tobacco smoke 

exposure among U.S. nonsmoking workers, 2015. MMWR Morb Mortal Wkly Rep. 

2019;68:604–607. 

10. Calvert GM, Luckhaupt SE, Sussell A, Dahlhamer JM, Ward BW. The prevalence of 

selected potentially hazardous workplace exposures in the US: findings from the 2010 

National Health Interview Survey. Am J Ind Med. 2013;56(6):635–646. 

11. Syamlal G, King BA, Mazurek JM. Workplace smoke-free policies and cessation programs 

among US working adults. Am J Prev Med. 2019;56(4):548-62. 

12. Cartmell KB, Miner C, Carpenter MJ, et al. Secondhand smoke exposure in young people 

and parental rules against smoking at home and in the car. Public Health Rep. 

2011;126(4):575-82. 

CHAPTER 4 - OUTCOME INDICATORS 241 
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OUTCOME 8 

13. Chambers C, Sung H-Y, Max W. Home exposure to secondhand smoke among people 

living in multiunit housing and single family housing: a study of California adults, 2003–2012. 

J Urban Health. 2015;92(2):279-90. 

14. King BA, Babb SD, Tynan MA, Gerzoff RB. National and state estimates of secondhand 

smoke infiltration among US multiunit housing residents. Nicotine Tob Res. 

2012;15(7):1316-21. 

15. Wilson KM, Torok M, McMillen R, Tanski S, Klein JD, Winickoff JP. Tobacco smoke 

incursions in multiunit housing. Am J Public Health. 2014;104(8):1445-53. 

16. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific 

literature. Tob Control. 2016;25(1):9–20. 

17. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke 

exposure. Accessed March 23, 2020. http://www.thecommunityguide.org/tobacco/index.html 

18. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in smoke-free workplace 

policies among food service workers. J Occup Environ Med. 2004 Apr;46(4):347-56. 

19. U.S. Department of Housing and Urban Development. Resident Characteristics Report. 

2020. Accessed April 24, 2020. https://pic.hud.gov/pic/RCRPublic/rcrmain.asp 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 242 
Indicator Rating 

←○ ◕ ●→ better 

 

► 

-

GOAL AREA 4 

OUTCOME 8 

Eliminate Disparities in Secondhand Smoke Exposure 

Number Indicator 

Overall Quality 

low ↔ high

Resources NeededStrength of Evaluation 

Evidence 

UtilityFace 

Validity 

Accepted Practice 

4.8.a 

Disparities in exposure to 

secondhand smoke among

people who do not smoke 

HP 

$$ ● ● ● ●

4.8.b 

Disparities in exposure to 

secondhand smoke in the 

workplace 

$$ ● ● ● ●

4.8.c 

Disparities in exposure to 

secondhand smoke in 

indoor public spaces 

$$ ● ● ● ●

4.8.d 

Disparities in exposure to 

secondhand smoke in 

homes and vehicles 

$$ ● ● ● ●

4.8.e 

Disparities in exposure to 

secondhand smoke among

multiunit housing residents

$$ ● ● ● ●

$ Dollar signs denote a qualitative rating of the resources (funds, time, and effort) needed to 

collect and analyze data using the most commonly available data source. The more dollar signs 

(maximum four), the more resources needed. Dollar signs do not represent a specific amount or 

range of costs but are instead a relative measure of expert reviewers’ ratings regarding

resources required to collect and analyze data to measure the indicator. 

HP Denotes the indicator aligns with Healthy People 2030 Objectives. 

CHAPTER 4 - OUTCOME INDICATORS 243 
 

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GOAL AREA 4 

OUTCOME 8 

Disparities in Exposure to Secondhand Smoke Among People Who Do Not 

Smoke HP 

Indicator 

number 

4.8.a 

Goal area 4. Identify and Eliminate Disparities 

Outcome 8. Eliminate disparities in secondhand smoke exposure 

What to 

measure 

Proportion of the nonsmoking population who report exposure to 

secondhand smoke, overall, and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of the nonsmoking population who report 

exposure to secondhand smoke by population group characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.4.a, “Proportion of nonsmokers exposed to secondhand

smoke.”

Rationale Secondhand smoke (SHS) exposure has been causally linked to a number 

of adverse health outcomes, including heart disease and lung cancer in 

adults, and increased risk of acute respiratory infections, ear problems, and 

sudden infant death syndrome in children.1,2 SHS contains more than 7,000 

chemicals; hundreds are toxic, and nearly 70 can cause cancer.2 About 1 

in 4 people in the U.S remain exposed to secondhand smoke.3 

Applying Studies have found that exposure to SHS remains higher among certain 

health population groups, including children, youth, African American or Black 

disparities persons, LGBTQ+ persons, persons with low educational attainment, 

framing persons with low income, blue collar and service workers, and multiunit 

housing residents. 

3-9 Moreover, persons residing in states without 

comprehensive smokefree policies and a lower proportion of households 

without smokefree home rules, including states in the Southern and 

Midwestern geographic areas of the U.S., have higher exposure to SHS.1-

2,10 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

National Health and Nutrition Examination Survey (NHANES), 2013-2014 

Social Climate Survey of Tobacco Control (SCS-TC), 2015 

Example From NYTS (2020) 

survey During the past 30 days, on how many days did you breathe the smoke question(s) from someone who was smoking tobacco products in an indoor public 

place? Examples of indoor public places are school buildings, stores, 

restaurants, and sports arenas. 

• 0 days 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 244 
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GOAL AREA 4 

OUTCOME 8 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

During the past 30 days, on how many days did you breathe the 

smoke from someone who was smoking tobacco products in an 

outdoor public place? Examples of outdoor public places are school 

grounds, parking lots, stadiums, and parks. 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

From NHANES (2017-2018) 

Measured serum cotinine level greater than or equal to 0.05 ng/mL and 

less than or equal to 10 ng/mL among self-reported non-tobacco users and 

those not using nicotine replacement therapy. (biochemical marker) 

From SCS-TC (2015) 

During the past SEVEN DAYS, in which of the following places have you 

smelled secondhand tobacco smoke? 

• In your home 

• In your car 

• At work 

• In an indoor public place, such as a restaurant or salon 

Comment Exposure to secondhand smoke can be measured in many ways, including 

by using self-reported data, biochemical markers, or environmental 

measures of air quality. Self-reported tobacco product users and those 

currently using nicotine replacement therapy should be excluded when 

measuring smoke exposure via biochemical markers. When employing 

survey options, questions about tobacco use status (current tobacco-user, 

former tobacco user, or non-tobacco user) should be connected to 

questions about exposure. Self-reported data is not feasible for measuring 

exposure among very young children. For more information on measuring 

secondhand smoke exposure, please refer to the Evaluation Toolkit for 

Smoke-free Policies. 

CHAPTER 4 - OUTCOME INDICATORS 245 
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GOAL AREA 4 

OUTCOME 8 

Exposure to e-cigarette aerosol should be examined separately. Tobacco 

control programs can refer Eliminating Exposure to Secondhand Smoke: 

Outcome Indicators for Comprehensive Tobacco Control Programs–2017, 

Indicator 2.4 “Proportion of non-users exposed to secondhand e-cigarette 

aerosol” for additional guidance.

This indicator is related to a Healthy People 2030 objective TU-19: 

Reduce the proportion of people who don't smoke but are exposed to 

secondhand smoke. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better

References 1. U.S. Department of Health and Human Services. The health

consequences of involuntary exposure to tobacco smoke: a report of

the Surgeon General. Atlanta, GA: 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.

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, National Center

for Chronic Disease Prevention and Health Promotion, Office on

Smoking and Health; 2014.

3. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in

nonsmokers’ exposure to secondhand smoke—United States, 1999–

2012. MMWR Morb Mortal Wkly Rep. 2015;64(4):103-108.

4. U.S. National Cancer Institute. A socioecological approach to

addressing tobacco-related health disparities. National Cancer Institute

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A.

Bethesda, MD: U.S. Department of Health and Human Services,

National Institutes of Health, National Cancer Institute; 2017.

5. Max WB, Stark B, Sung H-Y, Offen N. Sexual identity disparities in

smoking and secondhand smoke exposure in California: 2003–2013.

Am J Public Health. 2016;106(6):1136-42.

6. Gan WQ, Mannino DM, Jemal A. Socioeconomic disparities in

secondhand smoke exposure among US never-smoking adults: the

National Health and Nutrition Examination Survey 1988–2010. Tob

Control. 2015;24(6):568-73.

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 

$$ ● ● ● ●

246 
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GOAL AREA 4 

OUTCOME 8 

7. Arheart KL, Lee DJ, Dietz NA, et al. Declining trends in serum cotinine 

levels in U.S. worker groups: the power of policy. Journal Occup 

Environ Med. 2008;50(1):57-63. 

8. Nguyen KH, Gomez Y, Homa DM, King BA. Tobacco use, secondhand 

smoke, and smoke-free home rules in multiunit housing. Am J Prev 

Med. 2016;51(5):682–692. 

9. Licht AS, King BA, Travers MJ, Rivard C, Hyland AJ. Attitudes, 

experiences, and acceptance of smoke-free policies among US 

multiunit housing residents. Am J Public Health. 2012;102(10):1868–

1871. 

10. Singh GK, Siahpush M, Kogan MD. Disparities in children's exposure to 

environmental tobacco smoke in the United States, 2007. Pediatrics. 

2010;126(1):4-13. 

CHAPTER 4 - OUTCOME INDICATORS 247 
 

 

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OUTCOME 8 

Disparities in Exposure to Secondhand Smoke in the Workplace 

Indicator 

number 

4.8.b 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 8. Eliminate disparities in secondhand smoke exposure 

What to 

measure 

Proportion of the population who are employed outside the home and who 

report exposure to secondhand smoke in the workplace, overall, and 

among population groups experiencing tobacco-related disparities 

Differences in the proportion of the population who are employed outside 

the home and who report exposure to secondhand smoke in the workplace 

by population group characteristics and occupation 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.4.b, “Proportion of the employed population exposed to 

secondhand smoke in the workplace.”

Rationale The workplace is a primary source of involuntary exposure to tobacco 

smoke for adults.1,2 Secondhand smoke exposure in the workplace has 

been linked to an increased risk of adverse health outcomes, including 

heart disease and cancer.1,2 About one-fifth of employed U.S. adults who 

do not smoke report secondhand smoke exposure in the workplace.3 

Studies have shown significantly higher levels of tobacco smoke exposure 

in restaurants, bars, and casinos not covered by comprehensive smokefree 

policies.1,3 

Applying Certain population groups, including young adults, men, African American 

health or Black persons, Latino/Hispanic persons, persons with low educational 

disparities attainment, and persons with low income, have reported higher exposure to 

framing SHS in the workplace.4-8 Research has shown that blue collar and service 

workers experience higher exposure to workplace SHS than do Whitecollar workers.3-5 In particular, persons who work in certain occupations, 

including construction, mining, accommodation and food services, and 

repair and maintenance, are disproportionately exposed to SHS.3-6 

Example data 

source(s) 

National Health and Nutrition Examination Survey (NHANES), 2019-2020 

National Health Interview Survey (NHIS), 2015 

Social Climate Survey of Tobacco Control (SCS-TC), 2015 

Example From NHANES (2019-2020) 

survey While {you were/SP was} working at a job or business outside of the home, question(s) did someone else smoke cigarettes or other tobacco products indoors? 

• Yes 

• No 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 248 
 

► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 8 

• Refused 

• Don’t know

From NHIS (2015) 

DURING THE PAST 12 MONTHS, while at work, how often were you 

exposed to tobacco smoke from other people? Would you say... 

• Never 

• Less than twice a week 

• Twice a week or more, but not every day 

• Every day 

• Refused 

• Don't know 

From SCS-TC (2015) 

During the past SEVEN DAYS, in which of the following places have you 

smelled secondhand tobacco smoke? 

• In your home 

• In your car 

• At work 

• In an indoor public place, such as a restaurant or salon 

Comments Tobacco control programs may want to assess this indicator by occupation 

since exposure to secondhand smoke can vary by occupation type. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

the Surgeon General. Atlanta, GA: 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. 

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: 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. 

CHAPTER 4 - OUTCOME INDICATORS 249 
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GOAL AREA 4 

OUTCOME 8 

3. Su C, Syamlal G, Tamers S, Li J, Luckhaupt SE. Workplace 

secondhand tobacco smoke exposure among U.S. nonsmoking 

workers, 2015. MMWR Morb Mortal Wkly Rep. 2019;68:604–607. 

4. Calvert GM, Luckhaupt SE, Sussell A, Dahlhamer JM, Ward BW. The 

prevalence of selected potentially hazardous workplace exposures in 

the US: findings from the 2010 National Health Interview Survey. Am J 

Ind Med. 2013;56(6):635-46. 

5. U.S. National Cancer Institute. A socioecological approach to 

addressing tobacco-related health disparities. National Cancer Institute 

Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. 

Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; 2017. 

6. U.S. Bureau of Labor Statistics. Labor force statistics from the Current 

Population Survey. 2019. Accessed April 23, 2020. 

https://www.bls.gov/cps/cpsaat11.htm 

7. Gan WQ, Mannino DM, Jemal A. Socioeconomic disparities in 

secondhand smoke exposure among US never-smoking adults: the 

National Health and Nutrition Examination Survey 1988–2010. Tob 

Control. 2015;24(6):568-73. 

8. Harris JK, Geremakis C, Moreland-Russell S, et al. Demographic and 

geographic differences in exposure to secondhand smoke in Missouri 

workplaces, 2007-2008. Prev Chronic Dis. 2011;8(6). 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 250 
 

► 

GOAL AREA 4 

OUTCOME 8 

Disparities in Exposure to Secondhand Smoke in Indoor Public Spaces 

Indicator 

number 

4.8.c 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 8. Eliminate disparities in secondhand smoke exposure 

What to 

measure 

Proportion of the population reporting exposure to secondhand smoke in 

indoor public spaces, overall, and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of the population reporting exposure to 

secondhand smoke in indoor public spaces by population group 

characteristics 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 4 (2017) 2.4.c, “Proportion of the population exposed to secondhand

smoke in indoor public places.”

Rationale Indoor secondhand smoke is the main source of exposure to tobacco 

smoke among people who do not smoke. 

1 SHS exposure has been 

causally linked to a number of adverse health outcomes, including heart 

disease and lung cancer in adults, and increased risk of acute respiratory 

infections, ear problems, and sudden infant death syndrome in children.1,2 

Persons in indoor locations not covered by comprehensive smokefree 

policies are at increased risk of exposure to SHS.1,3 

Applying Research shows that service and hospitality workers, largely comprised of 

health Latino/Hispanic persons and African American or Black persons, are at 

disparities increased risk of SHS exposure in indoor public spaces.5-7 One study also 

framing found that LGBTQ+ persons were disproportionately affected by SHS in 

bars.8 Studies have shown that SHS exposure in indoor public spaces also 

disproportionately impacts persons with low income and persons who live 

in states without comprehensive smoke free policies, including states in the 

Southern and Midwestern geographic areas of the U.S.1-6 

Example data 

source(s) 

National Health and Nutrition Examination Survey (NHANES), 2019-2020 

Social Climate Survey of Tobacco Control (SCS-TC), 2015 

Example From NHANES (2019-2020) 

survey While {you were/SP was} in a restaurant, did someone else smoke 

question(s) cigarettes or other tobacco products indoors? 

