Promoting Quitting Among 

Adults and Young People: 

Outcome Indicators for Comprehensive 

Tobacco Control Programs—2015 

National Center for Chronic Disease Prevention and Health Promotion 

Division name here 
Acknowledgments 

This technical assistance guide was developed by the Centers for Disease Control and Prevention’s Office 

on Smoking and Health. The resource was developed as the second part of a three-part series of technical 

assistance guides intended to update the first three goal areas of the Key Outcome Indicators for Evaluating 

Comprehensive Tobacco Control Programs, released in 2005. The guide is intended to help state and territorial 

health departments plan and evaluate state tobacco control programs. The updated guides can be found at 

the following web address: http://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/ 

surveillance_evaluation/index.htm. 

We would like to extend special thanks to the following individuals for their assistance in preparing and 

reviewing this publication: 

Expert Panel Members (Appendix B) 

Outcome Indicator Workgroup (Appendix B) 

Disclaimer 

Web site addresses of nonfederal organizations are provided solely as a service to readers. Provision of an 

address does not constitute an endorsement of this organization by the Centers for Disease Control and 

Prevention (CDC) or the federal government, and none should be inferred. CDC is not responsible for the 

content of other organizations’Web pages. 

Suggested Citation 

Suggested Citation: Centers for Disease Control and Prevention. Promoting quitting among adults and 

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

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

Office on Smoking and Health; 2015. 
 

 

 

 

 

Preface 

Purpose 

Cigarette smoking is the leading cause of preventable illness and death in the 

United States and has been causally linked to diseases of nearly all organs of the 

body.1,2 More than 20 million Americans have died as a result of smoking since 

the first Surgeon General’s report on smoking and health was released in 1964.1 

The earlier in life an individual successfully quits using tobacco products, the 

lower the person’s likelihood of suffering tobacco-related disease.2

 Promoting 

cessation is a core component of state tobacco control programs’ efforts to reduce 

tobacco use.3,4 Encouraging and helping tobacco users to quit is the quickest 

approach to reducing tobacco-related disease, death, and health care costs.

3,5 

To sustain comprehensive tobacco control programs, it is important to 

demonstrate that these efforts continue to have the intended public health impact. 

To produce such evidence, it is critical that state tobacco control programs 

continue to evaluate their efforts. Selecting appropriate outcome indicators is a 

key step in designing a rigorous evaluation. That is where this guide can help. 

This publication is the second in a series of updates to the guide released in 2005 

by the Centers for Disease Control and Prevention’s (CDC’s) Office on Smoking 

and Health (OSH), Key Outcome Indicators for Evaluating Comprehensive 

Tobacco Control Programs,

6 hereafter referred to as KOI 2005. As a companion 

to the 2001 publication, Introduction to Program Evaluation for Comprehensive 

Tobacco Control Programs,

7

 KOI 2005 was designed to provide information on 

selecting indicators and linking them to outcome objectives. This update provides 

a revised logic model and set of outcome indicators for Goal Area 3 of the 

National Tobacco Control Program, which addresses promoting quitting among 

adults and young people. Although this update focuses on tobacco cessation, 

comprehensive tobacco control programs that simultaneously address initiation, 

the elimination of secondhand smoke, and cessation are more effective than 

programs that address these issues in isolation. Therefore, until final updates are 

available, this resource should be used in combination with outcome indicators 

from KOI 2005 that address eliminating nonsmokers’ exposure to secondhand 

smoke. This update supports application of CDC’s Framework for Program 

Evaluation in Public Health Practice,

8

 which consists of the following six steps 

of good evaluation: 

PREFACE 

i 
 

 

 

 

1.	 Engage 

stakeholders. 

2.	 Describe the 

program. 

3.	 Focus the 

evaluation. 

4.	 Gather credible 

evidence. 

5.	 Justify your 

conclusions. 

6.	 Ensure that 

evaluation 

findings are used, 

and share lessons 

learned. 

This publication 

provides new and updated indicators and supporting information relevant to 

recent changes in the landscape of comprehensive tobacco control efforts to 

promote cessation. The Affordable Care Act requires new private health plans and 

state Medicaid programs to expand coverage of evidence-based tobacco use 

cessation treatments.9 Additionally, the passage of the 2009 Family Smoking 

Prevention and Tobacco Control Act 10 expanded federal, state, and local 

governments’ opportunities to regulate tobacco. Given these changes in the 

regulatory environment, OSH recognized the importance of revisiting and 

updating the outcome indicators. 

A primary purpose of this guide is to help advance state-specific and national 

evaluation and surveillance efforts by encouraging managers and evaluators to 

focus on evidence-based outcome indicators and to measure and report these 

using protocols and operational definitions drawn from widely available state or 

national data collection systems. In this publication, we provide examples of data 

sources, survey questions, and protocols that evaluators can use to measure each 

outcome indicator. Special care was taken to choose example data sources and 

survey questions; most are drawn from common state and national surveys and 

surveillance systems, and using them may allow managers and evaluators to 

compare their findings with data collected across states and nationally. 

To help users make informed choices about which indicators are most suitable for 

each program and context, a panel of tobacco control science and practice experts 

rated each indicator on relevant criteria, including overall quality, resources 

needed, strength of evaluation evidence, utility, face validity to policy makers, 

uniqueness, and accepted practice. The ratings will help the reader decide, for 

example, which indicators can be measured within budget or which indicators are 

likely to carry the most informative for key decision makers. In essence, this 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

ii Tobacco Control Programs—2015 
 

 

 

publication is a consumer’s guide to tobacco control outcome indicators for 

program managers, evaluators, epidemiologists, researchers and others. 

Tobacco control program staff can use the information in this guide to focus their 

evaluations (step 3 of CDC’s Framework for Program Evaluation). The guide 

will inform the selection of indicators and enable linkage of indicators to 

outcomes. The guide also assists in gathering credible evidence (step 4 of the 

Framework for Program Evaluation) and establishes the value of each indicator 

for measuring the progress of state tobacco control program efforts by providing a 

summary of scientific evidence, example questions, and data sources for each 

indicator. 

Applying rigorous surveillance methods and evaluation designs will enable state 

tobacco control program staff to assess progress toward expected outcomes and 

refine program activities as needed.To the extent that state programs use 

comparable indicators, measures, and methods (such as those described in this 

guide), those who are engaged in tobacco control planning and evaluation can be 

better equipped to assess the state-specific and national impact of these efforts. 

Technical Assistance 

This guide may be used in coordination with CDC’s workbook, Developing an 

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

1 

as well as other OSH surveillance and evaluation resources, which can be 

accessed at 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/i 

ndex.htm. 

CDC helps state and territorial health departments plan, implement, and evaluate 

tobacco control programs. To contact CDC’s OSH, please call (800) 232-4636 or 

e-mail at tobaccoinfo@cdc.gov. 

References 

1.	 U.S. Department of Health and Human Services. The health consequences of 

smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and 

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

Office on Smoking and Health; 2014. 

2.	 U.S. Department of Health and Human Services. The health consequences of 

smoking: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health Promotion, Office on Smoking and 

Health; 2004. 

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

tobacco control programs—2014. Atlanta, GA: U.S. Department of Health and 

PREFACE 

iii 
 

Human Services, Centers for Disease Control and Prevention, National Center for 

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

2014. 

