User Guides 

Health Equity 

in Tobacco Prevention and Control 
Acknowledgements
 

This guide was produced by the Center for Public Health Systems Science (CPHSS) at the 

Brown School at Washington University in St. Louis. 

Primary contributors: 

Laura Brossart, Sarah Moreland-Russell, Stephanie Andersen, Anne Shea, Heidi Walsh, Sarah Schell, Laura Bach, 

Jennifer Cameron, Anneke Mohr, Laura Edison, Megan Multack, Susan Vorkoper 

Valued input was provided by: 

Stephen Babb, Diane Beistle, Rebecca Bunnell, Gloria Bryan, Kevin Collins, Shanna Cox, Monica Eischen, John 

Francis, Bridgette Garrett, Carissa Holmes, Brian King, Brick Lancaster, Rod Lew, Tim McAfee, Jane Mitchko, 

Jeannette Noltenius, Janet Porter, Gabbi Promoff, Coletta Reid, Brenda Richards, William Robinson, Robert Rodes, 

Anna Schecter, Scout, Karla Sneegas, Anne Sowell 

Valued input for the case studies was provided by: 

Bob Gordon, California LGBT Tobacco Education Partnership 

Janae Duncan, Utah Tobacco Prevention and Control Program 

Other contributions: 

Photograph on page 12 from the collection of Stanford University (tobacco.stanford.edu) 

Photograph on page 14 courtesy of Jóvenes de Salud 

Photograph on page 15 courtesy of Counter Tobacco 

Photograph on page 22 courtesy of Oklahoma State Department of Health 

Photograph on page 32 courtesy of the Jefferson County Department of Health and the Health Action Partnership 

Photograph on page 34 courtesy of the LGBT Tobacco Education Partnership, California 
 

 

 

 

Table of Contents
 

Guide to the Reader.......................................................................... 1
 

Making the Case ............................................................................. 2
 

Brief History.................................................................................. 3
 

How to........................................................................................4
 

What is Health Equity in Tobacco Prevention and Control?.................................4
 

Understanding Tobacco-Related Disparities ..............................................4
 

Figure: Graph of Current Cigarette Smoking Prevalence among Adults 18 and Older ..........4
 

Factors Influencing Tobacco-Related Disparities .......................................... 5
 

Table: Tobacco-Related Disparities & Helpful Resources ..................................8
 

Policy Interventions to Promote Health Equity.......................................... 10 


Figure: Map of Smoking Cessation Medicaid Coverage ................................. 16
 

Implementing Policies to Promote Health Equity ....................................... 18 


Table: Links Between Tobacco Control and Other Priority Issues ......................... 28
 

Providing Support ......................................................................... 33
 

In Action.................................................................................... 34
 

Case for Investment........................................................................ 38
 

Resources................................................................................... 40
 

References ................................................................................. 46
 
Health Equity l 1 

User Guides GUIDE TO THE READER

Purpose 

The Centers for Disease Control and Prevention’s 

(CDC) Office on Smoking and Health and the Center 

for Public Health Systems Science at Washington 

University in St. Louis are developing a set of user 

guides for the Best Practices for Comprehensive 

Tobacco Control Programs—2014 (Best Practices).

1 

The purpose of the user guides is to help tobacco 

control staff and partners implement evidence-based 

best practices by translating research into practical 

guidance. The user guides will focus on strategies (e.g., 

programs and interventions) that have shown strong or 

promising evidence of effectiveness. 

Content 

This user guide focuses on how comprehensive tobacco 

control programs can work to achieve health equity 

in tobacco prevention and control. Best Practices 

recommends that “Identifying and eliminating tobaccorelated disparities among population groups” be a 

primary goal of every state tobacco control program, 

along with preventing initiation among youth and 

young adults, promoting quitting among adults and 

youth, and eliminating exposure to secondhand 

smoke.1

 To further reduce overall tobacco use and 

secondhand smoke exposure, tobacco use must be 

reduced in population groups with the greatest burden 

of tobacco use and secondhand smoke exposure. 

Because tobacco control policies take a populationbased approach to improving health, policies have the 

potential to reach groups most affected by tobacco and 

reduce disparities. This guide offers tobacco control 

program staff and partners information on how to 

work toward achieving health equity when planning, 

implementing, and enforcing tobacco control policies. 

Note to the Reader 

Each instance of italicized, bolded blue text in the guide 

indicates a link to an additional resource or a page 

within the guide itself with more information. Website 

addresses for all of the blue resources noted throughout 

the guide are also included in the Resources section. 

Organization 

8	 Making the Case: a brief overview of why 

tobacco control programs should work to achieve 

health equity 

8	 Brief History: how health equity has become a 

main goal of tobacco prevention and control efforts 

8	 How to: strategies to promote health equity and 

reduce tobacco-related disparities 

8	 Providing Support: how tobacco control 

programs can support efforts to achieve health 

equity 

8	 In Action: real-world examples of efforts to achieve 

health equity in tobacco prevention and control 

8	 Case for Investment: information that can be 

used to gain support for tobacco control efforts that 

focus on health equity 

8	 Resources: publications, toolkits, and websites to 

help in planning efforts 

Best Practices for Comprehensive 

Tobacco Control Programs–20141 

The Best Practices for Comprehensive 

Tobacco Control Programs is an 

evidence-based guide to help states plan 

and establish comprehensive tobacco 

control programs. The report offers 

recommendations and supporting evidence 

for five essential components of effective 

tobacco control programs: state and 

community interventions, mass-reach health 

communication interventions, cessation 

interventions, surveillance and evaluation, 

and infrastructure, administration, and 

management. 
Health Equity l 2 

User Guides making the case

Making the Case for Health Equity 

In public health, health equity is the opportunity for everyone to reach their full health potential, regardless of any 

socially determined circumstance.2

 Health equity can be achieved in tobacco prevention and control by eliminating 

differences in tobacco use and exposure to secondhand smoke between certain groups. Well-enforced and 

comprehensive tobacco control policies (i.e., those that do not include exceptions or unclear language that may leave 

some population groups unprotected) can reduce these disparities. Unlike traditional direct-service interventions 

that focus on individual behaviors, tobacco control policies focus on large-scale, population-level changes. They 

have the potential to influence and change social norms related to tobacco initiation, use, and secondhand smoke 

exposure.1 Comprehensive tobacco control policies help achieve health equity by: 

8	 Reducing disparities among groups most affected 

by tobacco use and secondhand smoke exposure. 

Multiple, coordinated efforts can reduce tobaccorelated disparities among groups with the highest 

rates of use and secondhand smoke exposure.1,3,4,5 

These efforts can include implementing 

comprehensive smoke-free laws, increasing 

tobacco product prices, reducing targeted tobacco 

industry advertising, and offering comprehensive 

cessation services (i.e., those that include all 

seven FDA-approved cessation medications 

along with individual, group, and telephone 

counseling). Comprehensive policies can reduce 

smoking initiation, tobacco use, and exposure to 

secondhand smoke.1,6 

8	 Addressing the factors that influence tobaccorelated disparities. 

Tobacco-related disparities are challenging 

problems created and affected by a complex 

mix of factors, including social determinants of 

health, tobacco industry influence, a changing U.S. 

population, and a lack of comprehensive tobacco 

control policies. These difficult problems do not 

have a single or simple solution.7,8 Comprehensive, 

well-enforced policies help address these factors 

by changing social norms about tobacco use, 

increasing protections against exposure to 

secondhand smoke, and improving access to 

cessation resources among populations facing the 

greatest burden of tobacco use and exposure.1,9 

8	 Creating a return on investment. 

Tobacco control policies are a cost-effective way 

to reduce the health care costs of tobacco use and 

secondhand smoke exposure.6,10 Tobacco control 

programs can increase their return on investment 

when populations experiencing tobacco-related 

disparities are protected by comprehensive 

policies. Because populations experiencing health 

disparities make up a significant portion of health 

care costs, policies that focus on protecting these 

groups have the potential to significantly reduce 

overall health care costs.11 

8	 Building support for tobacco control among 

diverse parts of the community. 

Policies are interventions that can have broad 

community support. Participation from a variety 

of stakeholders creates a powerful force that can 

work to eliminate tobacco-related disparities 

and achieve health equity. For example, coalition 

efforts can increase awareness of social and cultural 

differences, challenges facing specific populations, 

the harms of tobacco use, and the importance 

of comprehensive tobacco control programs. 

When developing, implementing, and enforcing 

tobacco control policies, coalitions can create the 

sustainable partnerships that are needed to reduce 

tobacco use and secondhand smoke exposure in 

these communities. 
User Guides brief history

A Brief History 

In the fifty years since the landmark 1964 Surgeon 

General’s report, Smoking and Health, tobacco control 

policies have changed social norms and led to large 

declines in tobacco use.12 Despite reductions among 

the general population, tobacco use and secondhand 

smoke exposure is still higher among some groups.5

 In 

the early to mid-20th century, smoking was considered 

a sign of prestige; now tobacco use and secondhand 

smoke exposure represents the marginalization of 

certain groups.13 

As awareness of tobacco-related disparities has grown, 

the need to address these differences has become a 

focus of the national public health agenda. Eighteen 

national reports on the differential effects of tobacco 

use among specific populations have been published 

since 1980, with a notable increase in the past ten 

years. The 1980 Surgeon General’s report, The Health 

Consequences of Smoking for Women, was the first to 

discuss a specific population group.14 

The 1998 Surgeon General’s report, Tobacco Use Among 

U.S. Racial/Ethnic Minority Groups, discussed four 

major racial/ethnic groups and explained that tobacco 

use results from a complex interaction of factors (e.g., 

socioeconomic status, social and cultural characteristics, 

targeted advertising, and tobacco product pricing).15 

The 1999 Best Practices broadened the definition of 

disparities to include any group differently impacted by 

tobacco use and secondhand smoke exposure, not just 

particular racial or ethnic groups.16 In 2001, the Surgeon 

General’s report, Women and Smoking, made the first 

mention of smoking disparities by sexual orientation.17 

In 2008, CDC began funding National Networks for 

Tobacco Control and Prevention to reduce tobaccorelated disparities. In 2013, the CDC expanded 

this effort to include cancer-related disparities.18 

Organizations funded from 2013-2018 focus on 

the following groups: American Indians/Alaska 

Natives; Hispanics/Latinos; African Americans; Asian 

Americans; lesbian, gay, bisexual, and transgender 

(LGBT) individuals; people with low socioeconomic 

status; geographically defined populations; and 

people with mental health disorders or substance 

abuse conditions.18 

Eliminating tobacco-related disparities continues to 

be a focus of recent national reports. Healthy People 

2020 includes eliminating health disparities as one 

of four overarching goals of the initiative.19 The 

persistence of tobacco-related disparities was also 

one major conclusion of the 2014 Surgeon General’s 

report, The Health Consequences of Smoking—50 

Years of Progress.

12 The 2014 Best Practices added 

more evidence and recommendations that states 

can follow to eliminate these disparities.1

 The CDC 

report, A Practitioner’s Guide for Advancing Health 

Equity, also offers strategies to achieve health equity 

in tobacco use, access to healthy food and beverages, 

and active living opportunities.7

 These reports, along 

with increased funding for health equity initiatives, 

more data on tobacco use and secondhand smoke 

exposure among specific populations, and a growing 

evidence base for the effectiveness of populationbased policies, have accelerated efforts to eliminate 

tobacco-related disparities. 

National Reports on Tobacco-Related Disparities 

1998

SGR: Tobacco 

Use Among 

U.S. 

Racial/Ethnic 

Minority 

Groups 

2006

SGR: The 

Health 

Consequences 

of Involuntary 

Exposure to 

Tobacco Smoke 

2009

IOM: 

Combating 

Tobacco in 

Military and 

Veteran 

Populations 

2011

CDC: Health 

Disparities 

and 

Inequalities 

Report 

(MMWR) 

1994

SGR: 

Preventing 

Tobacco Use 

Among 

Young People 

2007

IOM: Ending 

the Tobacco 

Problem: A 

Blueprint for 

the Nation 

2013

CDC: A 

Practitioner’s 

Guide for 

Advancing 

Health Equity 

2000

USDHHS: 

Healthy 

People 

2010 

1980 2014

CDC = Centers for Disease Control and Prevention 

IOM = Institute of Medicine 

MMWR = Morbidity and Mortality Weekly Report 

SGR = Surgeon General’s Report 

USDHHS = United States Department of Health & Human Services 

1999

CDC: Best 

Practices 

1999 

2001

SGR: 

Women and 

Smoking 

2007

CDC: Best 

Practices 

2007 

2009

CDC: Health 

Disparities 

and 

Inequalities 

Report 

(MMWR) 

2010

USDHHS: 

Healthy 

People 

2020 

2012

SGR: 

Preventing 

Tobacco Use 

Among 

Youth and 

Young Adults 

2013

CDC: Health 

Disparities 

and 

Inequalities 

Report 

(MMWR) 

2014

SGR: The Health 

Consequences of 

Smoking-50 Years 

of Progress 

2014

CDC: Best 

Practices 2014 

Health Equity l 3
 

1980

SGR: The Health 

Consequences of 

Smoking for 

Women 
Race 

AI/AN†
 

White‡
 

African American‡
 

Hispanic
 

Asian‡
 

Education 

Less than high school 

High school graduate 

Some college 

College graduate 

Income 

Below poverty level 

At or above poverty level 

Unknown 

Geography 

Midwest 

South 

Northeast 

West 

23.9% 

Total Population 22% 

22.6% 

8.3% 

38.5% 

31.5% 

27.4% 

23.4% 

10.4% 

32.5% 

20.0% 

7.5% 

25.1% 

22.9% 

18.7% 

15.2% 

20.6% 

0% 50% 

User Guides HOW TO: What is Health Equity in Tobacco Control?
 

How To Work Toward 

Health Equity 

What is Health Equity in Tobacco 

Prevention and Control? 