• Yes 

• No 

• Refused 

CHAPTER 4 - OUTCOME INDICATORS 251 
 

 

 

 

► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 8 

• Don’t know

While {you were/SP was} in a bar, did someone else smoke cigarettes or 

other tobacco products indoors? 

• Yes 

• No 

• Refused 

• Don’t know

From SCS-TC (2015) 

During the past SEVEN DAYS, in which of the following places have you 

smelled secondhand tobacco smoke? 

• In your home 

• In your car 

• At work 

• In an indoor public place, such as a restaurant or salon 

Comments Indoor public spaces include (but are not limited to) bars, restaurants, 

casinos, sporting arenas, and concert venues. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

the Surgeon General. Atlanta, GA: 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. 

2. Agaku IT, Singh T, Rolle I, Olalekan A-Y, King BA. Prevalence and 

determinants of secondhand smoke exposure among middle and high 

school students. Pediatrics. 2016;137(2):e20151985. 

3. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in 

smoke-free workplace policies among food service workers. J Occup 

Environ Med. 2004 Apr;46(4):347-56. 

4. Agaku IT, Vardavas CI. Disparities and trends in indoor exposure to 

secondhand smoke among US adolescents: 2000-2009. PLoS One. 

2013;8(12):e83058. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 252 
► 

GOAL AREA 4 

OUTCOME 8 

5. Huang J, King BA, Babb SD, Xu X, Hallett C, Hopkins M. 

Sociodemographic disparities in local smoke-free law coverage in 10 

states. Am J Public Health 2015;105:1806–13. 

6. U.S. Bureau of Labor Statistics. Labor force statistics from the Current 

Population Survey. 2019. Accessed April 23, 2020. 

https://www.bls.gov/cps/cpsaat11.htm 

7. Americans for Nonsmokers’ Rights Foundation. Secondhand smoke 

and gaming facilities. Accessed February 10, 2021. https://nosmoke.org/secondhand-smoke-gaming-facilities/ 

8. Fallin A, Neilands TB, Jordan JW, Ling PM. Secondhand smoke 

exposure among young adult sexual minority bar and nightclub 

patrons. Am J Public Health. 2014;104(2):e148–e153. 

CHAPTER 4 - OUTCOME INDICATORS 253 
 

 

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OUTCOME 8 

Disparities in Exposure to Secondhand Smoke in Homes and Vehicles 

Indicator 

number 

4.8.d 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 8. Eliminate disparities in secondhand smoke exposure 

What to 

measure 

Proportion of population groups reporting exposure to secondhand smoke 

at home, overall, and among population groups experiencing tobaccorelated disparities 

Proportion of population groups reporting exposure to secondhand smoke 

in their vehicles, overall, and among population groups experiencing 

tobacco-related disparities 

Differences in the proportion of the population reporting exposure to 

secondhand smoke at home by population group characteristics 

Differences in the proportion of the population reporting exposure to 

secondhand smoke in their vehicles by population group characteristics 

Similar Goal 2 (2017) 2.4.h, “Proportion of the population exposed to secondhand

existing smoke originating in their homes.”

indicator(s) Goal 2 (2017) 2.4.i, “Proportion of the population exposed to secondhand

from other smoke in vehicles.”

goal areas 

Rationale Private settings such as homes and vehicles remain a major source of 

exposure to secondhand smoke for many people who do not smoke; 

homes are the main source of SHS exposure for children.1 SHS exposure 

has been causally linked to a number of adverse health outcomes, 

including heart disease and lung cancer in adults, and increased risk of 

acute respiratory infections, ear problems, and sudden infant death 

syndrome in children.1-3 Although exposure among people who do not 

smoke in the U.S. has declined in the past few decades overall and in 

private settings, many people, including children, continue to be exposed to 

SHS in private settings.4,5 Exposure to SHS is higher in homes and 

vehicles without voluntary smokefree rules.6-8 

Applying Research has found that certain population groups, including children, 

health youth, African American or Black persons, Latino/Hispanic persons, 

disparities LGBTQ+ persons, persons with low educational attainment, persons with 

framing low income, and persons who reside in the Midwestern and Southern 

geographic areas of the U.S., experience higher prevalence of SHS 

exposure in private settings.4,5,8-14 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 254 
 

► 

GOAL AREA 4 

OUTCOME 8 

Example data 

source(s) 

National Youth Tobacco Survey (NYTS), 2020 

National Health and Nutrition Examination Survey (NHANES), 2019-2020 

Social Climate Survey of Tobacco Control (SCS-TC), 2015 

Example From NYTS (2020) 

survey During the past 7 days, on how many days did someone smoke tobacco question(s) products in your home while you were there? 

• 0 days 

• 1 day 

• 2 days 

• 3 days 

• 4 days 

• 5 days 

• 6 days 

• 7 days 

During the past 7 days, on how many days did you ride in a vehicle when 

someone was smoking a tobacco product? 

• 0 days 

• 1 day 

• 2 days 

• 3 days 

• 4 days 

• 5 days 

• 6 days 

• 7 days 

Does anyone who lives with you now...? (Select one or more)

• Smoke cigarettes 

• Smoke cigars, cigarillos, or little cigars 

• Use chewing tobacco, snuff, or dip 

• Use e-cigarettes 

• Smoke tobacco in a hookah or waterpipe 

• Smoke pipes filled with tobacco (not waterpipes) 

• Use snus 

• Use dissolvable tobacco products 

• Smoke bidis (small brown cigarettes wrapped in a leaf) 

• No one who lives with me now uses any form of tobacco 

From NHANES (2019-2020) 

While {you were/SP was} riding in a car or motor vehicle, did someone else 

smoke cigarettes or other tobacco products? 

• Yes 

CHAPTER 4 - OUTCOME INDICATORS 255 
 

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- I 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 8 

• No 

• Refused 

• Don’t know

While {you were/SP was} in a home other than {your/his/her} own, did 

someone else smoke cigarettes or other tobacco products indoors? 

• Yes 

• No 

• Refused 

• Don’t know 

From SCS-TC (2015) 

Over the past 3 months, has anyone smoked anywhere in your home? 

• Yes 

• No 

Over the past 3 months, has anyone smoked in your car? 

• Yes 

• No 

During the past SEVEN DAYS, in which of the following places have you 

smelled secondhand tobacco smoke? 

• In your home 

• In your car 

• At work 

• In an indoor public place, such as a restaurant or salon 

Comments Not applicable. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

←○ ◕ ●→ better 

References 1. U.S. Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

the Surgeon General. Atlanta, GA: 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. 

2. Nguyen KH, King BA, Dube SR. Association between current asthma 

and secondhand smoke exposure in vehicles among adults living in 

four US states. Tob Control. 2015;24(4):376–381. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 256 
► 

GOAL AREA 4 

OUTCOME 8 

3. Sly PD, Deverell M, Kusel MM, et al. Exposure to environmental 

tobacco smoke in cars increases the risk of persistent wheeze in 

adolescents. Med J Aust. 2007;186(6):322. 

4. Agaku IT, Vardavas CI. Disparities and trends in indoor exposure to 

secondhand smoke among US adolescents: 2000-2009. PLoS One. 

2013;8(12):e83058. 

5. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in 

nonsmokers’ exposure to secondhand smoke—United States, 1999–

2012. MMWR Morb Mortal Wkly Rep. 2015 Feb 6;64(4):103–8. 

6. King BA, Dube SR, Homa DM. Smoke-free rules and secondhand 

smoke exposure in homes and vehicles among US adults, 2009-2010. 