4.	 U.S. Department of Health and Human Services. Reducing tobacco use: a report of 

the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, 

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

Prevention and Health Promotion, Office on Smoking and Health; 2000. 

5.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. 

Washington, DC: National Academies Press; 2007. 

6.	 Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key outcome 

indicators for evaluating comprehensive tobacco control programs. Atlanta, GA: 

Centers for Disease Control and Prevention; 2005. 

7.	 MacDonald G, Starr G, Schooley M, Yee SL, Klimowski K, Turner K. Introduction 

to program evaluation for comprehensive tobacco control programs. Atlanta, GA: 

U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Office on Smoking and Health; 2001. 

8.	 Centers for Disease Control and Prevention. Framework for program evaluation in 

public health practice. Morbidity and Mortality Weekly Report. 1999;48(RR-11):1– 

40. 

9.	 The Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119; 

March 23, 2010. 

10. Family Smoking Prevention and Tobacco Control Act. Public Law 111-31, 123 U.S. 

Statutes at Large 1776; 2009. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

iv Tobacco Control Programs—2015 
 

 

 

 

 

 

Table of Contents 

Preface i 

Chapter 1 ► Introduction 1 

Chapter 2 ► Goal Area 3: Promoting Quitting Among Adults and Young 

People 19 

Goal Area 3: Promoting Quitting Among Adults and Young 

People................................................................................21 

Outcome 1: Increased Intention to Quit, Perceived Harm of 

Tobacco Use, and Awareness of and Support for 

Cessation Services.............................................................28 

Outcome 2: Increased Availability and Expanded Coverage of 

Comprehensive Cessation Services ...................................55 

Outcome 3: Increased Health Care Systems Change to Promote 

and Support Cessation.......................................................62 

Outcome 4: Increased Policy and Environmental Changes to 

Support Quitting, Strengthen Smokefree Laws, and 

Increase Tobacco Product Price ........................................84 

Outcome 5: Reduced Tobacco Industry Influence ..............................100 

Outcome 6: Increased Quit Attempts and Attempts Using 

Evidence-Based Cessation Services ................................122 

Outcome 7: Increased Cessation of All Tobacco Products as 

Early in Life as Possible..................................................141 

Outcome 8: Reduced Tobacco-Use Prevalence and Consumption......156 

Appendices and Glossary 173 

Appendix A: National Tobacco Control Program.................................175
 

Appendix B: Expert Panel Members ....................................................177
 

Appendix C: Selecting and Rating the Indicators.................................181
 

Appendix D: Data Source Indicator Table............................................189
 

Glossary and Acronyms .........................................................................195
 

TABLE OF CONTENTS 

v 

CHAPTER 1
 

Introduction 

 

 

CHAPTER 1
 

Introduction 

Purpose 

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

and Health (OSH) developed this publication to help state and territorial health 

departments plan and evaluate state tobacco control programs. This publication 

provides an updated logic model linking activities to outcomes for Goal Area 3— 

Promoting Quitting Among Adults and Young People—of the National Tobacco 

Control Program (NTCP). It contains in-depth information on indicators to 

measure progress toward outcomes, including Consumer Reports®–type ratings to 

allow for tailored selection of indicators at local, state, and territorial levels. 

Finally, it highlights how to use indicators to integrate program and evaluation 

planning. This guide may be used in coordination with CDC’s workbook, 

Developing an Effective Evaluation Plan: Setting the Course for Effective 

Program Evaluation,

1 as well as other OSH surveillance and evaluation resources, 

which can be accessed at 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/i 

ndex.htm. 

Audience 

The primary audiences for this publication consist of planners, managers, and 

evaluators of state tobacco control programs. 

The National Tobacco Control Program 

The goal of CDC’s NTCP is to reduce tobacco-related disease, disability, and 

death. The NTCP seeks to achieve this goal by working in four goal areas: 

►	 Preventing initiation among youth and young people. 

►	 Eliminating exposure to secondhand smoke. 

►	 Promoting quitting among adults and young people. 

►	 Identifying and eliminating tobacco-related disparities among population 

groups.
 

For more information on the NTCP, see Appendix A. 

Logic Models 

As explained in Introduction to Program Evaluation for Comprehensive Tobacco 

Control Programs, logic models depict the presumed causal pathways that 

CHAPTER 1 ► Introduction 

1 
 

 

 

 

connect program inputs, activities, and outputs with short-term, intermediate, and 

long-term outcomes.2 An example of a basic logic model is presented in Figure 1. 

Figure 1: Example of Logic Model 

Generic Logic Model 

Inputs Activities Outputs 

Short-term Intermediate Long-term 

Outcomes 

6 

2 

1 7 

9 

10 

8 

4 

3 

Generic Logic Model 

5 

To help tobacco control programs with 

planning and evaluation, we numbered 

each outcome in the logic model to allow 

for easy reference in discussing the links 

between logic model components. 

The NTCP logic models can be used in 

several ways: 

►	 To see the links between program 

activities; outputs; and short-term, 

intermediate, and long-term 

outcomes. 

►	 To identify relevant short-term, 

intermediate, and long-term 

outcomes. 

►	 To assist in selecting indicators to
 

measure outcomes.
 

Outcome Components 

The outcome components in the NTCP logic models are categorized as shortterm, intermediate, or long-term to indicate a presumed causal sequence. 

For each outcome box, we summarize the scientific evidence that supports 

assumptions about the links between program activities, outputs, and short-term 

or intermediate outcomes, which affect long-term outcomes (last four boxes in the 

example model). Using the model in Figure 1, for example, a program may select 

box 5 as a primary intermediate outcome. Program activities designed to achieve 

changes in short-term Outcomes 1 through 5 (linked vertically on the logic model) 

should lead to changes in Outcome 6. Indeed, not only will changes to Outcomes 

1 through 5 affect Outcome 6, but they will also affect long-term Outcomes 7 

through 10. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

2 Tobacco Control Programs—2015 
 

 

 

 

 

The revised Goal Area 3 logic model includes the following changes to outcomes 

from the original 2005 Key Outcome Indicators for Evaluating Comprehensive 

Tobacco Control Programs (KOI 2005 hereafter): 

►	 Changed the outcome “Increased awareness, 

knowledge, intention to quit, and support for 

policies that support cessation” to “Increased 

intention to quit, perceived harm of tobacco use, 

and awareness of and support for cessation 

services” and moved the outcome box to the top of 

the short-term outcomes column. These 

modifications were intended to better reflect the 

recent science in this area and account for the fact 

that tobacco users can quit successfully without 

using cessation services. 

►	 Changed the outcome “Increased insurance 

coverage for cessation services” to “Increased 

availability and expanded coverage of 

comprehensive cessation services.” This 

modification was intended to broaden the scope of 

the outcome and reflect opportunities for 

expanded coverage under the Affordable Care 

Act. 

►	 Changed the outcome “Increase in the number of 

health care providers and health care systems 

following Public Health Service (PHS) 

guidelines” to “Increased health care systems 

change to promote and support cessation.” This 

modification was intended to better reflect the 

breadth of health care systems changes to promote 

and support cessation. 