In public health, health equity is the opportunity for 

everyone to reach their “full health potential.”2

 No one 

is prevented “from achieving this potential because 

of their social position or other socially determined 

circumstance.”2 Health equity in tobacco prevention 

and control is the opportunity for all people to live 

a healthy, tobacco-free life, regardless of their race, 

level of education, gender identity, sexual orientation, 

the job they have, the neighborhood they live in, or 

whether or not they have a disability. Tobacco control 

programs can work toward health equity by focusing 

efforts on decreasing the prevalence of tobacco use 

and secondhand smoke exposure and improving 

access to tobacco control resources among populations 

experiencing greater tobacco-related health and 

economic burdens.1 

Understanding Tobacco-Related Disparities 

Health disparities are differences in health outcomes 

between population groups based on characteristics 

like income, race, or geography.20 CDC’s Best Practices 

defines tobacco-related disparities as: “Differences 

that exist among population groups with regard to 

key tobacco-related indicators, including patterns, 

prevention, and treatment of tobacco use; the risk, 

incidence, morbidity, mortality, and burden of tobaccorelated illness; and capacity, infrastructure, and access 

to resources; and secondhand smoke exposure.”1 

Tobacco-related disparities affect many different 

population groups based on socially determined 

circumstances and characteristics like age, disability, 

education, income, occupation, geographic location, 

race, ethnicity, sex, sexual orientation, gender identity, 

mental health status, substance abuse, and military 

status.1,21 These groups have a higher prevalence of 

tobacco use (i.e., the proportion of a population group 

that uses tobacco), lower cessation rates, and poorer 

health outcomes.1,12 Tobacco-related disparities have 

also been reported among people who are homeless and 

those who are incarcerated.22,23 

Cigarette smoking prevalence is one example of 

these disparities. Despite overall declines in smoking 

prevalence in the U.S., large differences still exist among 

population subgroups. Higher smoking prevalence has 

been reported in the LGBT community and among 

populations living in poverty, those with mental health 

disorders and substance abuse conditions, and those 

living in the South and Midwest.12,24,25 Other geographic 

differences also exist. For instance, rural populations 

have a higher smoking prevalence than urban 

Current Cigarette Smoking Prevalence 

among Adults 18 and Older* 

Source: The Health Consequences of Smoking—50 Years of Progress. A Report of 

the Surgeon General12 

*Current cigarette smoking is defined as smoking in the 30 days before the survey 

and having used 100 cigarettes or more in lifetime. 

† American Indian/Alaska Native, non-Hispanic 

‡ Non-Hispanic 

Health Equity l 4
 
HOW TO: Factors Influencing Tobacco-Related Disparities
 User Guides 

A Note about Data on Disparities 

Tobacco use and secondhand smoke exposure rates included in this guide are mainly reported from 

peer-reviewed articles and national reports like the National Survey on Drug Use and Health and 

the National Health Interview Survey. These data have been adjusted for a variety of demographic 

characteristics. Adjusting rates is a way to make fairer comparisons between groups with different 

demographic distributions.26 For example, one ethnic group might have more young people. If youth 

smoking prevalence is high, it will result in a higher smoking prevalence among the entire group, 

preventing a fair comparison with other groups. The adjusted characteristics vary by survey but most 

commonly include age, sex, or race/ethnicity. Surveys also use different estimates of these characteristics 

to make adjustments (e.g., 2000 Census data or 2010 Census data). Because of these differences, 

prevalence rates from different data sources should not be directly compared. For more information on 

how a specific rate was calculated, please review the source. 

Many national surveys also do not include people who are incarcerated, military personnel, or people 

who are homeless. Surveys also may only be offered in some languages and may include fewer responses 

from people that do not speak those languages. As a result, all data reported in this guide may not be 

generalizable to these groups. 

populations.27 The American Indian and Alaska Native 

population has a higher smoking prevalence than any 

other racial or ethnic group.12 The graph on page 4 

illustrates differences in cigarette smoking prevalence 

by race, education, income, and geographic location. 

The table beginning on page 8 describes smoking 

prevalence and other tobacco-related disparities among 

different populations in more detail and includes links 

to resources for working with specific groups. 

Factors Influencing Tobacco-Related 

Disparities 

Tobacco-related disparities are created and affected 

by a complex mix of factors. Social determinants 

of health, tobacco industry influence, a lack of 

comprehensive tobacco control policies, and a 

changing U.S. population can contribute to and 

maintain tobacco-related disparities. 

Social Determinants of Health 

Social determinants of health are the conditions in 

which people are born, grow, live, work, and age.28 

Healthy People 2020, a set of national objectives for 

health promotion and disease prevention, describes five 

key areas of social determinants that affect health:29 

•	 Economic stability; 

•	 Education; 

•	 Neighborhood and built environment (i.e., the 

housing, environmental conditions, and safety 

of a person’s neighborhood); 

•	 Health and health care; and 

•	 Social and community context (i.e., family 

structure, community civic participation, and 

perceptions of discrimination and equality). 

Social determinants within each of these broad 

areas, such as poverty, housing, social support, 

discrimination, quality of schools, health care access, and 

transportation,29 influence tobacco-related disparities. 

For example, people that lack quality housing may 

be at greater risk of exposure to secondhand smoke, 

and people with limited health care access may lack 

information about the dangers of tobacco use and 

available cessation options. For more information 

on how public health programs can address social 

determinants of health, see the CDC workbook, 

Promoting Health Equity: A Resource to Help 

Communities Address Social Determinants of Health.

30 

Health Equity l 5
 
User Guides HOW TO: Factors Influencing Tobacco-Related Disparities
 

Social 

Determinants 

of Health 

Health and 

Health Care 

Health and 

Health Care 

Economic

 Stability 

Social and 

Community 

Context 

Education 

Neighborhood 

and Built 

Environment 

Source: Healthy People 202029 

Together, social determinants of health and tobacco 

use also affect other chronic disease health outcomes. 

Tobacco use combined with other risk factors like an 

inactive lifestyle, poor diet, and diabetes poses a greater 

combined risk and poorer prognosis for many chronic 

diseases than the sum of each individual risk.1 Learn 

more about the connections between tobacco and other 

priority areas on page 26. 

Tobacco Industry Influence 

The tobacco industry heavily markets its products to 

populations affected by tobacco-related disparities.15,31 

Marketing, advertising, and promotional strategies 

are often directed at low-income, minority, and young 

adult populations.31-33 Historically, the industry has 

also funded groups that work with communities 

affected by tobacco-related disparities, such as LGBT 

organizations. For example, in the mid-1990s, an 

R.J. Reynolds marketing campaign known as Project 

SCUM (Sub-Culture Urban Marketing) was designed 

to target LGBT and homeless populations.34 The 

tobacco industry made donations to AIDS research and 

supported programs for people with AIDS, sponsored 

and distributed free cigarettes at LGBT pride events, 

and paid for smoking lounges at GLAAD (formerly the 

Gay & Lesbian Alliance Against Defamation) events.35 

Industry funding and support may have contributed to 

a lack of awareness among the LGBT community about 

the dangers of tobacco. The industry also developed 

relationships with organizations that worked with 

homeless populations and those with mental illness by 

making financial and other contributions.36 In 1994, 

Philip Morris donated 7,000 “Merit” cigarette brand 

blankets to New York City homeless shelters.36 

Lack of Comprehensive Policies 

Inconsistent adoption and enforcement of tobacco 

control policies create disparities in protections from 

secondhand smoke exposure and support for cessation. 

For example, geographic tobacco-related disparities 

exist in the South and Midwest,12,24 regions with fewer 

comprehensive smoke-free laws, lower tobacco taxes, 

and limited tobacco control funding.37 Some of the 

greatest disparities in lung cancer and coronary heart 

disease rates are found in these same regions.38,39 

Service and hospitality workers experience some of 

the greatest disparities in protection from secondhand 

smoke. For example, casinos often do not have smokefree policies. Some states exempt casinos from statewide 

smoke-free laws, and others allow casinos to have 

smoking areas, exposing their employees to high levels 

of secondhand smoke.40 One study found casino workers 

were exposed to air pollution from tobacco smoke that 

was 4 to 6 times that of outdoor levels.41 Many casinos 

operated by American Indian and Alaska Native tribes 

are also exempt from smoke-free laws. Because federal 

law recognizes these tribes as sovereign nations, tribes 

can choose to exempt the casinos and gaming facilities 

they run from statewide smoke-free laws. 

Health Equity l 6
 
HOW TO: Factors Influencing Tobacco-Related Disparities
 User Guides 

Changing U.S. Population 

The U.S. population is growing and changing. From 

2007 to 2013, the poverty rate for American households 

increased from 12.5% to 14.5%.42 Income inequality has 

also increased. Some subgroups have fared worse than 

others. For instance, since the 1960s, the poverty rate 

among adults with less than a high school education 

has increased from 15% to 34%.43 Other population 

characteristics are also changing. By 2050, more than 

half of the U.S. population will come from racially and 

ethnically diverse backgrounds.44 

These changes have the potential to worsen health 

disparities, including those that are tobacco-related. 

Poverty has fundamental associations with overall health 

status, mental health status, and risk factors for poor 

health. The population of adults living in poverty is 

more likely to forego needed medical care, experience 

psychological distress like hopelessness and anxiety, 

and smoke cigarettes.12,43 They are also less likely to 

quit tobacco use, even though most express interest in 

quitting.12 Understanding and monitoring the shift to a 

more diverse American population will be important in 

determining how to achieve health equity for all groups. 

A CLOSER LOOK: Disparities in Other Tobacco Product (OTP) Use 

Patterns of tobacco use are changing. People are now smoking cigarettes less often and increasingly using 

other tobacco products (OTPs).12 Also known as “non-cigarette tobacco products,” OTPs are all products 

other than cigarettes that contain nicotine.45 Often milder-tasting or sweetened, these products include 

combustible products that burn tobacco when smoked (e.g., cigars, pipes, and hookah), non-combustible 

products like smokeless tobacco (e.g., chew, dip, snuff, and snus) and dissolvables (e.g., orbs, strips, and 

sticks), and electronic nicotine delivery systems (ENDS) (e.g., e-cigarettes, e-cigars, e-hookahs, and 

others).46,47 Despite research linking some of these products to cancers and oral health problems, they 

are less regulated.47 Many of these products also have strong youth appeal; for young people, the mild 

flavors may encourage them to try tobacco.47 Youth and adults also use OTPs while continuing to smoke 

traditional cigarettes, a practice commonly known as “dual use.”12 

Disparities in the use and promotion of OTPs mirror trends in cigarette use and marketing. The 

American Indian and Alaska Native population has the highest prevalence of smokeless tobacco and 

cigar use of any racial or ethnic group.12 This population is also most likely to use multiple tobacco 

products.12 Other populations that have a high prevalence of multiple product use include young 

adults, those with less than a high school education, and those living in poverty.12 Additionally, African 

Americans and young adults see more advertising and lower prices for OTPs in their neighborhoods.48 

Data has shown recent increases in the use of ENDS, including e-cigarettes, which typically contain 

nicotine that is derived from tobacco. E-cigarette use increased among adults from 3% in 2010 to 8.5% in 

2013.49 Among current cigarette smokers, e-cigarette use increased from 10% to 36.5%.49 From 2011-2012, 

e-cigarette use nearly doubled among middle and high school students.12 National surveillance data on the 

awareness and use of e-cigarettes is still limited.12,49 Collecting data on emerging electronic products and 

other tobacco products will help capture changing tobacco use patterns. Tobacco control programs and 

partners can use information on OTPs to implement policies that protect populations against all forms of 

tobacco use, regardless of whether the products are combustible, non-combustible, or electronic. 

Health Equity l 7
 
User Guides HOW TO: Factors Influencing Tobacco-Related Disparities 

Tobacco-Related Disparities & Helpful Resources 

POPULATION CHARACTERISTIC* TOBACCO CONTROL RESOURCE 

Age 

Most established smokers begin smoking during youth.50 Among adults who smoke 

daily, 87% tried their first cigarette before age 18.12 Young people also have a high 

prevalence of OTP use. Despite declines in cigarette use among youth, e-cigarette 

use is on the rise, use of smokeless tobacco has remained steady, and the decline in 

cigar use has slowed.12,51 The population of adults aged 65 and older is less likely to 

try to quit than other age groups.52 

• Quitting Smoking for Older 

Adults, National Institutes of 

Health 

• Youth Resources, Campaign for 

Tobacco-Free Kids 

Disability/limitation 

The population living with disabilities has a higher cigarette smoking prevalence 

(23%) than those without disabilities (17%).25 Although more likely to receive 

tobacco cessation information than smokers without disabilities, more than 40% of 

• Smoking Cessation Resources, 

American Association on Health 

and Disability 

smokers with disabilities still lacked information about cessation options.53 

Education 

Groups with less education have higher cigarette smoking prevalence than groups 

with more education.12 For example, 32% of adults who did not complete high 

school smoke, compared to only 10% of people with at least a college degree.12 

Groups with more education are also more likely to try and succeed in quitting.12 

• How Schools Can Help Students 

Stay Tobacco-Free, Campaign for 

Tobacco-Free Kids 

Income •	 SelfMade Health Network† 

Populations living below the poverty level have a much higher prevalence of •	 Tobacco Cessation and the 

cigarette smoking and OTP use than other income groups.12,25 Low-income Affordable Care Act, American 

populations are less likely to successfully quit and more likely to not have access to Lung Association affordable cessation support.7,12 

Geographic location 

Total cigarette smoking prevalence varies dramatically within and between24 

communities, states, and regions. Populations in the South and Midwest, and places with 

large American Indian or Alaska Native populations, have a high smoking prevalence.24 

Rural populations also have higher smoking prevalence (26%) than urban populations 

(18%), and they use smokeless tobacco at twice the rate of urban populations.27,54 

• Geographic Health Equity 

Alliance† 

• Prevent Tobacco Use: A CADCA 

Toolkit, Community Anti-Drug 

Coalitions of America 

• Cutting Tobacco’s Rural Roots, 

American Lung Association 

Mental health disorders 

The population of adults with mental illness is twice as likely to smoke cigarettes as 

the general population.55 This population also smokes more cigarettes per month 

and is less likely to quit smoking.1 

•	 DIMENSIONS: Tobacco-Free 

Toolkit for Healthcare Providers, 

University of Colorado 

•	 National Behavioral Health 

Network for Tobacco and Cancer† 

Occupation 

There are large differences in cigarette smoking across occupational groups. In 

2011, smoking prevalence ranged from less than 9% among adults who worked 

in education to over 30% among adults who worked in construction.56 Smoking 

prevalence is also high among workers in occupations like food preparation and 

serving (30%) and transportation (29%).56 

• Workplace Health Promotion: 

Tobacco-Use Cessation, CDC 

• Guide to Safe & Healthy 

Workplaces, American Lung 

Association 

* This table describes tobacco-related disparities for certain population groups. This list may not be exhaustive, and disparities may vary by community. 