Prev Chronic Dis. 2013;10:E79. 

7. Cartmell KB, Miner C, Carpenter MJ, et al. Secondhand smoke 

exposure in young people and parental rules against smoking at home 

and in the car. Public Health Rep. 2011;126(4):575–582. 

8. Agaku IT, Singh T, Rolle I, Olalekan A-Y, King BA. Prevalence and 

determinants of secondhand smoke exposure among middle and high 

school students. Pediatrics. 2016;137(2):e20151985. 

9. Max WB, Stark B, Sung H-Y, Offen N. Sexual identity disparities in 

smoking and secondhand smoke exposure in California: 2003–2013. 

Am J Public Health. 2016;106(6):1136-42. 

10. Singh GK, Siahpush M, Kogan MD. Disparities in children's exposure to 

environmental tobacco smoke in the United States, 2007. Pediatrics. 

2010;126(1):4-13. 

11. Margerison-Zilko C, Cubbin C. Socioeconomic disparities in tobaccorelated health outcomes across racial/ethnic groups in the United 

States: national health interview survey 2010. Nicotine Tob Res. 

2012;15(6):1161-5. 

12. Gamarel KE, Kahler CW, Lee JH, et al. Sexual orientation disparities in 

smoking vary by sex and household smoking among US adults: 

Findings from the 2003–2012 National Health and Nutrition 

Examination Surveys. Prev Med. 2016;82:1-6. 

13. Brody DJ, Lu Z, Tsai J. Secondhand smoke exposure among 

nonsmoking youth: United States, 2013-2016. NCHS Data Brief. 2019 

Aug;(348):1-8. 

14. Jordan JN, McElroy JA, Everett KD. Smoking initiation, tobacco product 

use, and secondhand smoke exposure among general population and 

sexual minority youth, Missouri, 2011-2012. Prev Chronic Dis. 

2014;11:E113-E. 

CHAPTER 4 - OUTCOME INDICATORS 257 
 

 

► 

GOAL AREA 4 

OUTCOME 8 

Disparities in Exposure to Secondhand Smoke Among Multiunit Housing 

Residents 

Indicator 

number 

4.8.e 

Goal area 4. Identify and eliminate tobacco-related disparities 

Outcome 8. Eliminate disparities in secondhand smoke exposure 

What to 

measure 

Proportion of multiunit housing residents reporting exposure to secondhand 

smoke from nearby housing units or shared areas, overall, and among 

population groups experiencing tobacco-related disparities 

Differences in the proportion of multiunit housing residents reporting 

exposure to secondhand smoke from nearby housing units or shared areas 

by population characteristics and type of multiunit housing 

Similar 

existing 

indicator(s) 

from other 

goal areas 

Goal 2 (2017) 2.4.g, “Proportion of multiunit housing residents exposed to 

secondhand smoke in their homes from nearby units or shared areas.”

Rationale About 80 million (1 in 4 people) in the U.S. live in multiunit housing, 

including about 7 million living in government-subsidized housing.1,2 

Persons who live in multiunit housing are at increased risk of SHS 

exposure because SHS can enter their units from nearby units and 

common areas.1-4 Each year, about a third of U.S. multiunit housing 

residents with smokefree home rules experience secondhand smoke 

incursions in their unit from elsewhere in their building.5 

Applying Certain types of multiunit housing, including government-subsidized 

Health housing, are occupied by large proportions of vulnerable population groups 

Disparities that are at higher risk for chronic disease and poor health outcomes, 

Framing including children, older adults, racial/ethnic minorities, persons with low 

income, and persons with disabilities. 

1,4,6-7 Moreover, certain population 

groups, including African American or Black persons, Latino/Hispanic 

persons, persons with low educational attainment, and persons with low 

income have reported higher levels of multiunit housing SHS 

exposure.4,5,8,9 Research has also shown that children who live in multiunit 

housing have higher levels of SHS exposure than those living in single 

family homes.10 

Example data 

source(s) 

National Health and Nutrition Examination Survey (NHANES), 2019-2020 

Example 

survey 

question(s) 

From NHANES (2019-2020) 

I would like to ask you a few questions about your home. Please look at 

this card. Which best describes your house or building? 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 258 
 

► 

GOAL AREA 4 

OUTCOME 8 

• A one-family house detached from any other house 

• A one-family house attached to one or more houses 

• A building with 2 apartments 

• A building with 3 or 4 apartments 

• A building with 5 to 9 apartments 

• A building with 10 to 19 apartments 

• A building with 20 to 49 apartments 

• A building with 50 or more apartments 

• A mobile home, trailer, or manufactured home 

• A dormitory or similar boarding house 

• Refused 

• Don't know 

Is this home owned, being bought, rented, or occupied by some other 

arrangement by {you/you or someone else in your family}? 

• Owned or being bought 

• Rented 

• Other arrangement 

• Refused 

• Don't know 

Not counting decks, porches, or detached garages, how many people who 

live here smoke cigarettes, cigars, little cigars, pipes, water pipes, hookah, 

or any other tobacco product inside this home? 

• [Enter number of persons] 

• Refused 

• Don't know 

During the past 7 days, that is since last [TODAY’S DAY OF WEEK], on

how many days did {anyone who lives here/you}, smoke tobacco inside 

this home? 

• [Enter number of days] 

• Refused 

• Don't know 

Comments When assessing this indicator, tobacco control programs can also measure 

secondhand smoke in common areas or residences by monitoring indoor 

air quality. 

Rating Strength Overall 

of quality Resources evaluation Face Accepted 

low ↔ high needed evidence Utility validity practice 

CHAPTER 4 - OUTCOME INDICATORS 259 
► 

$$ ● ● ● ●

GOAL AREA 4 

OUTCOME 8 

←○ ◕ ●→ better 

References 1. King BA, Babb SD, Tynan MA, Gerzoff RB. National and state 

estimates of secondhand smoke infiltration among US multiunit 

housing residents. Nicotine Tob Res. 2012;15(7):1316-21. 

2. King BA, Travers MJ, Cummings KM, Mahoney MC, Hyland AJ. 

Secondhand smoke transfer in multiunit housing. Nicotine Tob Res. 

2010;12(11):1133-41.U.S. Department of Housing and Urban 

Development, Public Housing Agency Profiles. Accessed March 24, 

2020. https://www.huduser.gov/portal/pdrdatas_landing.html 

3. Chambers C, Sung H-Y, Max W. Home exposure to secondhand 

smoke among people living in multiunit housing and single family 

housing: a study of California adults, 2003–2012. J Urban Health. 

2015;92(2):279-90. 

4. Wilson KM, Torok M, McMillen R, Tanski S, Klein JD, Winickoff JP. 

Tobacco smoke incursions in multiunit housing. Am J Public Health. 

2014;104(8):1445-53. 

5. Nguyen K, Gomez Y, Homa DM, King BA. Tobacco use, secondhand 

smoke, and smoke-free home rules in multiunit housing. Am J Prev 

Med. 2016 Nov;51(5):682-692. 

6. U.S. Department of Health and Human Services. The health 

consequences of involuntary exposure to tobacco smoke: a report of 

the Surgeon General. Atlanta, GA: 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. 

7. U.S. Department of Housing and Urban Development. Resident 

characteristics report. 2020. Accessed April 24, 2020. 

https://pic.hud.gov/pic/RCRPublic/rcrmain.asp 

8. Delgado-Rendon A, Cruz TB, Soto D, Baezconde-Garbanati L, Unger 

JB. Second and thirdhand smoke exposure, attitudes and protective 

practices: results from a survey of Hispanic residents in multi-unit 

Housing. J Immig Min Health. 2017;19(5):1148-55. 