►	 Changed the outcome “Increased price of tobacco 

products” to “Increased policy and environmental 

changes to support quitting, strengthen smokefree 

laws, and increase tobacco product price.” This 

modification was intended to broaden the scope of 

the outcome beyond price and better reflect the 

implied logic and order of effects. 

►	 Added the outcome “Reduced tobacco industry
 

influence” to reflect the science showing the 

impact of tobacco industry actions in sustaining 

the tobacco epidemic.3
 

CHAPTER 1 ► Introduction 

3 
 

 

 

 

 

 

 

►	 Changed the outcome “Increased cessation among 

adults and young people” to “Increased cessation 

of all tobacco products as early in life as possible.” 

This modification was intended to emphasize the 

importance of achieving permanent cessation early 

in life to avoid most of the risk of dying from a 

smoking- related disease4and to clarify the 

importance of eliminating use of all tobacco 

products. 

Indicators 

Outcome indicators are specific, observable, and measurable characteristics or 

changes that represent achievement of an outcome.5

 For example, if your program 

is trying to “Increase policy and environmental changes to support quitting, 

strengthen smokefree laws, and increase tobacco product price” (Outcome 4) and 

you measured the “Proportion of tobacco users with smokefree home or vehicle 

rules ” (Indicator 3.4.d), the result would indicate progress toward increasing 

policy and environmental changes to support quitting. 

Although monitoring a single indicator can serve as a helpful guidepost, including 

indicators from across the short-term, intermediate, and long-term outcomes 

within a logic model is needed for a robust evaluation. By mapping a causal 

pathway across the logic model and measuring key indicators along this pathway, 

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

where they are not. Much like an ordered row of dominoes, the sequence of 

indicators across short-term, intermediate, and long-term outcomes clarifies where 

progress is and is not being made. When a key indicator within the pathway fails 

to improve or begins declining, additional inquiry can determine whether the 

program itself is failing to achieve the intended effects or whether contextual 

factors along the causal pathway are responsible. In either case, understanding the 

roadblocks in achieving the intended public health goals provides important 

information to guide program improvement efforts. More information on using 

outcome indicators to develop an evaluation plan is provided in this section and in 

CDC’s workbook, Developing an Effective Evaluation Plan: Setting the Course 

for Effective Program Evaluation,

1 which can be accessed at 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/i 

ndex.htm. 

Tobacco Products Other than Cigarettes 

Some of the indicators we discuss in this publication are particularly useful for 

measuring progress toward reducing cigarette use. In addition, given ongoing 

evidence that tobacco products other than cigarettes are being heavily marketed 

and new and alternative tobacco products are being developed by the tobacco 

industry,3

 we have explicitly attempted to update indicators so that they address a 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

4 Tobacco Control Programs—2015 
 

 

 

 

wide breadth of tobacco products. We encourage programs to consider the 

tobacco use patterns of their community when making decisions regarding 

surveillance and evaluation activities in terms of measuring different forms of 

tobacco use. 

Identifying and Eliminating Disparities 

To reduce the overall health burden of tobacco use in the U.S., tobacco control 

programs should focus on identifying and eliminating tobacco-related disparities 

across all elements of the logic model. This involves designing and implementing 

initiatives that effectively reach and have an impact on populations at the greatest 

risk, ensuring culturally meaningful outputs, and collecting and analyzing data in 

a manner that allows for the identification of populations experiencing tobaccorelated disparities and the monitoring of outcomes in these populations. In 

considering what outcomes to monitor, it is important to remember that no single 

factor determines patterns of tobacco use and the impact of tobacco use in a 

particular population, but rather, that tobacco use involves a complex interaction 

of multiple factors.6 As with types of tobacco products, we encourage programs to 

consider their local context when making decisions regarding their need to 

capture information by population characteristics, such as race and ethnicity, age 

group, educational attainment, occupation, income, geographic location, cooccuring health conditions, sexual orientation and gender identity, and veteran 

and military status. Throughout this guide, we have highlighted population 

characteristics associated with particular indicators when the evidence is 

particularly strong in demonstrating associations. Programs should consistently 

assess indicators by state-specific priority population characteristics to better 

understand the reach and impacts of their activities and to build the evidence base 

needed for improved tobacco prevention and control. 

Organization of Indicators 

In this publication, indicators are organized by outcome component in the logic 

model. Indicators to measure distal outcomes (i.e., reduced tobacco-related 

morbidity, mortality, and disparities) are not included in this guide for two 

reasons. First, the research base establishing linkages between behavioral 

outcomes (e.g., reductions in tobacco consumption and tobacco use prevalence) 

and the distal outcomes is well established. Therefore, tobacco control programs 

could consider demonstrating an effect on behavioral outcomes, and they can then 

assume that these will lead to favorable health effects. Second, we determined that 

the greatest expressed needs of the states for evaluation assistance would be 

addressed best by identifying short-term and intermediate outcome indicators. 

This does not mean that programs should not monitor their effect on the distal 

outcomes in the logic model. Some long-standing programs (e.g., California 

Tobacco Control Program7

) have been able to show an effect on long-term 

outcomes, but most states have not had comprehensive, well-funded programs in 

place long enough to show such effects.8-10 We also do not intend to imply that 

CHAPTER 1 ► Introduction 

5 
 

 

 

 

 

measuring outcomes alone is sufficient for evaluating a tobacco control program. 

Equally important is process evaluation, which focuses on measuring program 

implementation. (See Introduction to Process Evaluation in Tobacco Use 

Prevention and Control11 for information on process evaluation.) 

Indicator Selection and Rating 

To develop this guide, CDC proposed a set of outcome indicators (including some 

new indicators and some existing and revised indicators from KOI 2005) and 

engaged a panel of 13 experts (see Appendix B) in tobacco control practice, 

evaluation, and research to assess each indicator on the basis of the following 

criteria: overall quality, resources needed, strength of evaluation evidence, utility, 

face validity to policy makers, conformity with accepted practice, uniqueness, and 

how essential the indicator is for evaluating state tobacco control programs. In 

addition to rating the indicators that CDC proposed, the experts suggested other 

indicators and sources of data for those indicators. 

CDC reviewed the experts’ responses, comments, and suggestions and compiled 

the results into an individual rating across criteria for each indicator. A few 

indicators, however, have no ratings because they were added at the suggestion of 

the experts after the rating process was complete. These indicators have the 

symbol NR, which stands for “Not Rated,” after their numbers. The “uniqueness” 

criterion was used only to narrow the indicator lists (see Appendix C). For 

detailed information on how CDC selected indicators, how the expert panelists 

conducted their tasks, and how the ratings were calculated, see Appendix C. 

Indicator Rating Tables 

For each outcome component of the logic model, we provide an indicator rating 

table. Each table lists all indicators associated with the outcome component and 

the ratings for each indicator by criterion. Using this table makes it easy to 

compare all of the indicators for one outcome. The number and name of each 

relevant indicator are provided in each table, as are graphic displays of the 

criteria scores for each indicator. 

An example of an indicator rating and an explanation of how to read it are 

provided in Figure 2. The following are definitions of the criteria on which the 

ratings are based: 

►	 Overall quality. A summary rating that reflects the overall quality of the 

indicator and its general worth in evaluating state tobacco control programs. 