† CDC-funded National Network from 2013-2018. 

Health Equity l 8
 
HOW TO: Factors Influencing Tobacco-Related Disparities 

Tobacco-Related Disparities & Helpful Resources 

User Guides 

POPULATION CHARACTERISTIC* TOBACCO CONTROL RESOURCE 

Race and ethnicity 

Tobacco use disparities exist among racial and ethnic populations. The American 

Indian and Alaska Native population has the highest cigarette smoking prevalence 

compared to other racial and ethnic groups (38.5%).12 This group also has the highest 

prevalence of cigar smoking, smokeless tobacco use, and use of multiple tobacco 

products.12 There is also a high prevalence of cigar smoking among the African 

American population, particularly among young adults.12 Some racial and ethnic 

groups suffer from higher rates of smoking-related diseases like cancer, are more 

likely to be exposed to secondhand smoke, and are less likely to successfully quit than 

the general population.12,37,57 

• National African American 

Tobacco Prevention Network† 

• National Native Network† 

• Nuestras Voces† 

• The RAISE Network† 

Sex 

Cigarette smoking prevalence is higher among males than among females across all 

racial and ethnic groups, though the gap is decreasing (only a 3% difference in 2012, 

compared to 5% in 1996).12,24 Differences are greatest among Asian populations, 

where the smoking ratio is about three males to every one female.12 Although 

females have a lower overall smoking prevalence, the tobacco industry uses targeted 

marketing strategies designed for female smokers. These strategies use themes like 

weight control, style, and sophistication to appeal to female consumers.58 

•	 Resources for Health 

Professionals, 

Smokefreewomen.gov 

•	 Tobacco Use and Pregnancy: 

Resources, CDC 

Sexual orientation and gender identity 

Tobacco use is higher among LGBT populations (38.5%) than among heterosexual/ 

straight populations (25%).59 The population of LGBT youth and young adults also 

have a very high prevalence of tobacco use compared to the heterosexual population.60 

• LGBT HealthLink† 

• MPOWERED: Best and 

Promising Practices for LGBT 

Tobacco Prevention and 

Control, LGBT HealthLink 

Substance abuse conditions 

The population who enters treatment for substance abuse is more likely to use 

tobacco than the general population, and tobacco use kills more people who seek 

substance abuse treatment than the alcohol or drug use that brings them there.61 A 

long-term study that tracked people who had been in treatment for an addiction 

found that 51% of their deaths were caused by tobacco-related conditions.61 

•	 Tobacco Use Cessation During 

Substance Abuse Treatment 

Counseling, Substance Abuse 

and Mental Health Services 

Administration 

Veteran and military status 

Active duty military personnel and veteran populations have a dramatically higher 

cigarette smoking prevalence than the general population. A 2011 Department of 

Defense study found that almost half of all military service members used a nicotine 

product in the past year.62 Military personnel deployed to combat since September 

11, 2001, have a higher prevalence of current and heavy smoking than other military 

members not combat-deployed.62 

• Quit Tobacco – Make Everyone 

Proud, U.S. Department of 

Defense 

• Tobacco and Health, U.S. 

Department of Veterans Affairs 

* This table describes tobacco-related disparities for certain population groups. This list may not be exhaustive, and disparities may vary by community. 

† CDC-funded National Network from 2013-2018. 

Health Equity l 9
 
User Guides HOW TO: Policy Interventions to Promote Health Equity
 

Policy Interventions to Promote 

Health Equity 

Tobacco control policy interventions are the cornerstone 

of state and local tobacco control efforts.12 Because 

tobacco control policies take a population-based 

approach to improving health, they have the potential 

to reach more people and can be particularly effective at 

reducing tobacco-related disparities.3

 Like most issues 

addressed by tobacco control policies, tobacco-related 

disparities are complex problems that do not have a 

single cause or solution.7,8 Reducing tobacco-related 

disparities will take multiple, coordinated efforts.1 

Policies that focus on adolescence and young adulthood, 

a time when most people begin using tobacco, will 

be especially important to reduce tobacco-related 

disparities.63 Policies to reduce tobacco-related disparities 

should focus on the following goals:1,5,12 

•	 Increasing the number of people covered by 

comprehensive smoke-free laws; 

•	 Increasing the price of tobacco products; 

•	 Reducing exposure to targeted tobacco industry 

advertising, promotions, and sponsorship; and 

•	 Improving the availability, accessibility, and 

effectiveness of cessation services for populations 

affected by tobacco-related disparities. 

Create Smoke-Free Environments 

Comprehensive smoke-free laws can benefit people 

from all socioeconomic, educational, and racial/ethnic 

backgrounds equally by increasing places where people 

are protected from tobacco smoke.3,4 Smoke-free laws 

are comprehensive when they prohibit smoking in all 

indoor areas of workplaces, restaurants, and bars.64 

These laws are the most effective way to protect all 

workers from secondhand smoke exposure in the 

workplace. They can also reduce the social acceptability 

of smoking, which can motivate smokers to quit.1 

Although great progress toward creating smoke-free 

environments has been made in recent years, several 

groups and many regions of the country are not yet 

covered by comprehensive smoke-free laws. About 

25% of nonsmokers and 40% of children ages 3-11 

are still exposed to secondhand smoke.65 Geographic, 

occupational, and demographic disparities still exist. 

For instance, people with lower socioeconomic status, 

living in states without comprehensive smoke-free laws, 

or that work in service and hospitality jobs have the 

greatest disparities in exposure to secondhand smoke.12 

Tobacco control programs and partners should focus 

on implementing comprehensive smoke-free laws that 

protect these populations. 

Tobacco control programs and partners should 

also encourage smoke-free policies in multi-unit 

housing, which can pose other secondhand smoke 

dangers. Even in units where residents do not allow 

smoking, secondhand smoke can enter through shared 

ventilation systems and hallways. Research has shown 

that children are 3 to 4 times as likely as adults to be 

exposed to secondhand smoke in the home.12 African 

Americans are most likely to be exposed to secondhand 

smoke at home, and low-income families are three 

times as likely to be exposed as wealthier families.12 

Secondhand smoke may particularly affect low-income 

residents of multi-unit subsidized public housing who 

may not be able to afford to move.7 Owners of multiunit housing may be hesitant to adopt smoke-free 

policies because of the mistaken belief that restricting 

residents’ smoking is against the law. In fact, state 

and federal courts have ruled that smokers are not a 

protected class under fair housing laws, and smoking is 

not a protected activity under the U.S. Constitution or 

state constitutions.66 Prohibiting smoking may actually 

reduce landlords’ legal liability and maintenance costs.66 

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HOW TO: Policy Interventions to Promote Health Equity
 User Guides 

A CLOSER LOOK: Tobacco Use in Rural Communities54 

Tobacco use is firmly established 

in many rural communities. 

Rural populations are more likely 

to use tobacco products, start 

smoking at a younger age, smoke 

more heavily, and be exposed to 

secondhand smoke than urban 

populations. Smokeless tobacco 

use is also twice as common in 

rural areas. Rural residents do not 

smoke more just because they live 

in rural areas. Lower incomes, 

higher unemployment, and lower 

education levels also contribute to 

higher smoking prevalence among 

rural populations. For many rural 

communities, growing tobacco has also been a source of income, and as a result, tobacco use has been 

perceived as more acceptable. 

The tobacco industry has a long history of targeting rural populations, particularly young men, with images 

showing cowboys, hunters, and race car drivers using tobacco. This advertising has been very successful; 

a study found that boys and men in rural Ohio consider smokeless tobacco use as a key to acceptance 

into male social networks and as a “rite of passage” into manhood. These beliefs often reduce the demand 

for policy change. States and local governments in rural areas are also less likely to implement policies 

that encourage cessation, like raising the price of tobacco products and enacting comprehensive smokefree laws. Youth living in rural areas are less likely to hear anti-tobacco messages in the media, and rural 

populations who want to quit tobacco have fewer resources available to help them. 

Though tobacco use continues to be a complex issue in rural communities, policy approaches that 

recognize that rural communities have unique needs and strengths are more likely to be successful. 

Tobacco control programs and partners can work to reduce tobacco use in rural areas by: 

•	 Collecting data on tobacco use and secondhand smoke exposure in rural communities; 

•	 Working with rural community members to select tobacco control policies and messages that will 

resonate with the community; 

•	 Finding a community champion who is committed and willing to tackle the status quo of tobacco 

culture, especially in communities located near tobacco-producing areas; 

•	 Buying spots in media markets that reach rural areas; 

•	 Using e-learning and mobile technologies that can reach people in rural areas to promote tobacco 

control efforts; and 

•	 Implementing media and education campaigns about the dangers of smokeless tobacco use. 

Health Equity l 11
 
User Guides HOW TO: Policy Interventions to Promote Health Equity
 

Increase the Price of Tobacco Products 

Strong evidence shows that increasing the price of 

tobacco products is effective in reducing tobacco use 

and preventing initiation.1,10 It also prevents relapse 

among people who have quit.45 Evidence also shows 

that increasing the price of tobacco products can reduce 

tobacco-related disparities among different income 

groups and may reduce disparities among different 

racial and ethnic groups.10 

Studies have found that sensitivity to tobacco prices 

is highest among Hispanics, followed by African 

Americans and whites (regardless of differences 

in income).10 Low-income smokers, certain lowerincome occupational groups, and youth are also 

more responsive to price increases.67 After tobacco 

price increases have gone into effect, tobacco use has 

decreased among low-income groups.10 

Increasing the price of tobacco products through 

excise taxes on the manufacture, sale, or use of tobacco 

products can create large revenues for states.45,68 When 

tax increases are not feasible, states can also raise the 

price of tobacco products through other policies, 

like banning price discounting or implementing 

(or strengthening) minimum price laws. To prevent 

tobacco users from using loopholes like switching to 

other tobacco products or discount brands, tobacco 

control partners should work to craft price increases 

that do not have product exceptions.45 Increasing 

tax rates on tobacco products and dedicating part of 

the resulting revenue to cessation services for lowincome populations can be an effective way to increase 

cessation and reduce tobacco-related disparities.1,45 

Because low-income smokers often have limited access 

to cessation services, price increases can be combined 

with evidence-based cessation services to have the 

greatest impact on tobacco use. Learn more about 

promoting cessation on page 15. 

Tobacco control programs should also work with tribal 

governments to make sure prices for tobacco products are 

comparable to state sales prices. Tribes have the right to 

exempt tobacco products sold to members of their tribe 

from state tobacco taxes.45 However, other smokers visit 

American Indian reservations to purchase these cheaper, 

tax-free tobacco products. Some states have entered into 

special agreements with reservations where the tribe 

agrees to collect state tobacco taxes on all tobacco product 

sales.45 In exchange, the tribes may keep this revenue. 

Reduce Exposure to Targeted Tobacco Industry 

Advertising, Promotion, and Sponsorship 

Decades of tobacco industry targeting have 

overwhelmed minority and low-income communities 

with tobacco advertising, promotion, and 

sponsorship.15,31 Before the 1998 Master Settlement 

Agreement banned and restricted many forms of 

sponsorship and advertising, messages were often 

delivered through magazines, billboards, and product 

giveaways.1,12 As advertising restrictions have tightened, 

the industry has become more covert and strategic 

in its approach, often using philanthropy to improve 

its image among target populations. For example, the 

tobacco industry has sponsored social and cultural 

events and made financial contributions to colleges, 

elected officials, and community organizations that 

serve these populations.15,69 With limited budgets, 

community groups have welcomed tobacco industry 

funding and sponsorship. These factors may have 

reduced the capacity and will of some populations 

to advocate for the changes needed to rid their 

communities of the tobacco industry’s strong influence. 

Advertisement from Brown & Williamson 2004 promotional campaign 

Health Equity l 12
 
HOW TO: Policy Interventions to Promote Health Equity
 User Guides 

A CLOSER LOOK: Regulation of Menthol Cigarettes 

As part of the 2009 Family Smoking Prevention and Tobacco Control Act, the U.S. Food and Drug 

Administration (FDA) banned cigarettes with characteristic flavors other than tobacco. Menthol-flavored 

cigarettes, which have accounted for at least 25% of cigarettes sold in the U.S. since 1973, were also 

excluded from the ban.70 Menthol is produced from the peppermint plant and adds a minty flavor and a 

cooling sensation that masks the tobacco taste and throat irritation associated with smoking.71,72 In 2010, 

there were an estimated 20 million menthol cigarette smokers in the U.S., the majority of whom were 

African Americans and young adults.73 

From 2008 to 2010, 57% of youth smokers (ages 12-17) and 45% of young adult smokers (ages 18-25) 

used menthol cigarettes.74 Although the overall cigarette smoking prevalence rate declined in recent 

years, prevalence of menthol cigarette use increased among young adults and remained stable among 

youth between 2004 and 2010.73 Research studies have linked menthol with smoking initiation and 

dependence among youth.75,76 Because most adult smokers begin smoking before age 18,50 the link 

between menthol cigarettes and youth initiation is particularly concerning. Tobacco industry documents 

suggest that the industry has increased both the amount of menthol in cigarettes and targeted marketing 

of menthol products to youth and young adults to get them to start smoking and increase dependence.77 

Menthol cigarette use is also high among other groups, including adult women, those living in the 

Northeast, and low-income populations.78 Research studies and tobacco industry documents have shown 

the industry’s targeted marketing of menthol cigarettes to racial and ethnic groups, including African 

Americans and Hispanics/Latinos.79 From 2004 to 2008, almost 85% of African Americans who smoked 

used menthols, compared to only 27% of white smokers.80 

The effects of menthol on tobacco use initiation, dependence, and cessation have been the focus of 

intense scientific study. To estimate the effect that a menthol ban could have on smoking-related deaths, 

researchers modeled three scenarios in which menthol smoking initiation decreased and cessation 

increased by 10%, 20%, and 30% each.81 They found that if these assumed effects were to occur, between 

323,000 and 633,000 menthol smoking-related deaths could be avoided.81 Almost one-third of the 

prevented deaths would be African Americans.81 A national survey also found that over half of all 

Americans would support a menthol ban.82 

In July 2013, the FDA released for public comment an independent preliminary scientific review of the 

impact of menthol in cigarettes. The analysis supported the conclusion that “...menthol use is likely 

associated with increased smoking initiation by youth and young adults. Further, the data indicate that 

menthol in cigarettes is likely associated with greater addiction.”83 The number of menthol smokers is 

projected to increase if smoking initiation and cessation rates remain steady.81 

Also in July 2013, the FDA issued an Advanced Notice of Proposed Rulemaking (ANPRM), a request 

for more information from the public and the research community on specific questions, to help 

FDA officials make informed decisions about menthol.84 As of September 2015, the FDA is reviewing 

comments submitted in response to the ANPRM. 