9. Hewett MJ, Sandell SD, Anderson J, Niebuhr M. Secondhand smoke in 

apartment buildings: renter and owner or manager perspectives. 

Nicotine Tob Res. 2007;9(Suppl_1):S39-S47. 

10. Wilson KM, Klein JD, Blumkin AK, Gottlieb M, Winickoff JP. Tobacco 

smoke exposure in children who live in multiunit housing. Pediatrics 

2011:127(1):85-92. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 260 

APPENDICES 

 

 

 

 

 

 

Appendix A: Instructions for Expert Panel Reviewers 

CDC/OSH Key Outcome Indicator 2019 

Instructions for Expert Reviewers 

Background and Purpose 

In 2005, CDC’s Office on Smoking and Health (OSH) released the guidance document, Key 

Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs (KOI Guide) to 

assist state and territorial tobacco control program evaluation efforts under the National 

Tobacco Control Program (NTCP). The guide described key outcome indicators (KOIs) for 

evaluation of comprehensive tobacco control programs that were linked to the following National 

Tobacco Control Program (NTCP) goal areas: (1) Prevent initiation among youth and young 

adults; (2) Eliminate exposure to secondhand smoke; and (3) Promote quitting among adults 

and youth. The primary audiences for the publication included (1) planners, managers, and 

evaluators of state programs to prevent or control tobacco use, and (2) CDC’s national partners.

Since the release of the 2005 guide, there have been substantial changes and advances in 

tobacco control. Between 2014 and 2017, OSH collaborated with partners to review, revise, and 

release updated KOI guides for NTCP goal areas 1 through 3 to reflect changes in the tobacco 

control landscape. For each of the goal areas, indicators, data sources, and survey items were 

updated to reflect the current state of the science. At the time, the 2005 KOI Guide did not 

describe indicators for NTCP Goal Area 4: Eliminating Tobacco-related Disparities but identified 

the goal area as a future direction for the work of OSH. 

OSH is currently working on developing a KOI guide for NTCP goal area 4. When complete, this 

guide will serve as the fourth in a series of outcome indicator guides and the first to focus on 

tobacco-related disparities. We are implementing a similar process to what was used during the 

development and external review of the prior outcome indicator guides. As a first step, a list of 

draft outcome indicators has been developed based on the existing outcome indicator guides 

and a literature review of tobacco-related disparities research. 

The updated KOI Guide will serve the same functions as the initial report, including: 

• Serve as a companion to OSH’s Best Practices for Comprehensive Tobacco Control 

Programs and Introduction to Program Evaluation for Comprehensive Tobacco Control 

Programs, as well as to the updated KOI guides for NTCP goal areas 1 through 3. 

• Describe key outcome indicators for evaluation of statewide, comprehensive tobacco 

control programs, and suggest appropriate data sources and measures for these indicators. 

• Encourage states to use consistent evaluation measures and comparable data sources. 

• Guide the provision of consistent surveillance and evaluation technical assistance to states. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs II 
Methods 

The candidate indicators included in the following document have been identified through an 

extensive review of the literature, review of the prior indicators, and input from OSH. Each of the 

proposed indicators included in this document is linked to a component of the proposed Goal 

Area 4 logic model included in Exhibit 1. Internal indicator selection decisions were guided by a 

need to highlight key indicators for planning and evaluating comprehensive tobacco control 

programs. Linkages connecting antecedent and consequent logic model components (boxes), 

and nested indicators were reviewed for evidence of association. An initial draft of the logic 

model was sent to a handful of external experts for preliminary review, and their feedback was 

used to update the draft logic model. 

While OSH does not directly fund many institutions that strongly influence disparities (e.g., 

education, housing), state, territorial, and local tobacco control programs are encouraged to 

partner and include these institutions in their coalitions as part of their capacity building efforts. 

Consequently, this guide focuses on indicators and markers of progress for tobacco-related 

disparities outcomes. However, unlike the logic model in Goal 1, 2, and 3 KOI Guides, we 

incorporated antecedent community capacity indicators necessary to effectively implement 

interventions to identify and eliminate tobacco-related disparities before consequent short, 

intermediate, and long-term outcomes can occur. We included these indicators to recognize and 

emphasize that community and institutional level changes are critical to achieving individual and 

population-level health outcomes. 

Rating Process 

The principal purpose of this expert review process is to provide CDC/OSH with expert opinion 

about the quality and utility of the candidate indicators for use in planning and evaluating 

comprehensive state tobacco control programs, and what data sources and measures would be 

most useful for tracking these indicators. Reviewers are asked to do the following: 

• Rate each indicator on a set of criteria 

• Comment on the data source and measures that have been identified for each proposed 

indicator 

• Suggest alternative data sources and measures 

• Comment on the priority populations that have been identified for each proposed 

indicator 

• Comment on the degree to which the proposed indicators would influence disparities 

• Offer additional indicators that may be useful for state tobacco control program 

evaluation 

• Identify indicators that are redundant or, for other reasons, should be deleted 

This review process also aims to gather expert feedback on the quality and utility of the 

proposed Goal Area 4 logic model. Reviewers are asked to provide open-ended comments 

reflecting the strengths and weaknesses of the model, if any. 

Appendix A III 
 

 

 

 

The final product will be similar to the original and updated KOI Guides in that it will include 

tables displaying the indicators, ratings of the indicators along the review criteria, and detail 

summary information on each indicator. 

We would like you to rate the indicators based on your expertise and experience in this 

substantive area using the following criteria: 

• Strength of evidence 

• Costs (in money, time, and other resources) required to collect and analyze indicator 

data 

• Utility 

• Face validity 

• Uniqueness 

• Conformity with accepted practice 

• Overall quality 

Below you will find additional clarification and guidance regarding these rating criteria. 

Rating Form 

The proposed Goal Area 4 logic model is followed by an open-ended response box, 

independent from the indicator rating forms. No particular criteria are required to comment on 

the model. 

Each indicator is presented on a separate rating form. The rating forms have three sections: 

• Summary information on the proposed indicator, including what to measure, example 

data sources, priority population group(s), example survey questions, other relevant 

information, and a reference regarding the evidence supporting use of the indicator, 

where available. Please note that the references provided are intended to support the 

inclusion of certain priority population groups and not intended to be a comprehensive 

bibliography. 

• Rating criteria scales for reviewer response 

• Space for open-ended reviewer comments on priority populations included and on the 

proposed indicator, including data sources/measures 

In the summary information section on the rating forms, the example data sources/measures 

suggested are intended only to help operationalize the indicators and do not represent a 

comprehensive list of all possible measures for the indicators. Additionally, information 

included in the “Comments” section has been limited to what will help to provide clarity or

address nuances of the specific indicator. The final, updated KOI Guide will include suggestions 

for other uses of the indicator, the indicator’s limitations (if any) as a measure of a program’s

progress, or sources of other information on data collection methods. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs IV 
 

IMPORTANT NOTE: Given our plan to provide information on current, relevant indicators for 

tobacco control, we ask that you not reference the original KOI Guide or the subsequent goal 

area guides when rating these candidate indicators. Please rate the following indicators based 

on your expertise and knowledge of the current state of the science on tobacco-related 

disparities. This will help to identify indicators that are not pertinent or that have limited 

supporting evidence. 

Rating Criteria 

The following criteria are to be used to rate each indicator: 

1. Strength of the evaluation evidence—extent to which you believe that the literature 

supports use of the indicator for the evaluation of comprehensive, statewide tobacco 

control programs, as characterized by the logic model. The references included on each 

indicator rating form are intended to provide guidance in your ratings on this criterion, but 

your knowledge of the literature should also be used. Please add your comments 

regarding conflicting evidence, additional citations, and/or concerns with methodology. 