►	 Resources needed. Quantity of resources needed to collect reliable and 

precise measures and to appropriately analyze primary or secondary data on 

the indicator. Considerations affecting cost include availability of existing 

data (e.g., archival records or other secondary data) versus need for primary 

data collection, and methodological and sampling issues. Dollar signs show 

the amount of resources (funds, time, and effort) needed to collect and 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

6 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

analyze data on the indicator using the most commonly available data source: 

the more dollar signs (maximum four), the more resources needed. The dollar 

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

and analyzing an indicator varies by the existing capacity of a state health 

department or organization to evaluate its programs. 

Figure 2: Example of Rating Table 

Outcome 1 

Increased Intention to Quit, Perceived Harm of Tobacco Use, and Awareness of and 

Support for Cessation Services 

►	 Strength of evaluation evidence. The degree to which scientific evidence 

supports the assumption that implementing interventions to effect change in a 

given indicator will lead to a subsequent favorable outcome. This includes 

the extent to which reviewers believed that the scientific literature supports 

use of the indicator for the evaluation of comprehensive, statewide tobacco 

control programs and considers conflicting evidence as well as concerns 

regarding the methodology of supporting studies. Indicators with the highest 

ratings have a strong demonstrated relationship between the indicator and a 

downstream logic model outcome. Indictors with moderate ratings 

demonstrate an association between the indicator and an outcome in the logic 

model. However, the extent of evidence and/or the study designs supporting 

this association may not be as strong. Indicators with low ratings may have 

substantial conflicting literature and/or weak methodological designs. 

►	 Utility. The extent to which the indicator will help to answer important 

comprehensive tobacco control program evaluation questions. 

CHAPTER 1 ► Introduction 

7 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

►	 Face validity. The degree to which data on the indicator will appear valid to 

tobacco program stakeholders, such as policy and decision makers who may 

be users of tobacco control program evaluation results. 

►	 Accepted practice. The degree to which use of the indicator is consistent
 

with currently accepted, real-world tobacco control practice.
 

In addition, the following symbols are associated with some of the ratings: 

►	 An asterisk (*) indicates low reviewer response. If fewer than 75% of 

reviewers provided a valid rating on a criterion for an indicator, the criterion 

is flagged as having low reviewer response. For the purposes of this 

assessment, invalid responses included “don’t know,” missing data, and 

rating errors (e.g., selection of two non-adjacent ratings). An example of a 

rating for which there was low reviewer response is the utility score for 

indicator 3.1.h: Level of support for community policies that promote 

cessation. 

►	 A dagger (†) indicates a low level of agreement among reviewers. For the 

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

accepted practice criteria, a rating was considered to have a low level of 

agreement if fewer than 75% of valid reviewer responses were within ±1 

point of the median. For the overall quality criterion, a rating was considered 

to have a low level of agreement if fewer than 75% of valid reviewer 

responses were within ±2 points of the median (denoted by a double dagger 

††). An example of a rating with a low level of agreement is the overall 

quality score for 3.3.d: Proportion of tobacco users who have been assessed 

by a health care professional regarding their willingness to make a quit 

attempt. This low level of agreement represents a relatively high degree of 

variability in the raters’ responses for the criterion. 

Indicator Profiles 

Each indicator listed in this publication is associated with one short-term, 

intermediate, or long-term outcome component of the NTCP Goal 3 logic model. 

The number of indicators for each logic model component varies considerably; 

some have three to four indicators, whereas others have many. 

We provide a profile for each indicator. These profiles provide detailed 

information about each indicator, as follows: 

►	 Indicator number and name. Each indicator is uniquely identified by two 

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

number represents the outcome component (box) within the goal area logic 

model, and the letter represents the indicator. For example, indicator 3.1.a is 

first on the list of indicators (designated by the “a”) associated with outcome 

component 1 in the logic model for NTCP Goal Area 3. 

►	 Outcome box. The title of the outcome component (i.e., logic model box) is 

provided in the logic model. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

8 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

►	 What to measure. A description is included of what to measure in order to 

gather data on the indicator. Definitions of key terms are included in the
 

“Glossary and Acronyms” section at the end of this guide.
 

►	 Why this indicator is useful. The rationale is provided for using the
 

indicator as a measure of a specific outcome in the logic model.
 

►	 Example data source(s). Listed are some example surveys and other sources 

of data to measure the indicator, as well as the population from which the 

data could be collected (if not apparent from the title). Most data sources that 

we list are well known and widely used state or national surveys or 

surveillance systems.12 We also list non-standardized, topic-specific data 

sources (e.g., media tracking, policy tracking, worksite surveys, 

environmental scans, and other tobacco-related state surveys) that may not be 

as widely used by state tobacco programs but can be useful for evaluation. If 

similar survey questions are included in multiple data sources, we list the 

data sources most commonly available to state tobacco control programs. 

►	 Population group(s). The population group(s) includes the individuals from 

which data about this indicator are most commonly collected, if applicable. 

►	 Example survey question(s). These are usually survey questions from state 

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

possible responses to the survey questions is also given. If no state or 

national survey has an appropriate question, we created an example question 

when possible. 

►	 Comments. Here we provide additional information we have on this 

indicator that may be useful for program planning and/or evaluation 

purposes. For example, we may suggest other uses for the indicator, the 

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

information that may help guide measurement, or sources of information on 

data collection methods. Additionally, we alert readers when collecting 

sociodemographic data, such as survey respondents’ age, sex, race, ethnicity, 

city or county of residence, educational status, and income, may greatly 

enhance the utility of the indicator. For indicators with survey items specific 

to cigarettes, we speak to the issue of capturing information about broader 

groups or different types of tobacco products. Please note that changes to 

existing survey items should be made with caution. Sufficient cognitive 

testing should be used to ensure that the modified item captures the original 

intent of the question and still makes sense to the respondent. 

►	 Reviewers’ ratings. The rating tables include the criterion ratings given to 

the indicator by the panel of experts.
 

Using This Guide to Plan a State Tobacco Control Program 

Outcome Evaluation 

Engaged data use is one of the five core components of infrastructure according to 

the evidence-based Component Model of Infrastructure.13 Tobacco control 

program managers and evaluators need accurate and timely evaluation data to 

CHAPTER 1 ► Introduction 

9 
 

 

 

engage stakeholders and decision makers. Evaluation is essential for state tobacco 

control program managers to demonstrate the effects of the program, account for 

funding, and improve programs. Effective tobacco control programs require 

careful planning, implementation, and evaluation. To develop a successful 

program and a useful evaluation, program staff and program evaluators must work 

collaboratively on program planning and evaluation planning. A strong evaluation 

will not salvage a weak program, and a strong program cannot be proven effective 

without a defensible evaluation. 

Managers and evaluators can use this publication to help them focus their 

evaluations and guide the collection of credible evidence through the selection of 

appropriate program outcomes and indicators. Important evaluation 

implementation issues include: (1) ensuring timely evaluation planning and 

sufficient evaluation resources at the outset of intervention implementation, and 

(2) considering program evaluation needs versus research purposes when 

selecting indicators.2 

Below are the six major steps involved in planning and evaluating a state tobacco 

control program outlined in CDC’s Framework for Program Evaluation in Public 

Health Practice14 and the workbook, Developing an Effective Evaluation Plan: 

Setting the Course for Effective Program Evaluation.