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User Guides HOW TO: Policy Interventions to Promote Health Equity
 

Tobacco industry spending on marketing is on the 

rise. In 2011, cigarette companies spent $23 million 

every day to market their products in the U.S.85 That 

is nearly $1 million per hour. Increasingly, tobacco 

companies spend more of these dollars on promotions 

and sponsorship in stores than in any other venue. In 

2011, payments to cigarette retailers and wholesalers to 

secure retailer cooperation for product placement and 

promotion accounted for nearly 93% of total industry 

cigarette marketing and promotional spending.85 

Tobacco industry advertising is greater in low-income 

and minority communities.31-33,86 Youth cigarette 

smoking prevalence is also higher in communities 

with more tobacco retailers and advertising.87 Tobacco 

industry price promotions like discounts and multipack coupons are most often used by women, young 

adults, and African Americans, regardless of income.88 

Smokers of menthol cigarettes and Camel brand 

cigarettes, most of whom are African Americans and 

young adults, are more likely to take advantage of 

discounts than users of other cigarettes.88 

Tobacco control programs can combat these trends by 

implementing policies to reduce targeted marketing 

and sponsorship of tobacco products among vulnerable 

populations, including policies that:33 

•	 Refuse tobacco industry money and sponsorship 

for events; 

A CLOSER LOOK: Jóvenes de Salud Successfully Advocates for a Cinco de 

Mayo Free of Tobacco Industry Money 

Just weeks before the 2010 Cinco de Mayo Fiesta in St. 

Paul, Minnesota, event promoters announced they would 

not accept tobacco industry funds. This decision came 

at the prompting of a group of high school students 

from Jóvenes de Salud, a Latino youth program. Jóvenes 

de Salud offered bilingual educational health outreach 

to peers, family members, and community members.89 

Made up of 50 members from four schools in St. Paul, the 

group was a program of the Association of Non-Smokers 

Minnesota and was supported by Comunidades Latinas 

Unidas En Servicio (CLUES), a Latino community-based 

health organization. 

The students from Jóvenes de Salud convinced event 

promoter Riverview Economic Development Association (REDA) to refuse $9,000 from a tobacco 

company, even though finding sponsors for the event had become difficult. If REDA had accepted the 

tobacco money, industry representatives would have been able to distribute promotional items and 

coupons to the over 100,000 people at the festival, the largest Latino event in Minnesota.90 Youth from 

Jóvenes de Salud explained to REDA leadership the benefits of an event free from tobacco industry 

influence: Cinco de Mayo would be a more positive and family-friendly environment and would promote 

health and wellness in the Latino community.91 Jóvenes also committed to help obtain funds equaling 

those offered by the tobacco industry. The group received $5,500 from UCare, a Minnesota health care 

provider and resolved to raise the rest of the funds for the event through shoe shining, tamale sales, and 

sales of “Cinco de Mayo” buttons. Their efforts raised another $700, and Jóvenes de Salud pledged to keep 

fundraising throughout the year.90 

Jóvenes de Salud marches in tobacco-free Cinco de Mayo parade 

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HOW TO: Policy Interventions to Promote Health Equity
 User Guides 

Tobacco industry price discounting 

•	 Increase the cost of tobacco products through 

non-tax approaches (e.g., prohibit price 

discounting); 

•	 Reduce or restrict the number, location, density 

and types of tobacco retailers (e.g., prohibit 

the sale of tobacco products at certain types of 

stores); 

•	 Implement prevention and cessation messaging 

(e.g., require the posting of quitline information 

at retail stores); 

•	 Restrict point-of-sale advertising (e.g., restrict 

all advertising in store windows regardless of the 

content); 

•	 Restrict product placement (e.g., prohibit selfservice access to other tobacco products like 

cigars); and 

•	 Implement other point-of-sale strategies (e.g., 

prohibit the sale of flavored non-cigarette 

tobacco products like little cigars). 

Promote Cessation 

The majority of smokers want to quit, but some groups 

are less likely to be successful. For example, African 

American adults are more likely to express interest in 

quitting and more likely to have tried to quit than white 

adults, but they are less likely to use proven treatments 

and succeed in quitting.1

 Low-income adults also show 

interest in quitting but are less likely to receive cessation 

assistance and more likely to receive Medicaid than 

adults in other income groups.1

 A greater proportion 

of Medicaid recipients smoke, and they are also less 

likely to succeed at quitting than people with private 

insurance.1

 Interventions that combine individual 

or group counseling with medication are the most 

effective cessation interventions, but these may not 

be accessible to all groups because of language or 

geographical barriers.12 

Because of the high prevalence of tobacco use among 

low-income populations, providing comprehensive 

Medicaid coverage of cessation treatments is one of 

the most important steps a state can take to increase 

cessation and reduce tobacco use.1

 The 2010 Affordable 

Care Act made several changes to cessation coverage, 

including expanding state Medicaid coverage of 

tobacco cessation treatment and requiring most 

private insurance plans to offer cessation as no-cost 

preventative health care.92,93 Even with these changes, 

widespread barriers for Medicaid recipients seeking 

cessation coverage still exist. Many states still place 

limits on the number and duration of treatments, 

charge copayments, and require referrals from a 

patient’s doctor.94 Some recipients may simply be 

unaware that cessation is covered by Medicaid. 

Comprehensive cessation coverage means offering 

free-of-charge individual, group, and telephone 

counseling and offering all seven FDA-approved 

cessation medications (e.g., bupropion, varenicline, and 

five forms of nicotine replacement therapy, including 

the patch, gum, lozenge, nasal spray, and inhaler).1 

Comprehensive coverage also means getting rid of any 

other barriers to services and promoting coverage so 

that smokers are aware of the options available to help 

them quit.1,95 

Tobacco control programs and partners can use policy 

approaches to improve access to affordable, accessible, 

and culturally competent cessation services by: 

•	 Working with private health insurers, state 

Medicaid programs, state employee health plans, 

and large employers to offer comprehensive 

cessation coverage;1 

•	 Reducing barriers to cessation treatments, 

including language and cost barriers;1,95 

•	 Dedicating part of program resources to 

cessation, including funds from increases in the 

price of tobacco products;1 

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User Guides HOW TO: Policy Interventions to Promote Health Equity
 

•	 Supplying health care providers with cessation 

materials that are tailored to their clients’ cultures, 

literacy levels, native languages, and ages;96 

•	 Making tobacco use screening and cessation a 

standard part of all medical care by training staff 

and offering cessation services in community 

health clinics;1,96 

•	 Promoting and monitoring use of state Medicaid 

cessation coverage;1 

•	 Requiring private health insurers to offer 

comprehensive cessation coverage;1

 and 

•	 Monitoring implementation of the Affordable 

Care Act provisions related to cessation coverage.1 

State quitlines are also effective in reaching African 

American populations, those who predominantly speak 

Asian languages, and low-income smokers.1

 Quitlines 

offer counseling, information on how to quit and, in 

some instances, FDA-approved cessation medication. 

Quitlines can help reach broader audiences because 

they are easily accessible from any phone line in any 

location. Programs should promote quitlines among 

populations affected by tobacco-related disparities 

through policies and activities that: 

•	 Increase the state quitline’s reach to populations 

with high smoking prevalence, including 

promoting the national Spanish-language and 

Asian-language Quitlines;1 

•	 Expand quitline services by creating 

partnerships where health plans and employers 

reimburse the state quitline for services offered 

to their members/employees or offer their own 

quitline services;1 

Smoking Cessation Medicaid Coverage
 

June 30, 2014
 

What’s Covered 

Comprehensive coverage
 

(covers all 7-FDA approved smoking 


cessation medications and individual, 


group, and phone counseling)
 

Almost comprehensive coverage
 

(covers at least 7 treatments for 


all enrollees)
 

Inadequate coverage
 

(covers fewer than 7 treatments 


for all enrollees)
 

Source: Adapted from Helping Smokers Quit: Tobacco Cessation Coverage 2014, American Lung Association97 

Health Equity l 16
 
HOW TO: Policy Interventions to Promote Health Equity
 User Guides 

CDC Asian-language Quitline posters in Chinese, Vietnamese, and Korean 

•	 Implement e-referrals to the quitline from 

patient electronic health records;1 

•	 Integrate quitline services with text messaging 

like the SmokefreeTXT program that offers 

encouragement to people trying to quit;1 

•	 Train quitline staff in cultural competence; 

•	 Make sure that counseling is offered in the most 

commonly used local languages; and 

•	 Seek community input during the policy process 

to make sure cessation services effectively reach 

the population. 

Culturally competent cessation services should 

be planned to overlap with the implementation of 

comprehensive smoke-free laws. Even if offering 

comprehensive cessation services is not possible, 

cessation support is a critical part of all tobacco 

control policies. 

Selecting Policy Interventions 

Some states and communities may have considerable 

experience implementing tobacco control policies, 

while others are just beginning to explore policy 

options. A community’s capacity to implement certain 

policies and the need for particular policies will 

vary depending on the community’s current policy 

landscape. For example, comprehensive smoke-free air 

policies should be given highest priority, particularly 

in regions where these policies are weak. In states 

and communities that already have comprehensive 

smoke-free laws, tobacco control staff and partners 

should evaluate the effects of these policies on reducing 

tobacco-related disparities. Programs and partners 

should focus on filling gaps in existing policies and 

pursuing policies to further reduce disparities, such 

as those that increase the price of tobacco products 

or create smoke-free multi-unit housing.1 For more 

guidance on planning tobacco control policy efforts, see 

Policy Strategies: A Tobacco Control Guide.

9 

Health Equity l 17
 
User Guides HOW TO: Implementing Policies to Promote Health Equity
 

Implementing Policies to Promote 

Health Equity 

Policies are more effective when pursued as part 

of a comprehensive tobacco control program.1 

Policies supported by complementary community 

assessments, partnerships, health communication 

interventions, infrastructure, and evaluation have 

the best chance of successfully changing populationlevel behaviors.1,98 Comprehensive tobacco control 

programs are effective at reducing tobacco use across 

diverse racial and ethnic groups and groups with 

different education and income levels.98 But without 

thoughtful design and implementation, even the 

most comprehensive tobacco control efforts could 

actually widen disparities.7

 For example, unintended 

consequences of policies can sustain existing or create 

new disparities. Implementation barriers like the cost 

of and limited access to cessation services can reduce 

the effectiveness of tobacco control efforts. Tobacco 

control staff and partners can use the following 

strategies to make sure policies reach those most 

affected by tobacco-related disparities: 

•	 Review existing data and, if necessary, conduct a 

thorough community assessment; 

•	 Partner with members of the population(s); 

What is Cultural Competence and Why is it Important? 

Working to reduce tobacco-related disparities requires cultural competence—an organizational and 

personal commitment to diversity and inclusion. It is often used in combination with “linguistic 

competence,” or the ability to share information that is easily understood by diverse groups.99 Other 

terms similar to cultural competence are “cultural fluency” and “community competence.” Tobacco 

control programs can make cultural competence a priority by: 

•	 Broadening their definition of culture beyond traditional racial or ethnic groups to include other 

demographic characteristics or aspects of a person’s identity;44 

•	 Making sure materials, resources, policies, procedures, and training and professional development 

of tobacco control program staff reflect an understanding of the people being served;99 

•	 Asking tobacco control staff to complete cultural self-assessments of their own values, attitudes, 

and communication styles so they are prepared to be responsive and sensitive;100 

•	 Researching the values, attitudes, communication styles, language, literacy levels, histories, 

cultures, and social, economic, and physical environments of the people they serve;101 

•	 Making sure activities are sensitive to diverse cultural health beliefs and practices, preferred 

languages, and levels of health literacy;44 and 

•	 Communicating the program’s commitment to and progress toward cultural competence to 

stakeholders.44 

When fully integrated into a tobacco control program, cultural competence increases a program’s ability 

to develop, implement, and evaluate policies to reduce tobacco-related disparities. Cultural competence 

adds to the strength and credibility of tobacco control programs by:99,101 

•	 Involving people affected by tobacco-related disparities; 

•	 Preventing stereotypes or overgeneralizations about a population’s beliefs or practices; and 

•	 Reducing conflict among coalition members and unintended consequences of policies. 

Health Equity l 18
 
HOW TO: Implementing Policies to Promote Health Equity
 User Guides 

•	 Design program infrastructure to promote 

health equity; 

•	 Implement mass-reach health communication 

interventions that support policy work; 

•	 Make connections between tobacco control and 

other priority issues; and 

•	 Monitor tobacco-related disparities and evaluate 

the effects of policies on specific populations. 

Conduct a Community Assessment 

Community assessments can help tobacco control 

programs understand and describe the impact of 

tobacco on a specific community. Communities 

can be defined by geographic boundaries or other 

characteristics shared by a group of people.102 For 

example, a program might do a community assessment 

of a city or county, the LGBT community, or the 

African American community.102 Tobacco control 

programs can use assessments to decide which policy 

changes are most needed. Assessing past policy efforts 

can also help programs learn what worked and what did 

not in earlier policy change initiatives.7

 Additionally, 

community assessments can:8,102-104 

•	 Evaluate a community’s readiness for policy 

change; 

•	 Identify existing resources and potential partners; 

•	 Collect information that programs can 

use to decide where to focus resources 

and interventions, including information 

about community members’ tobacco use 

and secondhand smoke exposure, and the 

community’s assets, needs, and culture; 

•	 Educate community leaders and media outlets 

about how tobacco policies affect other public 

health issues like chronic disease prevention; 

•	 Share data to help partners understand the 

relationships between social determinants of 

health and tobacco use and secondhand smoke 

exposure; 

•	 Improve the cost-effectiveness of programs; and 

•	 Help design, plan, and implement policies that 

maximize community benefits and increase the 

likelihood of reducing tobacco-related disparities. 

What Populations are 


Affected by Tobacco Use in 


Your Community?
 