2. Costs required for collecting and analyzing indicator data—your rating of the cost (in 

money, time, other resources) to collect reliable and precise measures, and to analyze 

appropriately primary or secondary data on the indicator. In making your judgments, 

please consider availability of existing data (e.g., archival records or other secondary data) 

versus need for primary data collection, and methodological and sampling issues. 

3. Utility—extent to which you believe that the indicator would help to answer important 

comprehensive tobacco control program evaluation questions. Although these indicators 

may also be appropriate and useful for community-level evaluation, the utility criterion 

refers primarily to statewide efforts. 

4. Face validity—your estimation of how face valid the indicator would appear to be in the 

eyes of key program stakeholders, including policymakers and decision-makers who may 

be users of tobacco control program evaluation results. 

5. Uniqueness—your opinion of whether the indicator contributes distinct information for the 

evaluation of tobacco control efforts. If you believe that the indicator is not unique, please 

note the redundant indicator in the space provided. 

6. Conformity with accepted practice—your opinion of the degree to which use of the 

indicator is consistent with currently accepted, “real-world” tobacco control practice.

7. Overall quality—a summary rating that reflects your opinion of the overall quality of the 

indicator. 

Reviewer Comments 

Please provide comments and suggestions regarding the priority populations listed, proposed 

logic model, proposed indicators, data sources, and measures in the spaces provided. The 

electronic copy of the review materials limits where you may add information; however, there is 

no character limit to text responses, so please be as expansive with your responses as 

necessary. Upon completion, please save a copy and return as an email attachment. 

Appendix A V 
Rating Form 

Indicator: 

Please darken the square that best reflects your opinion: 

1. Scientific literature supports 

use of the indicator: 

2. Cost (in money, time, other 

resources) required to collect 

and analyze indicator data: 

3. Utility of the indicator to 

answer key program 

effectiveness and impact: 

Strong support Low cost Strong utility 

Moderate support Moderate cost Moderate utility 

Minimal support High cost Minimal utility 

No support Very high cost No utility 

Don’t know Don’t know Don’t know 

4. How face valid the indicator 

would be to policy- and 

decision-makers: 

5. Contributes unique 

information: 

6. How consistent the indicator is 

with accepted tobacco control 

practice: 

Highly valid Unique Highly consistent 

Moderately valid Not Unique Moderately consistent 

Minimally valid 

Not at all valid 

IF NOT UNIQUE, Write Number of 

Redundant Indicator 

Minimally consistent 

Not at all consistent 

Don’t know Click here to enter text. Don’t know

Comments (include any recommendations specific to priority populations listed only): 

Click here to enter text. 

8. Overall quality of the indicator: LOW HIGH 

1 2 3 4 5 6 7 8 9 10 

9. Reviewer Comments (including any recommendations on other data sources/measures or alternative 

indicators): 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs VI 
 

 

 

 

 

 

 

 

Analysis and Synthesis of Data from the Expert Reviews 

After CDC received the completed rating forms from the experts, all criteria ratings and written 

comments were entered into an electronic file using Python. We adjusted for multiple 

responses, skipped items, and coding errors. If, for example, a rater circled more than one 

adjacent response for a criterion, we averaged the responses unless the rater had noted a 

preference for one response over another. Skipped items and “don’t know” responses were

combined into a missing data category. All data were analyzed using SAS software, Version 9.4 

(SAS Institute Inc. 2013.) 

For each type of rating, numerical data were analyzed in various ways. Frequency distributions 

of numerical data were analyzed to help us understand the raters’ perceptions of the indicators.

To limit the effect of outliers, we used the median scores for each indicator. “Uniqueness”

ratings, which were dichotomous, were only used to determine redundant indicators. Narrative 

comments included on the raters’ rating sheets were also reviewed to help us understand why

raters gave an indicator a particularly high or low rating. 

Appendix A VII 
Appendix B: Data Source Indicator Table 

The following table cross-references example data sources and indicators in this publication. 

The example data sources do not represent all data sources available. When possible, Web 

addresses are provided. For additional information on tobacco-related data sources and data 

collection methods, refer to the Introduction to Program Evaluation for Comprehensive Tobacco 

Control Programs or Surveillance and Evaluation Data Resources for Comprehensive Tobacco 

Control Programs. 

Data source Indicator number For more information 

American Lung 

Association’s State 

Legislated Actions on 

Tobacco Issues (SLATI) 

4.2.a, 4.2.b, 4.2.c, 4.2.d, 4.2.e ► https://www.lung.org/policyadvocacy/tobacco/slati 

American Lung 

Association (ALA), State 

Cessation Coverage 

4.3.g ►https://www.lung.org/policyadvocacy/tobacco/cessation/statecessation-coverage 

American Nonsmokers’ 

Rights (ANR) 

Foundation, 100% 

Smokefree U.S. Hospital 

Campuses and 

Psychiatric Facilities, 

2019 

4.3.f ►https://no-smoke.org/wpcontent/uploads/pdf/smokefreehealthcar 

e.pdf 

American Nonsmokers’ 

Rights (ANR) Foundation 

U.S. Tobacco Control 

Laws Database 

4.2.a, 4.2.b, 4.2.f, 4.2.g, 4.2.h, 

4.2.i 

►https://no-smoke.org/tobacco-controllaws-database-tool-researchers/ 

Behavioral Risk Factor 

Surveillance System 

(BRFSS), 2019 

4.5.b, 4.5.e, 4.5.f, 4.7.a, 4.7.c ►https://www.cdc.gov/brfss/index.html 

Behavioral Risk Factor 

Surveillance System 

(BRFSS), 2011 

4.1.c ►https://www.cdc.gov/brfss/index.html 

California Adult Tobacco 

Survey (CATS), 2018 

4.1.e, 4.3.d ► Not publicly available 

Identifying and Eliminating Tobacco-Related Disparities: VIII Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 
Campaign for Tobacco 

Free Kids (CTFK) 

4.2.f, 4.2.m ►https://www.tobaccofreekids.org/what 

-we-do/us/state-tobacco-taxes 

CDC State Tobacco 

Activities Tracking and 

Evaluation (STATE) 

System 

4.2.a, 4.2.c, 4.2.d, 4.2.e, 4.2.g, 

4.2.h, 4.2.m, 4.2.n, 4.5.d 

► https://www.cdc.gov/statesystem/ 

FDA, Compliance Check 

Inspection of Tobacco 

Product Retailers 

4.2.o, 4.4.b ►http://www.accessdata.fda.gov/scripts 

/oce/inspections/oce_insp_searching.cf 

m 

National Adult Tobacco 

Survey (NATS), 2013-

2014 

4.2.k ►http://www.cdc.gov/tobacco/data_stati 

stics/surveys/nats/ 

National Adult Tobacco 

Survey (NATS), 2009-

2010 

4.1.c ►http://www.cdc.gov/tobacco/data_stati 

stics/surveys/nats/ 

National Health and 

Nutrition Examination 

Survey (NHANES), 2019-

2020 

4.8.b, 4.8.c, 4.8.d, 4.8.e ► https://wwwn.cdc.gov/nchs/nhanes/ 

National Health and 

Nutrition Examination 

Survey (NHANES), 2015-

2016 

4.6.c ► https://wwwn.cdc.gov/nchs/nhanes/ 

National Health and 

Nutrition Examination 

Survey (NHANES), 2013-

2014 

4.8.a ► https://wwwn.cdc.gov/nchs/nhanes/ 

National Health Interview 

Survey (NHIS), 2020 

4.3.c, 4.3.d, 4.5.e ► http://www.cdc.gov/nchs/nhis.htm 

National Health Interview 

Survey (NHIS), 2017 

4.3.b ► http://www.cdc.gov/nchs/nhis.htm 

National Health Interview 

Survey (NHIS), 2015 

4.8.b ► http://www.cdc.gov/nchs/nhis.htm 

National Health Interview 

Survey Cancer 

Supplement (NHIS-CS), 

2015 

4.5.c ► http://www.cdc.gov/nchs/nhis.htm 

Appendix B IX 
National Mental Health 

Services Survey (NMHSS), 2020 

4.3.a, 4.3.e, 4.3.f ► https://www.samhsa.gov/data/datawe-collect/n-mhss-national-mentalhealth-services-survey 