1

 This book provides 

assistance for facilitating and developing a written evaluation plan and 

implementing additional steps of CDC’s Framework for Program Evaluation in 

Public Health Practice. 

Step 1. Engage stakeholders 

Identify the purpose and users of the evaluation. The stated purpose of the 

evaluation will drive the expectations and set the boundaries for what the 

evaluation can and cannot deliver. Careful selection and ongoing, meaningful 

engagement of an Evaluation Stakeholder Workgroup (ESW) throughout the 

planning and implementation process will aid the program in determining and 

prioritizing key evaluation questions, facilitating data collection, implementing 

evaluation activities, increasing the credibility of analysis and interpretation of 

evaluation information, and ensuring that evaluation results are used.1

 This guide 

assists in clarifying the purpose of evaluation related to promoting quitting 

tobacco use and helps in engaging the ESW to clarify the scope of the evaluation 

and provide the basic information needed to complete step 2, describe the 

program. 

Step 2. Describe the program 

This guide assists in clarifying a comprehensive tobacco control program’s efforts 

and expected outcomes related to the goal of promotiong quitting among adults 

and young people. An updated logic model is included that shows how activities 

lead to outcomes based on evidence from research and practice. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

10 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

For program planning, it is often helpful to read logic models backward; that is, to 

begin with the long-term outcomes and trace a causal pathway back through 

immediate outcomes, to short-term outcomes, to program outputs and program 

activities. This critical exercise, done in coordination with the ESW, will help to 

clarify the scope of the evaluation and provide basic information needed to 

complete step 2, describe the program. 

Program staff and stakeholders must agree upon the program description, 

including public health goals. Using this guide to help map a program’s causal 

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

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

for identifying key evaluation questions, focusing the evaluation, and connecting 

program planning and evaluation. 

To assist with this step, use the outcome overviews for the long-term outcome 

components to obtain information regarding the rationale and empirical support 

for the logic model pathway that links specific program activities with specific 

outcomes. If you need more information, read some of the related articles listed 

after the references for each outcome overview in the section titled “For Further 

Reading.” Then, on the basis of this information, select one or more long-term 

outcomes and related short-term and intermediate outcomes, again keeping in 

mind your state and program’s context, resources, and needs. 

Step 3. Focus the evaluation 

The scope and depth of any program evaluation is dependent on program and 

stakeholder priorities; available resources, including financial resources; staff and 

contractor availability, and amount of time committed to the evaluation. This 

guide can be used to select indicators of progress toward your selected short-term, 

intermediate, and long-term outcomes. 

Examine the indicator rating tables relevant to the short-term, intermediate, and 

long-term outcomes you have selected. Compare ratings pertaining to the 

indicators’ overall quality, resources needed, strength of evaluation evidence, 

utility, face validity, and accepted practice. Select candidate indicators and learn 

more about them by reading each indicator profile. On the basis of your reading 

and your program’s circumstances, select indicators to measure and monitor 

progress toward your selected short-term, intermediate, and long-term outcomes. 

Step 4. Planning for gathering credible evidence 

Once the focus and scope of the evaluation and the key evaluation questions have 

been decided, it is necessary to select the appropriate data collection methods that 

best meet the needs of the evaluation. Use the example data source and survey 

questions included in the indicator profiles to help create a detailed plan for 

gathering evidence. 

CHAPTER 1 ► Introduction 

11 
 

 

 

 

 

Step 5. Planning for conclusions 

Justifying evaluation findings includes working with the ESW to analyze, 

interpret, and draw conclusions from the collected data in order to turn them into 

meaningful, useful, and accessible information. This guide summarizes evidence 

in the outcome summaries and indicator profiles and graphically displays 

connections across the logic model that may help stakeholders understand how 

indicator information is connected and, if gaps or shortcomings occur in intended 

effects of programmatic activities, where they may be occurring. 

Step 6. Planning for dissemination and sharing of lessons learned 

The final step in the evaluation process is the dissemination of results. It is 

important to plan for the use of evaluation results and identify how lessons 

learned may be best communicated from the beginning of the evaluation planning 

process. Planning for use is directly tied to the identified purposes of the 

evaluation and program and stakeholder priorities. 

The Importance of Coordinating Program and Evaluation Planning Early and 

Often in the Planning Process 

When a program is organized and planned on the basis of the goal area’s logic 

model, managers and evaluators essentially have an outline of their outcome 

evaluation plan early in the program planning process. As the program evolves, 

managers and staff can make adjustments to program activities and, at the same 

time, the evaluation plan. 

An additional step to coordinate program and evaluation planning is to carefully 

identify program objectives for ongoing monitoring. These objectives may be 

used to monitor state trends over time or potentially to compare with national data 

and with those of other states. 

Good program objectives are SMART (i.e., they are specific, measurable, 

achievable, relevant, and time-bound). An example of a SMART objective is 

“increasing the proportion of tobacco users who intend to quit from 68% in 

January 2014 to 75% in January 2015.” Indicator 3.1.d can be incorporated into a 

tobacco control program’s evaluation to track progress on this SMART objective. 

For more information on creating SMART objectives, see Introduction to 

Program Evaluation for Comprehensive Tobacco Control Programs.

2 

Planning an Evaluation of a State Tobacco Control Program: A Hypothetical 

Example 

It is important to effectively evaluate the entire comprehensive tobacco control 

program including all NTCP goals. For the purpose and scope of this update, the 

following example focuses on cessation of tobacco use. In practice, evaluation 

efforts related to the other goal areas will be occurring concurrently, providing 

numerous synergies in terms of program and evaluation planning. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

12 Tobacco Control Programs—2015 
 

 

 

 

 

 

In this example, assume that recent data from a state tobacco survey show an 

increase in tobacco use prevalence among adults, and state legislators are 

concerned about this increase. The legislators announced that new funds may 

become available if the state tobacco control program can show that it is effective 

in reducing tobacco use prevalence by promoting quitting among adults. 

On the basis of these factors, the state tobacco control program follows the 

evaluation planning steps previously described as follows: 

Step 1: Engage stakeholders 

The state tobacco control program clarifies the primary purpose of the evaluation 

plan as facilitating program development and improvement and reaches out to 

individuals who have a vested interest in the evaluation findings, such as clients, 

community groups, elected officials, and staff involved in running the tobacco 

control program. The program organizes an ESW of 10 members who will serve a 

consultative role on all phases of the evaluation. 

Step 2. Describe the program. 

The ESW considers the purpose of the initiative. The legislature is providing 

funds specifically to promote quitting. Therefore, the ESW chooses NTCP Goal 

Area 3: Promoting Quitting among Adults and Young People and reviews the 

logic model. The group then selects long-term Outcome 7 (Increased cessation of 

all tobacco products as early in life as possible) to focus on. To learn more about 

Outcome 7, program staff review the outcome component overview (page 141), 

cited references, and materials recommended for further reading and present the 

information to the ESW to help select short-term and intermediate outcomes for 

the program. 

Following our recommendations, the ESW read the logic model for NTCP Goal 

Area 3 backward (starting at the long-term outcome) to select intermediate and 

short-term outcomes that are linked to the long-term outcome. They select one 

intermediate outcome: Outcome 6. Increased quit attempts and attempts using 

evidence-based cessation services. 