During the community assessment, think 

beyond the groups facing tobacco-related 

disparities that you know exist in the 

population. California added military 

members as a separate priority group 

because there is a unique military culture 

in the state and the military population is 

targeted by the tobacco industry.105 

Tobacco control programs can approach community 

assessments in different ways. Depending on the 

amount of time and resources available, programs can 

use interviews, focus groups, surveys, observations, 

and opinion polls to gather information from 

members or representatives of the population.8,106 The 

Community Tool Box toolkit, Assessing Community 

Needs and Resources, discusses possible data sources 

for community assessments.106 Current census data 

and tools like Geographic Information Systems (GIS) 

software can also help visualize the demographic 

makeup of communities, identify areas of highest 

need, and tailor policy work. For example, Community 

Commons is a free online mapping tool that can 

overlay data on tobacco use with other indicators about 

the social, health, and environmental conditions of a 

community.107 The following questions can help guide 

community assessments:7,8,103,108 

“Who” questions: 

•	 Who is in the population(s)? 

“What” questions: 

•	 What are the rates of cigarette smoking and 

secondhand smoke exposure among the 

population? What are the rates of other tobacco 

product use (e.g., cigars, smokeless tobacco, or 

other tobacco products)? 

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User Guides HOW TO: Implementing Policies to Promote Health Equity
 

•	 What are the rates of tobacco initiation and 

cessation? 

•	 What infrastructure exists to support tobacco 

prevention and control efforts? 

•	 What does the population view as the main 

issue, and what should be done about it? 

What other issues are also important to the 

community? 

•	 What policies have been tried before? What 

worked and what did not? 

•	 What policies will most effectively protect the 

population from tobacco use and secondhand 

smoke exposure (e.g., workplace, multi-unit 

housing, or tobacco retailer policies)? 

•	 What tobacco control messages resonate with 

the community, and what media venues are best 

to communicate those messages? 

•	 What barriers or competing issues make it 

difficult to make tobacco control a priority in 

the community? 

“How” questions: 

•	 How does the tobacco industry target the 

population? 

•	 How can tobacco control programs identify and 

reach out to community leaders and partners? 

•	 How can tobacco control messages be most 

relevant to the population? 

Partner with the Population(s) 

Most issues addressed by tobacco policies are 

complicated problems that do not have a single cause 

or solution.7,8 A variety of perspectives and skills is 

necessary to plan, implement, and evaluate policies 

that tackle these tough issues.8

 Strong relationships 

with people from diverse parts of the community 

can be a tobacco control program’s greatest asset. In 

return, tobacco control programs can support local 

communities by helping them build the capacity and 

momentum needed to implement policies. Partnering 

with people affected by tobacco-related disparities and 

the organizations that serve them throughout the policy 

process also makes sure that policies take into account 

the needs, values, and culture of the population.7 

St. Louis, Missouri, Develops 

Community Partnerships7 

As part of the CDC’s Communities Putting 

Prevention to Work program, the St. Louis 

Department of Health partnered with 

trusted community-based organizations 

to deliver cessation services to three 

populations with high local smoking 

prevalence. The department worked with 

local health clinic Casa de Salud, LGBT 

advocacy group SAGE Metro St. Louis, and 

the St. Louis Christian Chinese Community 

Service Center to reach priority populations. 

Because the organizations had experience 

serving these groups, they were able to use 

strategies that resonated with community 

members. For example, the St. Louis 

Christian Chinese Community Service 

Center used traditional Chinese puppet 

shows to educate community members 

about cessation, reaching over 500 people. 

A collaborative policy process can support efforts to 

reduce tobacco-related disparities by:8 

•	 Developing the community’s sense of ownership 

of policy efforts because its members help create 

and implement policies; 

•	 Bringing together different skill sets that may 

lead to breakthroughs when problems occur; 

•	 Engaging community leaders who can bring 

credibility to tobacco control policies; 

•	 Bridging language and cultural differences to 

communicate tobacco control messages that can 

be understood by diverse audiences; 

•	 Increasing the likelihood that community 

members and groups will hear and respond to 

campaign messages; 

•	 Mobilizing and empowering the community 

through involvement and decision making; and 

•	 Making sure that all populations are included 

as active participants in discussions and 

decision making. 

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HOW TO: Implementing Policies to Promote Health Equity
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A CLOSER LOOK: Supporting Tobacco Control Policy Work in American 

Indian and Alaska Native Communities 

National survey data shows that the American Indian and Alaska Native population has the highest 

cigarette smoking prevalence of any major U.S. racial or ethnic group (38.5%).12 This population also has 

the highest rates of smokeless tobacco use, cigar use, and use of more than one tobacco product.12 In fact, 

data from tribe-specific surveys show that commercial tobacco use may be as high as 63% among certain 

tribes.109 Learn more about the difference between commercial and traditional tobacco on page 22. 

Federal law recognizes many American Indian and Alaska Native tribes as sovereign nations. This status 

gives tribes the right to self-govern and exempts them from many laws when on tribal land, including 

some statewide tobacco control policies. To achieve the goal of eliminating health disparities in the over 

550 federally recognized tribes in the U.S., tobacco control programs must work closely with tribes and 

encourage them to make tobacco control a priority in their communities. 

To reduce tobacco-related disparities, tribes also need access to valid and reliable data on commercial 

tobacco use by their members. The American Indian Adult Tobacco Survey and Alaska Native Adult 

Tobacco Survey are useful tools for measuring baseline rates of tobacco use, monitoring changes in 

tobacco use, developing culturally appropriate interventions, and gathering information to select 

policy interventions.109,110 

States, partners, and others working with tribes should recognize that tribal populations vary greatly in 

geographic location, government, language, culture, and tobacco use. They also have different capacities 

to carry out tobacco control strategies and have made varying progress toward policy change. Some are 

in need of basic tobacco education, others are ready for policy development, while still others already 

have smoke-free policies in place and are considering smoke-free regulations in casinos. Understanding 

community dynamics and the community’s capacity for policy work is important when working with any 

specific community or population. 

State programs and partners can support tribes in implementing tobacco control policies by: 

•	 Making a contact with someone in the tribal community, like a respected tribal elder or a health 

service provider already working in the community; 

•	 Recognizing that the needs of specific tribal communities may differ from state needs, especially 

when developing funding opportunities; 

•	 Helping tribal communities gather information about existing policies in their communities; 

•	 Tailoring messages to acknowledge the importance of ceremonial tobacco use in some tribes; 

•	 Recognizing that other health issues and social conditions may affect tribal communities, such 

as high rates of youth suicide, diabetes, heart disease, poverty, unemployment, and low levels of 

education; 

•	 Educating tribal partners about how tobacco use can worsen other health issues affecting their 

communities; and 

•	 Supporting tribal communities in creating policies that are developed, implemented, and enforced 

from within the communities. 

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Ceremonial vs. Commercial Tobacco 

Many American Indian and Alaska Native tribes have traditional practices for using tobacco and other 

plants that are considered sacred. Use of the word “tobacco” in these practices can be confusing, because 

“tobacco” has become a generic term for several plants that are ceremonially smoked or burned, many of 

which are unrelated to the tobacco plant (i.e., Nicotiana). 

Traditional tobacco, in its many forms, continues to be used by some tribes for ceremonial purposes. 

Tribes that use tobacco ceremonially consider it a sacred medicine provided by the Creator.111 Ceremonial 

tobacco is most often a blend of plants, which may or may not contain Nicotiana.112 Commercial tobacco 

is manufactured tobacco that is sold for recreational use. It includes brands like Camel, Marlboro, Natural 

American Spirit, Top, and Redman. Commercial tobacco is highly addictive, contains harmful chemicals, 

and causes many health problems. In some cases, commercial tobacco is used for ceremonial purposes.113 

Respecting ceremonial tobacco use while encouraging cessation of commercial tobacco can help 

tobacco control messages resonate with tribal communities. For example, using Communities Putting 

Prevention to Work funds, the Oklahoma State Department of Health worked with six Southern Plains 

tribes to develop the Honor 

What is Sacred campaign.114 

Tribal leaders delivered 

messages on honoring traditions 

and the body by emphasizing 

the difference between 

ceremonial and commercial 

tobacco use.114 Messages were 

placed in tribal newspapers, 

promoted on billboards on 

tribal lands, and broadcast on 

tribal radio stations.114 Billboard from Oklahoma State Department of Health’s “Honor What is Sacred” campaign 

Tobacco control programs should work with members 

of the population to select a policy intervention(s) to 

pursue and develop a plan to guide the policy process. 

The plan should be part of the program’s broader 

strategic plan and should include goals and objectives 

related to the policy intervention, identify who will 

carry out activities, give a timeframe to complete 

activities, and describe how the program will assess 

progress and outcomes.30 Learn more about evaluating 

policies to reduce tobacco-related disparities on page 

26. For more information on developing an action 

plan, refer to the CDC resource, Promoting Health 

Equity: A Resource to Help Communities Address 

Social Determinants of Health.

30 

Design Infrastructure to Promote Health Equity 

Funding, staffing, and planning decisions all affect a 

tobacco control program’s capacity to serve populations 

affected by tobacco use and secondhand smoke 

exposure. These decisions include who is hired, 

which populations are served, and how strategies are 

implemented.7 Considering health equity goals when 

making infrastructure decisions can help develop 

culturally competent, equitable policies. 

Programs can design infrastructure to promote health 

equity by: 

•	 Including health equity goals in mission 

statements and strategic plans;1,7 

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HOW TO: Implementing Policies to Promote Health Equity
 User Guides 

•	 Distributing resources to organizations that 

work with specific populations, like tribal 

health departments;1 

•	 Hiring staff with experience working with 

populations affected by tobacco-related 

disparities;7 

•	 Training staff on cultural competence and 

health disparities;7 

•	 Educating program leadership, partners, and 

decision makers about health disparities and 

the importance of reducing tobacco use among 

specific populations;1 and 

•	 Requiring funded organizations to implement 

similar practices.7 

Implement Mass-Reach Health Communication 

Interventions 

Health communication efforts can help partners 

build public support for policy interventions.115 

Communication efforts can also support policy goals by 

discouraging tobacco use initiation, promoting cessation, 

and shaping social norms among populations affected 

by tobacco-related disparities. Health communication 

interventions can take many forms, but to make 

population-level changes, approaches must reach large 

audiences.1 Mass-reach strategies should include:1 

•	 Paid media campaigns (e.g., television, print, 

radio, digital, and out-of-home media like 

billboards); 

•	 Media advocacy and earned media (e.g., press 

releases and social media); 

•	 Health promotion activities (e.g., promoting 

quitlines); and 

•	 Activities to reduce or replace tobacco industry 

advertising with cessation or health promotion 

messages (e.g., posting the quitline at the pointof-sale). 

Well-designed communications efforts can reach many 

people and capture the attention of decision makers. To 

achieve population-level change, efforts should promote 

policies and influence social norms, not just describe 

disparities.7

 Campaigns should also use community 

assessment findings on priorities, challenges, and values 

of the population to develop messages.7 

Paid Media Campaigns 

Effective paid media campaigns to support policy 

interventions and reduce tobacco-related disparities 

do not need to include unique messages for each 

audience.1

 General population campaigns resonate with 

diverse audiences when they include graphic, emotional 

testimonials about the negative consequences of 

smoking.1 The Tips From Former Smokers (Tips) 

campaign, for example, includes personal stories from 

former smokers describing the effects of smoking 

on themselves and their loved ones in vivid detail. 

However, it is still important to incorporate audience 

diversity in campaigns. For example, the Tips campaign 

features people from population groups with high 

prevalence of tobacco use.1 

“Tips” campaign ad featuring Michael, an Alaska Native former smoker 

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User Guides HOW TO: Implementing Policies to Promote Health Equity
 

South Carolina Adapts Tips 

Campaign to Promote State 

Quitline Services116 

The South Carolina Department of Health 

and Environmental Control compared 

Nielsen data on media preferences with health 

department data to plan media buys that 

would reach populations with high smoking 

prevalence. The department worked with 

the CDC to add the state quitline number 

to Tips campaign ads and coordinated the 

state’s media buys with the CDC’s national 

buys. During the campaign, South Carolina 

tracked quitline calls, adjusting ad placements 

and messaging weekly. The campaign 

tripled quitline call volume and increased 

the percentage of quitline callers without 

insurance by nearly 10%. 

To be successful, campaigns also need to reach a large 

portion of the population and run enough times and 

for a sufficient duration.12 In general, campaigns need 

to run for 3 to 6 months to create awareness of the 

message; 6 to 12 months to affect knowledge, attitudes, 

and beliefs; and 12 to 18 months to change behavior.1 

Programs can tailor media buys to reach specific 

audiences and reduce campaign costs by adapting 

existing ads and strategically choosing where and when 

to place them. By researching the population’s media 

habits and preferences, programs can select media 

outlets and times when the intended audience will 

be likely to see and hear the messages. For example, 

some audiences like to listen to the radio while at 

work; others watch cable news in the evenings. Other 

audiences walk or ride the bus to work and pass by 

bus shelters and billboards where ads can be placed. 

Tobacco control staff and partners can also work with 

minority-owned radio stations, newspapers, weekly 

publications, and TV stations that focus on a specific 

population. Adapting existing campaign materials 

like those available in the CDC’s Media Campaign 

Resource Center database can save time and money.1 

Earned Media & Media Advocacy 

Earned media is a term used to describe news coverage 

earned by communicating with the press. Media 

advocacy includes all communications efforts to 

promote a policy intervention. Health communication 

interventions work best when they include paid media, 

earned media, and media advocacy in an overall health 

communication plan.117 A well-thought-out plan can:117 

•	 Help frame policy issues for the public; 

•	 Keep issues alive in the media; 

•	 Garner public support for the campaign and the 

policy issue; and 

•	 Build credibility for paid media. 

For example, secondhand smoke policy messages could 

frame protection from tobacco smoke as a social justice 

and workers’ rights issue. 

Important questions to answer when planning media 

advocacy efforts include:117 

•	 What is the goal of the campaign? 

•	 Who is the intended audience(s) (e.g., 

community members or elected officials)? 

•	 What action do you want the audience(s) to take? 

•	 Is the message clear and understandable to 

audiences of all literacy levels? 

•	 Who should deliver the message? Who are the 

people that can influence the audience(s)? 

•	 What media channels are most effective to reach 

the intended audience(s)? 