National Survey of 

Substance Abuse 

Treatment Services (NSSATS), 2020 

4.3.a,4.3.e, 4.3.f ►https://www.samhsa.gov/data/datawe-collect/nssats-national-surveysubstance-abuse-treatment-services 

National Youth Tobacco 

Survey (NYTS), 2020 

4.1.a, 4.1.b, 4.3.b, 4.3.c, 4.4.c, 

4.4.e, 4.5.a, 4.5.b, 4.5.f, 4.6.a, 

4.6.c, 4.7.a, 4.7.b, 4.7.c, 4.7.d, 

4.7.e, 4.8.a, 4.8.d 

►https://www.cdc.gov/tobacco/data_sta 

tistics/surveys/nyts/ 

National Quitline Data 

Warehouse (NQDW) 

Intake Survey, 2020 

4.5.a ►https://www.naquitline.org/page/NatD 

ataWarehouse 

National Quitline Data 

Warehouse (NQDW), 

Quitline Services 

Survey, 2020 

4.5.d ►https://www.naquitline.org/page/NatD 

ataWarehouse 

Nationwide Adult 

Medicaid Consumer 

Assessment of 

Healthcare Providers 

and Systems (NAM 

CAHPS), 2014-2015 

4.3.d ► https://www.cms.gov/ResearchStatistics-Data-and-Systems/Files-forOrder/LimitedDataSets/CAHPS.html 

Nielsen Store Scanner 

Tobacco Product Pricing 

Data 

4.2.l, 4.4.f ►https://www.nielsen.com/us/en/solutio 

ns/measurement/retailmeasurement.html 

North American Industry 

Classification Systems 

(NAICS) 

4.4.a ►www.naics.com 

Population Assessment 

of Tobacco and HealthAdult Survey (PATH-A), 

2016-2017 

4.1.a, 4.1.b, 4.4.e, 4.4.g, 4.5.c, 

4.6.b, 4.7.b, 4.7.c, 4.7.d, 4.7.e 

►https://www.icpsr.umich.edu/icpsrweb 

/NAHDAP/series/606 

Identifying and Eliminating Tobacco-Related Disparities: X Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 
Population Assessment 

of Tobacco and HealthAdult Survey (PATH-A), 

2013-2014 

4.4.e ►https://www.icpsr.umich.edu/icpsrweb 

/NAHDAP/series/606 

Population Assessment 

of Tobacco and HealthYouth Survey (PATH-Y) , 

2016-2017 

4.1.a, 4.1.b, 4.4.e, 4.6.b ►https://www.icpsr.umich.edu/icpsrweb 

/NAHDAP/series/606 

Pregnancy Risk 

Assessment Monitoring 

System (PRAMS), 2016 

4.3.b, 4.3.c , 4.3.d ►http://www.cdc.gov/prams/AboutPRA 

MS.htm 

Print, Internet Media 

Monitoring: Kantar 

Media Intelligence’s

StrategyTM database 

4.4.d ► https://www.kantarmedia.com/us/oursolutions/advertising-monitoring-andevaluation 

Social Climate Survey of 

Tobacco Control (SCSTC), 2015 

4.8.a, 4.8.b, 4.8.c, 4.8.d ►http://www.socialclimate.org / 

Social Climate Survey of 

Tobacco Control (SCSTC), 2014 

4.2.j, 4.2.k ►http://www.socialclimate.org / 

Standardized Tobacco 

Assessment source(s) 

for Retail Settings 

(STARS) 

4.4.d, 4.4.f ►https://countertobacco.org/resourcestools/store-assessment-tools/stars/ 

State Departments of 

Revenue 

4.2.m ►State-Specific Data Source 

State/local policy 

tracking system 

4.2.b, 4.2.n ►Not publicly available 

Tobacco Use 

Supplement to the 

Current Population 

Survey (TUS-CPS), 2018-

2019 

4.1.f, 4.2.i, 4.2.l, 4.3.c, 4.5.a, 

4.5.c, 4.6.a 

►https://cancercontrol.cancer.gov/brp/t 

crb/tus-cps/ 

Tobacco Use 

Supplement to the 

Current Population 

Survey (TUS-CPS), 2014-

2015 

4.2.k ►https://cancercontrol.cancer.gov/brp/t 

crb/tus-cps/ 

Appendix B XI 
Youth Risk Behavior 4.6.c, 4.7.a, 4.7.b, 4.7.c ►http://www.cdc.gov/healthyyouth/yrbs/ 

Surveillance System index.htm 

(YRBSS), 2019 

References 

1. MacDonald G, Starr G, Schooley M, Yee SL, Klimowski K, Turner K. Introduction to program 

evaluation for comprehensive tobacco control programs. Atlanta, GA: 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; 2001. 

2. Yee SL, Schooley M. Surveillance and evaluation data resources for comprehensive 

tobacco control programs. Atlanta, GA: 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; 2001. 

Identifying and Eliminating Tobacco-Related Disparities: XII Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 
 

Glossary and Acronyms 

Activities 

The events or actions that are part of a tobacco control program.

Aerosol 

Emissions of electronic nicotine delivery systems. 

Attitudes 

Biases, inclinations, or tendencies that influence a person’s response to situations,

activities, other people, or program goals. 

 

Awareness 

The extent to which people in the target population know about an event, activity, or 

campaign. 

Capacity 

The resources (e.g., staff, data collection systems, funds) needed to conduct a tobacco 

control program or to evaluate such a program. 

CBOs 

Community-Based Organizations. 

CDC 

Centers for Disease Control and Prevention. 

CMI 

Component Model of Infrastructure. 

Commercial Tobacco 

Tobacco that is manufactured by companies for use in cigarettes, e-cigarettes, 

smokeless tobacco, pipe tobacco, cigars, hookahs, and other products. Commercial 

tobacco is mass-produced and sold for profit by tobacco companies. This definition 

excludes traditional tobacco that is used for ceremonial or medicinal purposes.1 

Cultural Competence 

A set of congruent behaviors, attitudes, and policies that come together in a system, 

agency, or among professionals and enables effective work in cross-cultural situations. 

Cultural Humility 

The ability to maintain an interpersonal stance that is other-oriented (or open to the 

other) in relation to aspects of cultural identity that are most important to the person. 

Cultural humility is one construct for understanding and developing a process-oriented 

approach to competency. 

Glossary and Acronyms XIII 
Data 

Documented information or evidence. 

Data sources 

Surveys or surveillance systems used to gather data. 

Diversity (Workforce) 

An appreciation and respect for differences, similarities and opportunities inherent in the 

individuals and organizational characteristics that shape the workplace. 

E-Cigarettes 

Battery-powered devices designed to deliver aerosolized nicotine and additives to users. 

These devices are referred to as “e-cigarettes,” “e-cigs,” “cigalikes,” “e-hookahs,”

“mods,” “vape pens,” “vapes,” and “tank systems.”