This intermediate outcome (Outcome 6) serves as a funnel between the long-term 

outcome and short-term outcomes in the NTCP Goal Area 3 logic model. The 

ESW select two short-term outcomes for the program: 

•	 Outcome 1: Increased intention to quit, perceived harm of tobacco use, 

and awareness of and support for cessation services 

•	 Outcome 3: Increased health care systems change to promote and support 

cessation 

The ESW understands that, based on the evidence, achieving one or more of these 

short-term and intermediate outcomes should lead to achieving the selected longCHAPTER 1 ► Introduction 

13 
 

 

 

 

term outcome, as well as the distal outcomes of reducing tobacco-related 

morbidity and mortality and decreasing tobacco-related disparities. Again, to 

learn more about the outcomes identified in their backward review of the logic 

model, the ESW members review outcome component overviews, cited 

references, and materials recommended for further reading. 

Step 3. Focus the evaluation 

As part of focusing the evaluation, the ESW develops evaluation questions and 

selects indicators of progress toward selected short-term, intermediate, and longterm outcomes. To do this, they first identify a set of indicator selection criteria 

(e.g., overall quality, resources needed, strength of evaluation evidence, utility, 

face validity, and accepted practice) that are most important to the program given 

its stage of development. 

Since the state legislature expressed an interest in this effort, the ESW wants to 

select indicators that have a high rating for face validity to key decision makers. 

Also, given budget constraints, the ESW wants to emphasize efficient use of 

resources during the selection of indicators. 

The program staff take this information and begin to look at the list of indicators 

associated with each selected outcome component (1, 3, 6, and 7), beginning with 

Outcome 1. The staff examine the indicator rating table for Outcome 1 (page 31). 

By doing so, they can begin to assess which indicators meet the criteria selected 

by the ESW. In addition to reviewing the rating information, the program staff 

also read the information in the indicator profiles associated with outcome 

component 1 (pages 32–54). 

To finalize indicator selection, the program staff present the summarized 

information to the ESW for consideration and decision making. 

Step 4. Planning for gathering credible evidence 

The ESW plans for gathering credible evidence by reflecting on the evaluation 

purpose, the logic model and program description, the stage of development of the 

program, and the evaluation questions. Given the limited resources available, the 

group considers the feasibility of the evaluation plan in the decision-making 

process. 

The ESW realizes that design and implementation of a new survey for all of the 

indicators would be expensive. However, one indicator associated with outcome 

component 1 can be measured using an existing state survey that states conduct 

regularly: 

3.1.d Proportion of tobacco users who intend to quit 

The planners and evaluators use the same process to select indicators for each of 

the chosen outcome components (3, 6, and 7): 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

14 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

3.3.b Proportion of the population that has been asked by a health care 

professional about tobacco use 

3.6.a	 Proportion of tobacco users who have made a quit attempt 

3.7.b Proportion of tobacco users who have sustained abstinence from 

tobacco use 

Step 5. Planning for conclusions 

As part of their comprehensive tobacco control program, based on the goals and 

objectives of the initiative and the strength of the core components of the 

comprehensive program infrastructure, the program planners select and design 

evidence-based interventions, such as mobilizing partnerships with large health 

care systems to integrate tobacco dependence treatment into their clinical 

workflows. 

The program staff implement the intervention activities and work with the ESW 

to continuously monitor: (1) whether the activities are being implemented as 

intended; and (2) the extent to which the program is reaching its target audiences. 

To assist in coordinating program and evaluation planning, program staff and the 

ESW translate indicators into SMART program objectives. 

As data are collected and shared with the program, the ESW is engaged once 

again to plan for analysis and interpretation. With an appreciation for the 

compressed project timeline, program staff and the ESW coordinate to develop a 

feasible plan that will best support program improvement. Additionally, during 

this phase, the ESW identifies key contextual information that will be needed to 

ensure that the evaluation results can be meaningfully interpreted. A date is set to 

reconvene with the purpose of reviewing interim data and assisting with the 

interpretation process needed to justify the evaluation conclusions. 

Step 6. Planning for dissemination and sharing of lessons learned 

To prepare for release of evaluation findings, program staff and the ESW 

carefully consider how, when, and with whom information will be shared. Given 

the focus on program development and improvement, information regarding 

performance and identified gaps will be shared throughout implementation with 

program staff, community partners, and clients. Reporting of this information will 

be tailored so that it is most useful to the target audience. Additionally, a plan is 

developed for creation of a final briefing document to engage state decision 

makers. This document is intended to be succinct and graphic and to highlight the 

program’s impact on public health outcome indicators. The graphic Goal 3 logic 

model is used as a framing device to present information on selected indicators. 

Additionally, information is included to track change over time and compare data 

with those from similar states. 

The timeframe for completing the six evaluation planning steps may vary based 

on state tobacco control needs. It may take weeks, months or even years to 

CHAPTER 1 ► Introduction 

15 
 

 

 

 

complete all steps. Stringent deadlines to meet funding requirements or other 

deadlinesmay influence methods used for capturing, analyzing, and reporting 

evaluation conclusions. Tobacco control programs will benefit from planning 

early, ensuring that sufficient time and resources are available to engage the ESW 

throughout the six steps, and pursing a methodologically sound approach that 

address high priority evaluation needs. 

References 

1.	 Centers for Disease Control and Prevention. Developing an effective 

evaluation plan: setting the course for effective program evaluation. Atlanta, 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 

Division of Nutrition, Physical Activity, and Obesity; 2011. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/s 

urveillance_evaluation/evaluation_plan/index.htm 

2.	 MacDonald G, Starr G, Schooley M, Yee SL, Klimowski K, Turner K. 

Introduction to program evaluation for comprehensive tobacco control 

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

Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health; 

2001. 

3.	 U.S. Department of Health and Human Services. The health consequences of 

smoking—50 years of progress: a report of the Surgeon General. Atlanta, 

GA: U.S. Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health; 2014. 

4.	 Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson 

RN, et al. 21st-century hazards of smoking and benefits of cessation in the 

United States. New England Journal of Medicine. 2013; 368(4):341–50. 

doi:10.1056/NEJMsa1211128 

5.	 United Way of America. Measuring program outcomes: a practical 

approach. Alexandria, VA: United Way of America; 1996. 

6.	 U.S. Department of Health and Human Services. Preventing tobacco use 

among youth and young adults: a report of the Surgeon General. Atlanta, GA: 

U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2012. 

7.	 Roeseler A, Burns D. The quarter that changed the world. Tobacco Control. 

2010;19(Suppl 1):i3–15. doi:10.1136/tc.2009.030809 

8.	 The Guide to Community Preventive Services. Reducing tobacco use and 

secondhand smoke exposure. Available at: 

http://www.thecommunityguide.org/tobacco/index.html. Last updated: June 

12, 2014. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

16 Tobacco Control Programs—2015 
 

 

 

9.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. 

Treating tobacco use and dependence: 2008 update. Clinical Practice 

Guideline. Rockville, MD: U.S. Department of Health and Human Services, 

Public Health Service; May 2008. 

10. U.S. Department of Health and Human Services. Preventing tobacco use 

among young people: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2004. 