Earned media coverage can be an especially useful 

communication strategy when campaign funds are 

limited.1

 Low-cost activities include pitching stories to 

the media, training partners to become spokespersons, 

attending editorial board meetings, writing letters to 

the editor, holding press conferences and other media 

events, and drafting press releases. 

Recently, tobacco control partners have effectively 

used digital media platforms (e.g., dedicated websites, 

Facebook, and Twitter) to alert supporters to important 

events. As a cost-effective way to quickly reach a large 

audience, digital media platforms can be used to collect 

information, share resources, and expand the campaign’s 

reach as intended audiences share messages among 

Health Equity l 24
 
HOW TO: Implementing Policies to Promote Health Equity
 User Guides 

How to Design a Media Campaign1,117 

8 Identify the population(s) most affected by tobacco use 

Analyze existing tobacco use data or conduct a needs assessment to identify the groups most affected 

by tobacco use and secondhand smoke exposure, and carefully select the intended audience(s) for 

the campaign. The campaign may need to be designed for multiple audiences (e.g., English-speaking 

and Spanish-speaking audiences). 

8	 Include representatives from the intended audience in the campaign’s development 

Consult with credible people or groups who represent the diversity among the intended 

audience about how to encourage participation by audience members. Recruit members of the 

population for formative research and gain insights to determine what messages, activities, 

and communication channels would be most effective. Involve native speakers in writing 

communications or translating materials. 

8	 Develop cultural competence 

Develop an organizational commitment to cultural competence. Learn about local groups affected by 

tobacco-related disparities, paying careful attention to subgroups, tobacco use, and social norms. 

8	 Use messages that resonate with the audience 

Use culturally competent language and images, including personal stories from people with 

backgrounds that are similar to the intended audience. To be effective, messages should offer the 

audience a benefit they value, reach the audience enough times, and engage the audience in a way 

that makes them feel understood. 

8	 Place messages where and when the audience is most receptive 

Study media use patterns and qualitative data about the audience’s knowledge, beliefs, and attitudes, 

to decide what form of marketing to use and when and where to place ads to most effectively reach 

the intended audience. 

8	 Test the campaign 

Test messages with representatives of the intended audience to make sure the messages are 

understood and accepted. Collect qualitative data, like responses from interviews or focus groups, 

along with quantitative data, like survey responses. Collecting both kinds of information can help 

capture meaningful feedback and decrease the chance of overlooking important issues. Testing helps 

make sure that messages are clear, relevant, persuasive, and not offensive to the intended audience. 

8	 Continue the campaign after the policy goes into effect 

Continue the media campaign after the policy is implemented to focus the attention of the audience 

and media on making sure the policy is fully and fairly implemented for all populations. If policies 

are not implemented equally, certain groups may be protected while others continue to be harmed. 

8	 Evaluate the effects of the media campaign on the population 

Evaluate the media campaign to assess how successful it was in changing the population’s awareness, 

knowledge, attitudes, beliefs, and behaviors. Evaluation can also help identify changes to make to 

increase the effectiveness of future media campaigns focusing on the population. 

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User Guides HOW TO: Implementing Policies to Promote Health Equity
 

their social circles. Social media messages are most 

likely to be shared by the audience when they relate to 

a topic of interest to the group.118 Campaigns can tie 

tobacco control messages to particular hobbies, useful 

tips, upcoming holidays or major sporting events, 

information about a specific region or community, or 

content that interests a specific audience (e.g., pregnant 

women). The CDC publication, CDC’s Guide to Writing 

for Social Media, offers guidelines and sample messages 

for Facebook, Twitter, and text messaging.118 

Ways to communicate messages are continually 

changing as new media platforms appear and existing 

platforms fall out of use. Digital media platforms 

vary in required staff time, cost, and effectiveness at 

engaging audiences.119 Although a promising new way 

to reach audiences, social media should complement 

paid and earned media, not replace them entirely.1 

Tobacco control staff and partners should evaluate 

new media efforts and share their findings to help 

understand what works best for specific audiences.1 

Connect with Other Priority Issues 

Tobacco control staff should seek opportunities to 

create partnerships with groups working on other 

community and public health issues. Communities 

whose members are most affected by tobacco use 

and secondhand smoke exposure often face other 

challenging issues like poverty, violence, and limited 

affordable housing. Community members may assign 

higher priority to problems like cardiovascular disease, 

diabetes, cancer, asthma, and substance abuse than 

to tobacco use and secondhand smoke exposure. 

Highlighting tobacco use as a key risk factor for other 

chronic conditions can bring new partners to the table 

who have existing connections and extensive policy 

experience. These new partnerships can help programs 

share tobacco control messages with a wider audience 

and mobilize support for policy changes.1 

Low-cost ways tobacco control programs can connect 

to other priority issues include: 

•	 Crafting joint messages; 

•	 Educating partners about opportunities to 

promote cessation; and 

•	 Working together to implement comprehensive 

smoke-free laws. 

“Tips” campaign ad featuring Bill, a former smoker with diabetes 

The table beginning on page 28 describes the 

connections between community priorities and 

tobacco use and offers ways tobacco control staff 

and partners can work with other groups to support 

tobacco control efforts. 

Monitor Tobacco-Related Disparities and 

Evaluate Policies 

Surveillance, or the continuous monitoring of attitudes, 

behaviors, and health outcomes over time, and 

evaluation are crucial to identifying and understanding 

tobacco-related disparities. Because populations 

change over time, collecting current, disaggregated 

data for specific populations can help tobacco control 

programs maintain an accurate picture of which groups 

have the highest tobacco use and secondhand smoke 

exposure. Programs can track tobacco use, secondhand 

smoke exposure, disease and death due to tobacco 

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HOW TO: Implementing Policies to Promote Health Equity
 User Guides 

New Mexico Links Secondhand 

Smoke and Diabetes120 

The New Mexico Department of Health 

used awareness of diabetes among Navajo 

communities to educate members on the 

less well-known dangers of secondhand 

smoke. With funding from Communities 

Putting Prevention to Work, the department 

created a single message about the harmful 

environment secondhand smoke creates for 

everyone, especially people with diabetes. 

The Have a Heart campaign used artwork 

by local artists, placed ads in English and 

the local tribal language on Navajo radio 

stations, and aired messages in Navajo 

Indian Health Service clinic waiting rooms. 

use, and tobacco industry advertising, marketing, 

and promotional activities.121 Collected data can help 

determine where tobacco control policies are needed 

and build support for stronger policies. 

States and communities adopt new tobacco control 

policies every day. Monitoring how new policies are 

implemented and enforced can identify which groups 

are protected (or not protected) by tobacco control 

policies. Evaluations can also help determine how 

effective strategies are so that future policies, programs, 

and services can be improved. 

Designing Evaluations to Promote Health Equity 

Evaluations of efforts to reduce disparities assess what 

works, for whom, and under what conditions.7 They 

also determine whether disparities have decreased, 

increased, or stayed the same.7 Tobacco control 

programs should include questions in evaluation plans 

about how activities affect disparities, even when 

reducing disparities is not the main focus or goal. 

Designing all evaluations to capture effects on specific 

populations makes sure that unintended effects on 

these groups are not overlooked.7 When designing 

evaluations, tobacco control staff and partners should:1,7 

•	 Include questions relevant to the program and 

the needs of the population; 

•	 Choose evaluation methods that take into 

account the population’s language needs, their 

literacy levels, and who they would be most 

comfortable speaking with; 

•	 Combine qualitative (e.g., interviews and 

focus groups) and quantitative data collection 

methods (e.g., surveys) to fully capture the 

effects of a policy on the population; 

•	 Collect data before and after implementing 

a policy, extending the time frame of the 

evaluation as needed; and 

•	 Design samples so that analysis can be conducted 

for subgroups of the population. 

Collecting Data about Specific Populations 

When collecting population-specific data, program 

staff and partners can start with existing data sources 

like state-level surveys or local data collected by 

health departments, universities, or hospitals.7 

Partners can adapt tobacco surveys, including the 

Adult Tobacco Survey, the Youth Tobacco Survey, 

and the Behavioral Risk Factor Surveillance System, 

to include other questions of interest.122,123 Although 

these data collection tools are useful, they have 

limitations. For example, most surveys do not include 

sexual orientation and gender identity questions, and 

some lump ethnicities into one large group, missing 

important differences between groups.124 

Program staff and partners may want to design their 

own data collection tools when existing measures are 

not available for a population or when they want to 

collect information about the effects of specific policies. 

New tools should take into account staff skills and 

available time for data collection, answer the evaluation 

questions, and be culturally competent.125 

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User Guides HOW TO: Implementing Policies to Promote Health Equity 

Links Between Tobacco Control and Other Priority Issues

 COMMUNITY PRIORITY LINK TO TOBACCO CONTROL WAYS TO SUPPORT TOBACCO CONTROL 

Asthma Childhood and adult asthma attacks can be 

triggered by secondhand smoke. Racial and ethnic 

minority groups, low-income populations, and 

children living in inner cities visit the emergency 

room, are hospitalized, and die from asthma 

more often than the general population.126 

Comprehensive smoke-free laws protect workers 

with asthma and reduce hospital admissions.12 

• Educate parent organizations and 

asthma advocacy groups on the link 

between secondhand smoke and 

asthma, especially among children 

• Encourage these groups to support 

smoke-free workplace and multi-unit 

housing policies8 

In 2015, smoking will cause an estimated 30% of all 

cancer deaths.127 One study found that secondhand 

smoke also caused about 7,300 lung cancer deaths 

in one year.12 

• Work with advocacy groups to support 

cessation and comprehensive smokefree laws as part of their efforts 

Cancer 

• Work with health care providers to 

screen for tobacco use and promote 

cessation 

Cardiovascular 

disease 

Cigarette smoking is responsible for more than 

151,000 deaths from cardiovascular diseases 

each year.12 Secondhand smoke exposure also 

increases the risk of cardiovascular disease, stroke, 

and coronary heart disease.12,128 Implementing 

comprehensive smoke-free laws reduces 

hospitalizations for heart attacks, stroke, and other 

coronary events, especially in younger people.12,129 

• Work with advocacy groups to support 

cessation and comprehensive smokefree laws as part of their efforts 

• Encourage health care providers to 

screen for tobacco use among patients 

who are at risk for or suffer from 

cardiovascular disease 

Research has shown cigarette smoking to be a cause Diabetes of diabetes.12 The risk of developing diabetes is 

30-40% higher for smokers than nonsmokers, and 

the danger increases with the number of cigarettes 

smoked.12 Smokers with diabetes also have greater 

risk of cardiovascular disease.12 

•	 Encourage health care providers to 

promote cessation for patients with 

diabetes 

•	 Encourage health care providers to 

screen for diabetes among patients who 

are known smokers 

HIV Compared to the general population, the HIVpositive population is 2 to 3 times more likely to 

smoke.130 Smoking while HIV-positive increases 

the risk of developing infections and long-term side 

effects of HIV disease and treatment.131 It is also 

linked with a higher rate of death.131 

• Work with advocacy groups to support 

comprehensive smoke-free laws as part 

of their efforts 

• Work with health care providers serving 

people with HIV to screen for tobacco 

use and promote cessation 

• Educate organizations that support 

people with HIV 

Mental health and 

substance abuse 

disorders 

People with mental health disorders or substance • Clarify misunderstandings about 

abuse conditions make up 25% of the total tobacco cessation for people with 

population, but smoke 40% of all cigarettes.132 substance abuse conditions or mental 

Treatment program staff often incorrectly assume health disorders 

tobacco is not as harmful as other substances, or that • Encourage treatment centers to screen 

tobacco cessation would be too stressful or prevent for tobacco use, promote cessation, 

treating other addictions.133 Only half of substance implement smoke-free policies, and 

abuse treatment centers screen for tobacco use, and encourage staff to quit135 

only 34% offer cessation counseling.134 

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HOW TO: Implementing Policies to Promote Health Equity 

Links Between Tobacco Control and Other Priority Issues

User Guides 

 COMMUNITY PRIORITY LINK TO TOBACCO CONTROL WAYS TO SUPPORT TOBACCO CONTROL 

Obesity Overweight smokers have a shorter average life 

expectancy than nonsmokers.136 The risk for obesity 

increases as the number of cigarettes smoked each 

day increases, especially for men.

137 

• Partner with healthy and active living 

advocates to develop policies that 

increase access to healthy foods and 

reduce access to tobacco products 

• Encourage health care providers to 

screen for tobacco use when screening 

for obesity 

Oral health Tobacco use increases the risk for oral cancer and 

periodontal disease.138 Smokers have four times 

• Encourage dentists to screen for 

tobacco use and promote cessation140 

the risk of developing gum disease compared to 

nonsmokers, and smokeless tobacco increases the 

risk of tooth decay.139 

Prenatal and child 

health 

Smoking during pregnancy increases the risk for 

early delivery and low-birthweight babies.128 Infants’ 

exposure to secondhand smoke increases the risk 

for sudden infant death syndrome, respiratory 

illnesses, respiratory and ear infections, and 

asthma.128,141 

• Work with health care providers 

serving pregnant women and families 

to promote cessation 

• Encourage secondhand smoke 

protections in homes and cars 

Low-income populations are more likely to smoke Poverty cigarettes and less likely to quit.12,25 Low-income 

smokers are less likely to receive cessation assistance 

and are more likely to be uninsured.1

 Low-income 

households with smokers spend more of their 

income on smoking.142 

•	 Promote smoke-free housing policies 

•	 Promote comprehensive insurance 

coverage for cessation, especially for 

Medicaid recipients1 

•	 Work with social service agencies to 

increase access to cessation 

•	 Educate family support services about 

how tobacco control can help protect 

health and limited family budgets 

Quality housing Secondhand smoke can spread between apartments 

in multi-unit housing and harm residents in 

nonsmoking apartments. Children living in multiunit housing are at particular risk. They experience 

greater secondhand smoke exposure than children 

in single-family homes.143 Smoking can also damage 

property and cause fires. It is the leading cause 

of fire deaths in multi-unit housing, killing both 

smokers and other residents.144 

• Educate tenants and rental property 

owners about how smoke-free 

housing policies can improve living 

environments and lower maintenance 

and liability costs8 

• Work with quality housing and child 

health advocates to support smoke-free 

multi-unit housing policies 

Youth violence 

prevention 

Youth who smoke are more likely to seriously 

consider suicide, engage in physical fights, and 

carry a weapon than youth who do not smoke.31 

• Educate youth employment and 

resiliency programs on the link 

between tobacco and youth violence 

•	 Encourage programs to promote 

cessation by increasing youth’s abilities 

to make healthy choices, including the 

choice not to use tobacco8 

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User Guides HOW TO: Implementing Policies to Promote Health Equity
 

Program staff and partners should be aware that different 

subgroups of the population may have different social 

norms around tobacco use and can be affected differently 

by tobacco control policies. For certain cultural groups, 

it may be important to survey multiple generations. 