Evaluation 

The process of determining whether programs—or certain aspects of programs—are 

appropriate, adequate, effective, or efficient and, if not, how to make them so. 

Example data source 

Surveys or surveillance systems used to measure an indicator and the population on 

which the data are needed. 

Face validity 

The degree to which data on an indicator appear reliable to stakeholders and policy 

makers. 

Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) 

Signed into law on June 22, 2009, it gives the Food and Drug Administration (FDA) the 

authority to regulate the manufacture, distribution, and marketing of tobacco products to 

protect public health. https://www.fda.gov/tobacco-products/rules-regulations-andguidance/family-smoking-prevention-and-tobacco-control-act-table-contents 

FDA 

U.S. Food and Drug Administration. 

FQHC 

Federally Qualified Health Center. 

Goal area 

One of the four components of the overall goal of CDC’s National Tobacco Control

Program. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs XIV 
Health Disparities 

Differences in health outcomes and their determinants between segments of the 

population, as defined by social, demographic, environmental, and geographic 

attributes.2-3 

Health Equity 

The attainment of the highest level of health for all people. Achieving health equity 

requires valuing everyone equally with focused and ongoing societal efforts to address 

avoidable inequalities, historical and contemporary injustices, and the elimination of 

health and health care disparities.4 

Health Inequities 

Systematic, unfair, unjust, and avoidable differences in health that result from 

discrimination based on socioeconomic status, age, race or ethnicity, sexual orientation 

and gender identity, education, income, disability status, geographic location, or a 

combination of these. 

HP 

Healthy People. 

Implementation 

Carrying out or putting into effect a plan or program. 

Inclusion 

A set of behaviors that encourage employees to feel valued for their unique qualities and 

experience a sense of belonging. 

Indicator 

An observable and measurable characteristic or change that shows the progress a 

program is making toward achieving a specified outcome. 

Indicator profile 

The term used in this manual for a table with detailed information on one indicator listed 

in this publication (see page 49 for an example). 

Indicator rating table 

The term used in this publication for the list of indicators associated with one outcome in 

one National Tobacco Control Program logic model. The experts’ rating for each

indicator is also included (see page 49 for an example). 

Inputs 

Resources used to plan and set up a tobacco control program. 

Intervention 

The method, device, or process used to prevent an undesirable outcome or create a 

desirable outcome. 

Glossary and Acronyms XV 
LGBTQ+ 

Lesbian, Gay, Bisexual, Transgender/Transexual, Queer. 

Logic model 

A graphic depiction of the presumed causal pathways that connect program inputs, 

activities, outputs, and outcomes. 

Morbidity 

Any departure, subjective or objective, from a state of physiological or psychological 

well-being. 

Multisectoral Partnerships 

Multi-sector partnerships are those that meaningfully include stakeholders from across 

multiple industries and groups (e.g. government, non-profit, private, and public 

organizations, community groups, and individual community members with lived 

experience), across geographic sectors (e.g. community/locality, county, multi-county 

level, state, multi-state) with varying sociodemographic characteristics (e.g. race, 

ethnicity, age, education, income, etc.), perspectives, and approaches to addressing 

SDOHs among disproportionately impacted population groups in community areas, 

tribes, and catchment areas. 

NCI 

National Cancer Institute. 

NIH 

National Institutes of Health. 

NR 

Not Rated. 

NRT 

Nicotine Replacement Therapy. 

NTCP 

National Tobacco Control Program. 

Observation 

A method of collecting data that does not involve any communication with the subjects 

being studied. The investigators merely watch for particular behaviors and record what 

they see. 

Outcome 

The results of an activity such as a countermarketing campaign or an effort to reduce 

secondhand smoke exposure among people who do not smoke. Outcomes can be 

short-term, intermediate, or long-term. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs XVI 
 

Outcome components 

The term used in this publication for the short-term, intermediate, and long-term results 

described in the National Tobacco Control Program logic models for the first three goal 

areas. These are the results expected if tobacco control programs provide the needed 

inputs and engage in the recommended activities also described in the logic models. 

Outcome evaluation 

The systematic collection of information to assess the effect of a program or an activity 

within such a program to reduce the adverse health effects of tobacco use. Good 

evaluation allows evaluators to draw conclusions about the merit of a program and make 

recommendations about the program’s direction.

Outcome overview 

The term used in this publication for the summary of the scientific evidence in support of the 

assumption that achieving an outcome on a National Tobacco Control Program logic model 

affects all concurrent and later activities and outcomes (see page 24 for an example). 

Outputs 

The direct products of a program (e.g., the materials needed for a media campaign). 

Preemption 

Federal or state legislation that prevents states or local jurisdictions from enacting tobacco 

control laws more stringent than or otherwise different from the federal or state law. 

Prevalence 

Proportion of persons in a population who have a particular disease or attribute at a 

specific point in time or over a specified period of time. 

Process evaluation 

Systematic collection of information to determine how well a program is implemented 

and the extent to which it was implemented as intended. 

Program evaluation 

Systematic collection of information about activities, characteristics, and outcomes of 

programs, used to make judgments about a program, improve its effectiveness, or 

inform decisions about future program activities. 

SDOH 

Social Determinants of Health are conditions in the environments where people are born, 

live, learn, work, play, worship, and age that lead to equal or unequal opportunities, choices, 

and access to resources needed and affect a wide range of health, functioning, and qualityof-life risks and outcomes to pursue healthy, thriving lives.5-7 

SHS 

Secondhand Smoke. 

Glossary and Acronyms XVII 
SMART 

Specific, Measurable, Achievable, Relevant, and Time-bound. 

Surveillance 

The ongoing, systematic collection, analysis, and interpretation of data about a hazard, 

risk factor, exposure, or health event. 

Survey 

A quantitative method of collecting information on a target population at one point in 

time. Surveys can be conducted by interview (in person or by telephone), mail, or 

electronically. 

Tobacco-related Health Disparities 

Differences in: (1) patterns, prevention, cessation, and treatment of commercial tobacco 

use and dependence; (2) commercial tobacco-related risk, prevalence, morbidity and 

mortality that exist among specific population groups in the United States, and globally; 

and (3) related differences in health capacity and infrastructure, access to health 

resources, and exposure to secondhand smoke and aerosol emissions.4 

Utility 

The extent to which evaluation produces reports that are disseminated to relevant 

audiences, that inform program decisions, and that have a beneficial effect. 

References 

1. National Native Network. Traditional vs. commercial tobacco. Accessed March 22, 2020. 

https://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-v-commercial/ 

2. Centers for Disease Control and Prevention. CDC health disparities and inequalities report -

United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60(Supplement):1-113. 

3. Centers for Disease Control and Prevention, Division of Community Health. A practitioner’s 

guide for advancing health equity: community strategies for preventing chronic disease. 

Atlanta, GA: US Department of Health and Human Services; 2013. 

4. US Department of Health and Human Services, National Partnership for Action to End 

Health Disparities. National stakeholder strategy for achieving health equity. Accessed July 

15, 2020.http://minorityhealth.hhs.gov/npa/files/Plans/NSS/NSS_05_Section1.pdf 

5. National Academies of Sciences, Engineering, and Medicine. Communities in action: 

pathways to health equity. 2017. Washington, DC: The National Academies Press. 

6. World Health Organization. Commission on Social Determinants of Health. Closing the gap 

in a generation: health equity through action on the social determinants of health. Accessed 

May 12, 2021. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1 

7. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related 

health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication 

8. No. 17-CA8035A. Bethesda, MD: U.S. Department of Health and Human Services, National 

Institutes of Health, National Cancer Institute; 2017. 

Identifying and Eliminating Tobacco-Related Disparities: 

Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs XVIII