11. Centers for Disease Control and Prevention. Introduction to process 

evaluation in tobacco use prevention and control. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2008. Available at: 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluati 

on/process_evaluation/pdfs/tobaccousemanual_updated04182008.pdf 

12. Centers for Disease Control and Prevention. Surveillance and evaluation data 

resources for comprehensive tobacco control programs. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2014. Available at: 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluati 

on/pdfs/surveillance_evaluation_508.pdf . 

13. Lavinghouze SR, Rieker P, Snyder K. An infrastructure model for evaluating 

tobacco control programs. Poster session presented at National Conference on 

Tobacco or Health. 6th Conference of the National Tobacco Control Program. 

Kansas City, MO; August 15-17, 2012. 

14. Centers for Disease Control and Prevention. Framework for program 

evaluation in public health practice. Morbidity and Mortality Weekly Report. 

1999;48(RR-11):1–40. 

CHAPTER 1 ► Introduction 

17 

CHAPTER 2
 

Goal Area 3: Promoting Quitting

Among Adults and Young People
 

GOAL AREA 3

Goal Area 3 

Promoting Quitting Among Adults and Young People
 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

21 
 

 

 

 

GOAL AREA 3
 

Goal Area 3 

Promoting Quitting Among Adults and Young People
 

Short-term Outcomes 

 Outcome 1: Increased intention to quit, perceived harm of tobacco use, and awareness of 

and support for cessation services 

► 3.1.a Level of awareness of anti-tobacco media messages 

► 3.1.b	 Level of receptivity to anti-tobacco media messages 

► 3.1.c	 Level of perceived risk of tobacco products among tobacco users 

► 3.1.d	 Proportion of tobacco users who intend to quit 

► 3.1.e	 Proportion of tobacco users who are aware of available cessation services 

► 3.1.fNR	 Total call volume to telephone quitline 

► 3.1.gNR Proportion of tobacco users who believe there are benefits to using 

evidence-based cessation services
 

► 3.1.h	 Level of support for community policies that promote cessation 

►	 3.1.i Level of support for policies within health care settings that promote
 

cessation
 

 Outcome 2: Increased availability and expanded coverage of comprehensive cessation 

services 

►	 3.2.a Proportion of the insured population with access to comprehensive cessation 

services 

►	 3.2.b Proportion of the insured population without health insurance barriers to 

accessing evidence-based cessation treatments 

 Outcome 3: Increased health care systems change to promote and support cessation 

►	 3.3.a Proportion of health care systems that have fully implemented current 

evidence-based cessation guidelines
 

►	 3.3.b Proportion of the population that has been asked by a health care
 

professional about tobacco use
 

►	 3.3.c Proportion of tobacco users who have been advised to quit tobacco use by a 

health care professional 

►	 3.3.d Proportion of tobacco users who have been assessed by a health care
 

professional regarding their willingness to make a quit attempt
 

►	 3.3.e Proportion of tobacco users who have been assisted in quitting tobacco use 

by a health care professional 

►	 3.3.f Proportion of tobacco users for whom a health care provider has arranged 

for follow-up contact regarding a quit attempt 

►	 3.3.g Proportion of health care facilities with comprehensive tobacco-free campus 

policies 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

22 Tobacco Control Programs—2015 
 

 

 

 

GOAL AREA 3 

 Outcome 4: Increased policy and environmental changes to support quitting, strengthen 

smokefree laws, and increase tobacco product price 

►	 3.4.a Proportion of jurisdictions with policies that regulate tobacco retail sales and 

marketing 

►	 3.4.b Proportion of jurisdictions with policies that regulate the extent and type of 

consumer-focused tobacco promotions 

►	 3.4.c Proportion of jurisdictions with comprehensive public policies for tobaccofree workplaces and other places 

► 3.4.d	 Proportion of tobacco users with smokefree home or vehicle rules 

► 3.4.e	 Amount of tobacco product taxes and fees 

► 3.4.f	 Tobacco product price 

 Outcome 5: Reduced tobacco industry influence 

► 3.5.a Extent and type of retail tobacco advertising 

► 3.5.b	 Extent and type of consumer-focused industry promotions 

► 3.5.c	 Extent and type of retailer-focused industry promotions 

► 3.5.d	 Extent of tobacco imagery in movies and television 

► 3.5.e	 Extent of pro-tobacco Internet presence 

►	 3.5.f Proportion of tobacco users reporting exposure to marketing and promotions 

for tobacco products (environmental cues) 

►	 3.5.g Proportion of tobacco users who report unplanned purchases of tobacco 

products
 

► 3.5.h	 Proportion of tobacco users who are aware of emerging tobacco products 

Intermediate Outcomes 

 Outcome 6: Increased quit attempts and attempts using evidence-based cessation 

services 

► 3.6.a	 Proportion of tobacco users who have made a quit attempt 

►	 3.6.b Proportion of tobacco users who have made a quit attempt using evidencebased strategies 

►	 3.6.c Proportion of tobacco users who have used individual or group cessation 

counseling 

►	 3.6.d Number of callers to telephone quitlines receiving assistance quitting 

tobacco
 

► 3.6.eNR Proportion of tobacco users who have used mobile telephone-based
 

cessation services (other than quitline services)
 

►	 3.6.f Proportion of tobacco users who have made a quit attempt by switching to a 

different tobacco product 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

23 
 

 

 

 

 

 

GOAL AREA 3
 

Long-term Outcomes 

 Outcome 7: Increased cessation of all tobacco products as early in life as possible 

► 3.7.a Proportion of former tobacco users with recent cessation success 

► 3.7.b Proportion of tobacco users who have sustained abstinence from tobacco use 

► 3.7.c Average age at which tobacco users successfully quit 

► 3.7.d Proportion of former tobacco users who re-initiate regular tobacco use 

 Outcome 8: Reduced tobacco-use prevalence and consumption 

► 3.8.a Tobacco use prevalence 

► 3.8.b Prevalence of tobacco use during pregnancy 

► 3.8.c Per capita consumption of tobacco products 

► 3.8.d Tobacco product preferences of tobacco users 

NR Denotes an indicator that is not rated (see Appendix C for an explanation). 

The table below summarizes changes made to Goal 3 indicators since KOI 2005. As shown, we 

deleted 12 KOI 2005 indicators, revised the titles of 20 KOI 2005 indicators, and added 24 new 

indicators. Indicator deletions were based on new evidence or changes in policy that made the 

previous indicators obsolete or unwarranted. For example, the 2005 indicator 3.10.1 “Proportion 

of insurance purchasers and payers that reimburse for tobacco cessation services” was deleted 

because provisions of the 2010 Patient Protection and Affordable Care Act provides expanded 

coverage for recommended clinical preventive services, including evidence based smokingcessation treatments, for many persons in the United States.

1 Indicator additions were included 

where new evidence demonstrated a gap in existing indicators. Title revisions were made to 

enhance the utility of indicators for state comprehensive tobacco control programs. 