First, second, and third generation immigrants may view 

and use tobacco differently. Hard-to-reach subgroups 

that might be excluded from surveys, like youth who 

have dropped out of high school, also have some of the 

highest rates of tobacco use and secondhand smoke 

exposure.5 It is important to collect data about these 

subgroups. Program staff and partners should ask 

participants about their specific tribes, racial groups, 

gender identities, or other characteristics early in data 

collection, and carefully select sites and participants so 

that samples represent these groups.7 

Tobacco control staff and partners should also collect 

data use of other tobacco products (OTPs) and exposure 

to tobacco advertising among specific groups. For 

example, the American Indian and Alaska Native 

population has the highest rate of smokeless tobacco use, 

cigar use, and use of more than one tobacco product of 

any racial or ethnic group.12 Menthol cigarettes are the 

main tobacco product used by African Americans and 

are popular among youth.12 These groups also see more 

advertising and lower prices for other tobacco products 

in their neighborhoods.48 By collecting data on OTPs, 

programs and partners can make sure that all tobacco 

use and exposure patterns are captured. 

Evaluating Policy Implementation and Enforcement 

Evaluating how policies are implemented and enforced 

can help tobacco control programs understand what 

works to reduce disparities and respond to possible 

challenges to successful implementation. To determine 

if the policy is reaching the population, programs 

and partners can collect data about what and where 

activities take place, who is using services, and what 

barriers to accessing services are encountered by the 

community.7

 For example, an evaluation of a smokefree multi-unit housing policy could assess which 

apartment buildings are enforcing the policy (and 

which are not). The evaluation could also examine if 

cessation support is offered to tenants affected by the 

policy and if tenants experience problems accessing 

these services, such as high costs or inconvenient 

location. Programs can use this information to adjust 

strategies and develop future policies. 

Designing Inclusive 

Evaluations145 

8	 Include people from populations 

affected by tobacco-related disparities in 

the evaluation process. 

8	 Train data collection staff in cultural 

competence and, when possible, have 

members of the population help collect 

data (e.g., store assessments). 

8	 Test surveys and instruments before 

use—members of different populations 

may not respond in the same way to 

certain questions. 

8	 Have members of populations affected by 

tobacco-related disparities review data, 

decide on key findings, and share results. 

Helpful Evaluation Resources 

The CDC has developed a comprehensive set of 

resources to help tobacco control programs monitor 

and evaluate tobacco use.146 Tobacco control programs 

can consult these workbooks for guidance on planning 

and implementing evaluations, selecting data sources 

and measures, and sharing and disseminating 

evaluation findings. The workbooks include: 

•	 Introduction to Program Evaluation for 

Comprehensive Tobacco Control Programs;

147 

•	 Developing an Effective Evaluation Plan;

148 

•	 Surveillance and Evaluation Data Resources for 

Comprehensive Tobacco Control Programs;

149 

•	 Preventing Initiation of Tobacco Use: Outcomes 

Indicators for Comprehensive Tobacco Control 

Programs;

150 

•	 Developing an Effective Evaluation Report;

151 

and 

•	 Impact and Value: Telling Your Program’s 

Story.

152 

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Overcoming Unintended Policy Consequences 

and Barriers to Success 

Tobacco control policies play a key role in changing 

social norms around tobacco use, but implementation 

barriers and unintended consequences of policies may 

limit their effectiveness or even worsen tobacco-related 

disparities.7,13 For example, policies implemented in 

high-income countries in the 1960s-1980s reduced 

smoking prevalence faster among groups with higher 

socioeconomic status, increasing disparities in tobacco 

use and secondhand smoke exposure over time.13 

Communities may lack the resources to fully implement 

and enforce policies. Policies that are limited, 

underfunded, not fully or consistently implemented, 

or that ignore the social, cultural, and economic 

environments that influence tobacco use, may lead to 

unintended consequences that preserve or even increase 

tobacco-related disparities. For example, exempting 

casinos from smoke-free laws maintains workplace 

disparities in secondhand smoke exposure.153 Often, 

tobacco control policies do not have the same effects 

for all groups because they are not equally enforced. 

For instance, policies limiting youth access to tobacco 

products have been enforced more often for white youth 

than for African American and Latino youth.154 

To make sure that tobacco control policies do not result 

in unintended consequences, tobacco control programs 

and partners can work to fully and equitably implement 

strong and comprehensive policies. Tobacco control 

policies are most effective when they: 

•	 Exclude exemptions;6 

•	 Protect all populations;7,6 

•	 Identify the partners responsible for 


enforcement;12,134
 

•	 Include resources for countermarketing 


campaigns and cessation services;1

 and
 

•	 Include adequate fees, penalties, or both.12 

Barriers like language, cost, transportation, or health 

literacy can all prevent community members from 

fully benefiting from a policy.7 For example, cessation 

information may not be available in community 

members’ native languages, or they may not have the 

capacity to understand and act on the information.7 

If someone from the community was not involved 

in policy development, community members may 

not be aware of the policy or it may not align with 

their cultural beliefs or customs.7 During policy 

development, programs can brainstorm potential 

barriers and make a plan to overcome them. 

Simply pushing for comprehensive tobacco control 

policies and planning for potential barriers is not 

enough. To avoid unintended consequences and 

overcome barriers, groups that have been historically 

excluded should be part of the policy process. 

Coalitions can help bring together people from a 

variety of backgrounds, represent diverse perspectives, 

and promote community buy-in for tobacco control 

policies.8

 Having community members help select, 

implement, and evaluate strategies also reduces the 

likelihood of unexpected effects or problems. 

To avoid potential unintended consequences, 

programs can:7 

•	 Educate community members about the policy 

and its benefits; 

•	 Find champions from the community to ease 

concerns and build support for policy efforts; 

•	 Assess knowledge gaps among partners and 

offer training and technical assistance where 

needed; 

•	 Implement complementary strategies that work 

together to reduce disparities (e.g., combine 

increases in tobacco product prices with 

cessation services); 

•	 Monitor changes in tobacco use and secondhand 

smoke exposure to look for widening or new 

disparities; 

•	 Evaluate policy implementation and 

enforcement to look for problems or barriers 

(e.g., conduct compliance checks to make sure 

policies are being implemented consistently in 

low-income communities); and 

•	 Share findings on tobacco industry targeted 

marketing and tobacco-related disparities with 

the affected populations to empower them to 

continue work to reduce disparities. 

Health Equity l 31
 
User Guides HOW TO: Implementing Policies to Promote Health Equity
 

A CLOSER LOOK: Jefferson County, Alabama, Adopts Comprehensive 

Smoke-Free Laws 

With a Communities Putting Prevention to 

Work grant received in 2010, the Jefferson 

County Department of Health (JCDH) and 

the Health Action Partnership (HAP), a 

coalition of over 80 diverse organizations, 

worked to reduce disparities in smokefree protections in Jefferson County, A smoke-free law now covers restaurants and bars in Birmingham, AL Alabama.155,156 The state’s most populated 


county and home to its largest city, 


Jefferson County has nearly 700,000 residents. JCDH and HAP conducted community assessments, 


built community partnerships, and implemented health communication interventions to promote 


comprehensive smoke-free laws. 


JCDH and HAP began policy work by conducting community assessments and using GIS mapping to 


determine where the need for secondhand smoke protections was greatest.7

 By overlaying maps of low-


income areas on maps of smoking, heart attack, and cancer rates, they were able to focus resources where 


they could have the greatest impact.7
 

After deciding where to concentrate their efforts, JCDH and HAP interviewed community members 


to identify champions and organizations that would be critical partners to reach these populations.7
 

Through partnerships with local organizations and faith-based leaders, they educated community 


members on the dangers of secondhand smoke and the need for comprehensive smoke-free laws. For 


example, they hosted a Smoke-Free Worship Weekend that reached nearly 500 congregations.156 Another
 

partner, The Friends of West End, educated 100 neighborhood association presidents on the need for 


smoke-free policies.7

 The association presidents then shared the information with their communities. 


JCDH and HAP also developed a culturally competent media campaign about the need for smoke-free 


protections. JCDH created a radio soap opera called Live Well Camberwell that aired on radio stations 


with large African American audiences.7
 

As of 2012, six cities including Birmingham had passed comprehensive smoke-free laws.155 Together, 


the policies protect nearly 300,000 people.155 To avoid problems that might limit the effectiveness of the 


policies and ensure compliance with the new laws, HAP offered technical assistance to the communities 


before and after laws went into effect.7
 

Health Equity l 32
 
Health Equity l 33 

PROVIDING SUPPORT User Guides

How Can Tobacco Control Programs Support 

Health Equity? 

A comprehensive tobacco control program requires coordinated efforts by state and community partners to provide 

education and support for policies that work to reduce and eliminate disparities. Although work toward achieving 

health equity may look different in each tobacco control program, staff and partners should use the following best 

practices as a guide: 

Commitment to Cultural Competence 

8	 Offer culturally competent technical assistance and 

training to grantees and partners. 

8	 Develop health communication materials in 

multiple languages and with culturally relevant 

themes. 

8	 Make sure that quitline services are culturally 

sensitive and have adequate reach to meet the 

needs of specific populations. 

Administrative & Evaluation Support 

8	 Conduct surveillance and evaluation activities to 

help understand the burden of tobacco-related 

disparities and guide policy development and 

implementation. 

8	 Share and disseminate data on targeted marketing 

and other industry practices with communities that 

experience tobacco-related disparities. 

8	 Develop accountability measures and take steps to 

make sure tobacco control policies are fully and 

consistently enforced. 

Coordination & Collaboration 

8	 Include diverse leaders from specific population 

groups, tribes, and community-based organizations 

in all phases of policy planning, implementation, 

and evaluation. Their experiences will help 

naturally tailor efforts to priority populations. 

8	 Distribute resources to organizations that can 

effectively reach and mobilize specific populations. 

8	 Work with representatives from community 

organizations to make sure that health equity issues 

are included in tobacco control strategic plans. 
Health Equity l 34 

IN ACTION User Guides

Case Study #1: San Francisco, California 

California Department of Public Health supports LGBT Partnership’s work to reduce 

tobacco-related disparities through first U.S. tobacco-free pharmacy policy. 

State program funds community grantee’s work to 

reduce tobacco use in priority population 

In 2003, the California Department of Public Health/ 

Tobacco Control Section funded the California LGBT 

Tobacco Education Partnership’s (the Partnership) 

work to reduce tobacco-related disparities among 

LGBT populations. Research has shown that tobacco 

use in LGBT communities is high and that the 

LGBT population is targeted by tobacco industry 

marketing.12,60,157 The Partnership educates LGBT 

communities and partners about policies limiting 

tobacco industry donations and reducing the 

availability of tobacco products. Led by project director 

Bob Gordon, the group began exploring tobacco 

product sales in San Francisco pharmacies in 2007. 

Different sales policies at two Castro district Walgreens 

spark idea for policy change 

The idea for the pharmacy ban came from observations 

made by the Partnership about two Walgreens 

pharmacies in the Castro district of San Francisco, 

one of the nation’s largest LGBT communities. A 

traditional Walgreens store located at the busy corner 

of 18th and Castro sold medications and other products, 

including tobacco. At one time, this store was known 

to have the highest revenue of the chain. Gordon 

worried that this high sales revenue translated to a high 

volume of cigarette sales to community members. A 

second Walgreens, located just half a block away, was 

a “specialty pharmacy” that sold only medications— 

no greeting cards, food items, office supplies—and no 

cigarettes. The difference in sales practices of the two 

stores prompted the Partnership to consider whether 

community members could have a say about what 

items are sold in their neighborhoods and particularly 

in their pharmacies. Because the state of California 

already encouraged grantees to work on increasing the 

number of tobacco-free pharmacies, the Partnership 

decided to begin formally working on this policy. 

State program guides academic, health, and community 

partners’ work to increase awareness of tobacco-free 

pharmacy issue 

The Partnership began work by developing a three-year 

plan required by the state program that described a 

set of activities leading to a policy change goal. When 

Ad promoting the “Cigarettes & Pharmacies Don’t Mix” awareness campaign 
Health Equity l 35 

User Guides IN ACTION

asked about the state’s guidance, Gordon said, “Having 

a detailed plan of where you are going to go and how 

you are going to get there, and having a measurable 

policy change at the end, is extremely helpful.” 

The Partnership’s original goal was to have the Board 

of Supervisors pass a non-binding resolution (i.e., 

a written motion that cannot progress into a law) 

that would help create awareness of the tobacco 

pharmacy sales issue. However, the Partnership 

quickly discovered that other stakeholders (faculty 

and students at University of San Francisco School of 

Pharmacy, the San Francisco Department of Public 

Health, community advocates, and the mayor’s and 

city attorney’s offices) were also interested in the 

issue. The Partnership surveyed over 400 community 

members at the October 2007 Castro Street Fair and 

found that 86% supported tobacco-free pharmacies in 

their neighborhoods. During the first year of the plan, 

it was announced that the mayor wanted to sponsor 

a tobacco-free pharmacy ordinance. Bob Gordon 

commented, “It all came together in the summer of 

2008...that’s when the policy work really took off...and 

we all worked together.” 

“	 Having a detailed plan of where 

you are going to go and how you 

are going to get there, and having 

a measurable policy change at the 

end, is extremely helpful. ” – Bob Gordon 

Media awareness campaign, earned media efforts, and 

vocal community support contribute to policy success 

The Partnership used several media strategies to move 

the process along. They launched the Cigarettes & 

Pharmacies Don’t Mix awareness campaign, posting 

ads on buses and inside historic trolley cars. Their goal 

was not to push for a specific ordinance but rather to 

spread awareness of the tobacco-free pharmacy issue. 

They also distributed flyers to pharmacies and other 

local businesses, trained advocates to educate the Board 

of Supervisors, wrote editorial pieces, and encouraged 

a position statement from a local university. Partners 

also asked independent pharmacists throughout San 

Francisco who were already not selling cigarettes to 

write letters of support. Hearing these stories was 

compelling to decision makers as they considered 

passing the ordinance. 

First tobacco-free pharmacy ordinance passes quickly 

with strong partner support 

Because of the strength of the broad tobacco control 

partnership, the mayor’s support, and great timing, the 

ordinance passed quickly in July 2008. Opposition came 

primarily from Walgreens representatives, individual 

rights advocates, and some retailer associations. The 

ordinance added an amendment to the San Francisco 

Health Code that prevented pharmacies from being 

issued tobacco retailer licenses after October 1, 2008. 

The ordinance was later broadened to remove an 

exemption for pharmacies housed within big-box (e.g., 

superstores or supercenters) and grocery stores. 

San Francisco policy serves as model for other 

communities 

What began as a single health equity policy education 

initiative by the Partnership in San Francisco has 

become a national tobacco control movement. The 

San Francisco ordinance spurred similar policies in 

other California and Massachusetts communities.158,159 

On February 5, 2014, CVS Health announced that its 

stores will stop selling all tobacco products, including 

cigarettes and cigars, by October 2014. In a statement 

explaining the change, CVS Health President Larry J. 

Merlo said, “We came to the decision that cigarettes 

and providing health care just don’t go together in the 

same setting.”160 Advocates continue to encourage other 

communities and pharmacy chains to follow suit. 
Health Equity l 36 

User Guides

Case Study #2: Utah 

Utah Tobacco Prevention and Control Program implements tobacco-free policies in 

mental health and substance abuse treatment centers. 

Data reveal two different stories of tobacco use 

Utah consistently has some of the lowest smoking 

prevalence rates in the nation. In 2009, only about 10% 

of Utah residents smoked, the lowest prevalence of any 

state.161 However, data on smoking among people with 

mental health disorders and substance abuse conditions 

painted a very different picture of tobacco use among 

these groups. Over 65% of Utah substance abuse 

treatment center clients smoked, and national data 

suggested similar prevalence rates among people with 

mental illness.162-164 To the Utah Tobacco Prevention 

and Control Program (TPCP) and the Division of 

Substance Abuse and Mental Health (DSAMH), 

these numbers stood out in stark contrast to smoking 

prevalence among all Utah adults.165 Dave Felt, Director 

of DSAMH said, “We realized that the smoking 

percentage of our population was way above the state 

norm. We also took a look at the fact that tobacco 

kills more individuals than all of the other substances 

combined, and we said it was time that we stop 

ignoring the elephant in the room and start addressing 

this very serious health problem.”165 This realization, 

coupled with evidence that tobacco control efforts 

work in these populations,162 prompted the partners to 

create the Recovery Plus initiative. With funding from 

the Communities Putting Prevention to Work program, 

the initiative aimed to make all publicly funded mental 

health and substance abuse treatment centers in the 

state tobacco-free. 

Coalition develops three-phase plan to go tobacco-free 

The two departments launched the initiative by forming 

a leadership team that included TPCP, DSAMH, local 

health departments, local mental health and substance 

abuse treatment centers, treatment center clients, 

advocacy groups, and the Department of Corrections. 

By engaging partners from treatment center clients 

to state agencies, TPCP and DSAMH developed 

leadership and buy-in at all levels of the initiative. 

Building on Utah State Hospital’s 2007 tobacco-free 

policy and using New York’s model for tobacco-free 

treatment facilities as a guide, the partners created a 

three-phase plan to reach the goal of 100% tobacco-free 

treatment centers. The plan was designed to first gather 

data about the current treatment center environment 

and to then use the information to inform policy 

design and implementation. This step-by-step process 

helped the team recognize barriers to successful policy 

implementation and adapt strategies as needed. 

“	 We took a look at the fact that 

tobacco kills more individuals 

than all of the other substances 

combined, and we said it was 

time that we stop ignoring the 

elephant in the room and start 

addressing this very serious 

health problem. ” – Dave Felt 
Health Equity l 37 

User Guides IN ACTION

Phase 1: Needs assessments inform policy process 

In Phase 1 of the plan, partners conducted a needs 

assessment of publicly funded substance abuse and 

mental health treatment centers. They examined 

current tobacco use by clients and staff and asked 

about their attitudes toward tobacco cessation. The 

needs assessment confirmed high smoking prevalence 

among treatment center clients (60-68%) and revealed 

a culture where smoking was acceptable. For example, 

smoking was sometimes seen as a reward for clients 

or as a secondary concern to treating clients’ other 

addictions. The assessment also revealed that, while 

clients were aware of the benefits of smoking cessation, 

staff needed education on how quitting could help 

clients fight their addictions and more training on how 

to help them quit. 

Phase 2: Systems changes help treatment center staff 

promote tobacco cessation 

TPCP and partners used the information gathered 

during the needs assessment to make sure that clinical 

staff had the necessary training, resources, and 

systems in place to support tobacco cessation among 

their clients. The team developed a new intake form 

to integrate tobacco use screening into the existing 

admissions process. They also worked with the state 

quitline to create a protocol to contact treatment 

center staff when clients called the quitline to request 

nicotine replacement therapy (NRT). The treatment 

center staff then distributed the NRT to the client 

and made a note in the client’s medical chart, so that 

it could be monitored along with other treatments. 

Both quitline and treatment center staff received 

training and resources on promoting cessation 

among people with mental health or substance abuse 

disorders. For example, TPCP developed a series of 

educational materials called Fighting Myths to dispel 

misunderstandings among treatment center staff about 

clients’ tobacco use. 

Phase 3: Mental health and substance abuse treatment 

centers implement tobacco-free policies 

On July 1, 2012, tobacco-free policies went into effect 

at all 155 publicly funded mental health and substance 

abuse treatment centers, reaching over 17,000 clients. 

The policies prohibited tobacco use on campus by staff 

or clients and included tobacco cessation in screening, 

treatment, and discharge protocols. 

Since the policies went into effect, TPCP has seen an 

increase in the number of people with mental health 

and substance abuse disorders using cessation services. 

For treatment center clients, the policies helped them 

accomplish a goal they never thought they could achieve. 

One client said of the program, “If I wasn’t coming in to a 

treatment facility to learn about my addictive behaviors, 

I probably would have never quit smoking. It seemed 

impossible.”165 TPCP Program Manager Janae Duncan 

says, “That’s what is important to us, that we’re improving 

the quantity and quality of life for people with mental 

health and substance abuse issues.”165 

Recovery Plus continues to improve and expand services 

The Recovery Plus leadership team’s work has not 

stopped since the policies went into effect. DSAMH 

reviews the policies annually during site visits with 

treatments centers, looking for ways to improve policy 

implementation and identifying technical assistance 

needs. The program will also continue to track tobacco 

use by clients and use of cessation services as they enter 

and leave treatment centers. In the future, Recovery Plus 

hopes to expand services to include other risk factors 

and chronic diseases affecting people with mental 

health and substance abuse disorders. 

Case Study adapted from: 

Centers for Disease Control and Prevention. Recovery 

PLUS: Utah’s Plan to Integrate Comprehensive Tobacco 

Policies into Mental Health and Substance Abuse 

Treatment. Atlanta, GA: U.S. 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; n.d. 
Health Equity l 38 

CASE FOR INVESTMENT User Guides

Why Invest in Health Equity? 

Reducing tobacco-related disparities is an essential part of all comprehensive tobacco control programs. 

Comprehensive, fully enforced policies can provide equal protection to everyone, regardless of their gender, job, age, 

race or ethnicity, sexual orientation, gender identity, where they live, or other factors. Tobacco control programs and 

partners can use the information in this section to educate decision makers and other leaders about how policies 

can reduce tobacco-related disparities and work to achieve health equity. 

History and Adoption 

For over 30 years, public health officials have 

recognized that tobacco use and secondhand smoke 

exposure affects some populations more than others. 

From the 1980 release of the Surgeon General’s report, 

The Health Consequences of Smoking for Women,

14 until 

the most recent Surgeon General’s report, The Health 

Consequences of Smoking–50 Years of Progress,

12 data on 

tobacco use among specific populations have been used 

to illustrate the need for tobacco control policies that 

promote health equity. 

The release of tobacco industry documents and the 

Surgeon General’s report, Tobacco Use Among U.S. 

Racial/Ethnic Minority Groups, in 1998 revealed that 

tobacco use among groups experiencing tobaccorelated disparities does not have a single cause.15 

Instead, tobacco use among these populations 

results from a complex interaction of factors 

(e.g., socioeconomic status, social and cultural 

characteristics, targeted advertising, and tobacco 

product pricing).15 

Eliminating tobacco-related disparities continues to 

be a focus of recent major national reports, including 

Healthy People 2020 and the 2014 Best Practices.

1,19 

These reports, along with greater understanding 

of tobacco-related disparities, growing evidence of 

the effectiveness of population-based policies, and 

emerging promising practices for high-risk groups have 

helped build momentum to reduce these disparities 

through policy. 

Scientific Evidence 

Tobacco control efforts have changed social norms 

and reduced tobacco use and exposure to secondhand 

smoke among the general population.12 Despite these 

overall declines, higher tobacco use prevalence, lower 

cessation rates, and poorer health outcomes have 

been reported among some populations. For example, 

certain racial or ethnic groups, the LGBT community, 

women, Southern and Midwestern populations, and 

groups with less education or lower incomes experience 

tobacco-related disparities.1,12,24 

To decrease overall tobacco use and secondhand 

smoke exposure, tobacco use must be reduced among 

these groups. Population-based policy interventions 

like creating smoke-free environments,4,6,7 increasing 

the price of tobacco products,1,10,12 reducing exposure 

to tobacco industry advertising,7,33,87 and improving 

access to cessation services1,7,166,167 can reduce tobaccorelated disparities. Comprehensive smoke-free laws in 

particular have been consistently linked to improved 

health outcomes, including fewer hospital admissions 

for strokes, heart attacks, and respiratory diseases like 

asthma.6,12,168 

Research has also shown that policies are more effective 

when pursued as part of a comprehensive tobacco 

control program.1 Comprehensive tobacco control 

programs are effective at reducing tobacco use across 

diverse racial and ethnic groups and groups with 

different education and income levels.98 
Health Equity l 39 

User Guides CASE FOR INVESTMENT

Cost 

Populations experiencing health disparities make up a 

significant portion of health care costs.11 For example, 

a 2009 study estimated that poorer health outcomes for 

African Americans, Asian Americans, and Hispanics 

added $229.4 billion in direct health care costs between 

2003 and 2006.11 Estimated indirect costs of poorer 

health outcomes among these groups amounted to 

more than one trillion dollars over the same period.11 

As the leading cause of preventable disease and death in 

the U.S., tobacco use and secondhand smoke exposure 

resulted in $175.9 billion in direct health care costs 

in 2013 and an additional $150.7 billion in annual 

productivity losses.12 An estimated 480,000 premature 

deaths each year are caused by cigarette smoking and 

exposure to secondhand smoke.12 Working toward 

health equity in tobacco control is a powerful way to 

help eliminate tobacco-related disparities and decrease 

health care costs. 

Policies to reduce tobacco-related disparities have 

already proven to be cost-effective ways to lower the 

health care costs of smoking.6,10 When Massachusetts 

expanded its Medicaid cessation benefit in 2006 to 

include comprehensive cessation coverage, smoking 

prevalence decreased from 38% to 28% among 

Medicaid recipients.1 Hospitalizations for cardiovascular 

conditions were cut in half, saving $3.12 for every dollar 

spent on the benefit.1 Annual smoking-related medical 

costs to states range from $258 million (Wyoming) to 

$13.3 billion (California).1

 Policies that reduce these 

costs would result in significant savings for states. 

Policy efforts supported by well-funded, comprehensive 

tobacco control programs can have even greater returns 

on a program’s investment. California’s comprehensive 

tobacco control program combines policy approaches 

with media campaigns and technical assistance. The 

program cost $2.4 billion over ten years, but saved 

$134 billion in health care costs.1

 Washington’s 

tobacco control program implemented a statewide 

comprehensive smoke-free law, along with price 

increases, quitline services, a media campaign, and 

community programs. From 2000 to 2009, the program 

achieved a $5 savings in health care costs for every $1 

spent on the program.169 

Sustainability 

By investing in policy efforts to reduce tobacco-related 

disparities, tobacco control programs can have a 

lasting effect on tobacco use and secondhand smoke 

exposure. Tobacco control policies change social 

norms around tobacco use and create systems to help 

people live a tobacco-free lifestyle.1 Interventions that 

change social norms are the most effective way to 

sustain behavior change.1 

Working on policies to reduce tobacco-related 

disparities also helps develop infrastructure and 

partnerships that support program sustainability. Policy 

efforts increase political will and public support for 

tobacco control programs by educating decision makers 

and engaging communities. Involving communities 

that have traditionally had a limited voice in shaping 

policy can help sustain the program by strengthening 

ties to those communities. Through training and 

technical assistance, tobacco control policy efforts build 

the capacity of communities to continue working on 

tobacco-related disparities on their own.1,7 

Policy efforts also help spread tobacco control 

messages to a wider audience. Media advocacy helps 

to educate the population about the harms of tobacco 

use, the value of strong policies, and the importance 

of comprehensive tobacco control programs. Linking 

tobacco control messages to other community and 

public health issues can increase awareness of the 

program and create partnerships that may lead to new 

funding opportunities. After a policy is passed, tobacco 

control partners can continue to educate decision 

makers about the importance of sustained funding for 

efforts to reduce tobacco-related disparities. Lessons 

learned from health equity policy efforts can inform 

future policy work and increase the effectiveness of 

tobacco control programs.7 
Health Equity l 40 

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Health Equity l 41 

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Health Equity l 42 

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Health Equity l 43 

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Health Equity l 44 

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Health Equity l 45 

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This document was produced for the Centers for Disease Control and Prevention by the 

Center for Public Health Systems Science (CPHSS) at the Brown School at Washington 

University in St. Louis. 

Suggested citation: 

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. 

Ordering information: 

To download or order copies of this report, go to www.cdc.gov/tobacco 

or to order single copies, call toll-free 1-800-CDC-INFO or 1-800-232-4636. 

More information: 

For more information about tobacco control and prevention, 

visit CDC’s Smoking & Tobacco Use website at www.cdc.gov/tobacco.