2014 Revised and 2005 KOI Goal 3 Indicators Crosswalk 

Revised Indicator Number Original KOI Number Revised Title 

Outcome 1 

3.1.a 3.8.1 

3.1.b 3.8.2 

3.1.c New 

3.1.d 3.8.3 

Deleted 3.8.4 

3.1.e 3.8.6, 3.8.7 

(continued) 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

24 Tobacco Control Programs—2015 
GOAL AREA 3 

2014 Revised and 2005 KOI Goal 3 Indicators Crosswalk (continued) 

Revised Indicator Number Original KOI Number Revised Title 

3.1.fNR New 

3.1.gNR New 

3.1.h 3.8.5 

3.1.i 3.8.8 

Deleted 3.8.9NR 

Outcome 2 

3.2.a New 

Deleted 3.10.1 

3.2.b New 

Outcome 3 

3.3.a 3.9.1 

3.3.b 3.9.2 

3.3.c 3.9.3 

3.3.d 3.9.4 

3.3.e 3.9.5 

3.3.f 3.9.6 

Deleted 3.9.7 

Deleted 3.9.8 

Deleted 3.7.5 

3.3.g New 

Outcome 4 

3.4.a New 

3.4.b New 

3.4.c New 

Deleted 3.7.6 

3.4.d New 

3.4.e 3.12.1 

3.4.f New 

(continued) 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

25 
GOAL AREA 3 

2014 Revised and 2005 KOI Goal 3 Indicators Crosswalk (continued) 

Revised Indicator Number Original KOI Number Revised Title 

Outcome 5 

3.5.a New 

3.5.b New 

3.5.c New 

3.5.d New 

3.5.e New 

3.5.f New 

3.5.g New 

3.5.h New 

Outcome 6 

3.6.a 3.11.1, 3.11.2 

3.6.b 3.11.3 

Deleted 3.7.2NR 

Deleted 3.7.3 

3.6.c 3.7.4 

Deleted 3.7.5 

Deleted 3.7.6 

3.6.d 3.7.1 

3.6.eNR New 

3.6.f New 

Outcome 7 

3.7.a 3.13.2NR 

3.7.b 3.13.1 

3.7.c New 

3.7.d New 

(continued) 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

26 Tobacco Control Programs—2015 
 

 

GOAL AREA 3 

2014 Revised and 2005 KOI Goal 3 Indicators Crosswalk (continued) 

Revised Indicator Number Original KOI Number Revised Title 

Outcome 8 

3.8.a 3.14.1 

3.8.b 3.14.2 

Deleted 3.14.3 

3.8.c 3.14.4 

3.8.d New 

NR Denotes an indicator that is not rated (see Appendix C for an explanation). 

References 

1.	 Patient Protection and Affordable Care Act, Public Law 111-148, US Statutes at Large 119 

(2010): 124. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

27 
 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Outcome 1 

Increased Intention to Quit, Perceived Harm of Tobacco Use, and 

Awareness of and Support for Cessation Services 

Two factors determine population quit rates: (1) the number of quit attempts (both the number of 

tobacco users who try to quit and the number of times they make a quit attempt), and (2) the odds 

that tobacco users who try to quit will succeed.1 Increasing awareness of and support for 

cessation services aids in both of these factors.2 Population-wide interventions, such as hardhitting media campaigns, comprehensive smokefree policies, and increases in the unit price of 

tobacco products, work to change environments and social norms related to tobacco use and 

subsequently increase tobacco cessation.2-7 

Hard hitting media campaigns increase negative feelings about tobacco use, increase perceived 

benefits of quitting, increase the desire to quit among tobacco users, increase intention to quit, 

and can increase calls to quitlines.8-12 Evidence shows that intention to quit using tobacco is a 

predictor of actual quit attempts and their success.13-20 Similarly, tobacco users who are aware of 

available evidence-based cessation services and perceive them to be effective are more likely to 

use them, which improves the odds of successfully quitting.13,21-27 

The following indicators are associated with this outcome: 

► 3.1.a	 Level of awareness of anti-tobacco media messages 

► 3.1.b	 Level of receptivity to anti-tobacco media messages 

► 3.1.c	 Level of perceived risk of tobacco products among tobacco users 

► 3.1.d	 Proportion of tobacco users who intend to quit 

► 3.1.e	 Proportion of tobacco users who are aware of available cessation services 

►	 3.1.fNR Total call volume to telephone quitline 

►	 3.1.gNRProportion of tobacco users who believe there are benefits to using evidence-based 

cessation services 

► 3.1.h	 Level of support for community policies that promote cessation 

► 3.1.i	 Level of support for policies within health care settings that promote cessation 

References 

1. Zhu SH, Lee M, Zhuang YL, Gamst A, Wolfson T. Interventions to increase smoking 

cessation at the population level: how much progress has been made in the last two decades? 

Tobacco Control. 2012;21(2):110–8. doi:10.1136/tobaccocontrol-2011-050371 

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

control programs—2014. Atlanta, GA: U.S. Department of Health and Human Services, 

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

and Health Promotion, Office on Smoking and Health; 2014. 

3. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, 

DC: The National Academies Press; 2007. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

28 Tobacco Control Programs—2015 
 

 

 

 

GOAL AREA 3 

► Outcome 1 

4. The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke 

exposure. Available at: http://www.thecommunityguide.org/tobacco/index.html. Last 

updated: June 12, 2014. 

5. U.S. Department of Health and Human Services. The health consequences of involuntary 

exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: U.S. Department 

of Health and Human Services, Centers for Disease Control and Prevention, Coordinating 

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

Promotion, Office on Smoking and Health; 2006. 

6. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the 

Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

Promotion, Office on Smoking and Health; 2000. 

7. Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. 

Cochrane Database of Systematic Reviews. 2008;(1):CD004704. 

8. Davis KC, Nonnemaker J, Duke J, Farrelly MC. Perceived effectiveness of cessation 

advertisements: the importance of audience reactions and practical implications for media 

campaign planning. Health Communication. 2013;28(5):461–72. 

doi:10.1080/10410236.2012.696535 

9. Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation 

among adults: an integrative review. Tobacco Control. 2012;21:127–38. 

doi:10.1136/tobaccocontrol-2011-050345 

10. Dillard JP, Weber KM, Vail RG. The relationship between the perceived and actual 

effectiveness of persuasive messages: a meta-analysis with implications for formative 

campaign research. Journal of Communication. 2007;57(4):613–31. doi:10.1111/j.1460­

2466.2007.00360.x 

11. National Cancer Institute. The role of the media in promoting and reducing tobacco use. 

Tobacco Control Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. 

Department of Health and Human Services, National Institutes of Health, National Cancer 

Institute; June 2008. 

12. Centers for Disease Control and Prevention. Impact of a national tobacco education 

campaign on weekly numbers of quitline calls and website visitors—United States, March 4– 

June 23, 2013. Morbidity and Mortality Weekly Report. 2013 Sep 20;62(37):763–7. 

13. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco 

use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; May 2008. 

14. Hyland A, Borland R, Li Q, Yong HH, McNeill A, Fong GT, et al. Individual-level 

predictors of cessation behaviours among participants in the International Tobacco Control 

(ITC) Four Country Survey. Tobacco Control. 2006;15(Suppl III):iii83–iii94. 

doi:10.1136/tc.2005.013516 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

29 
 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

15. Perkins KA, Lerman C, Stitzer ML, Fonte CA, Briski JL, Scott JA, et al. Development of 

procedures for early screening of smoking cessation medications in humans. Clinical 

Pharmacology & Therapeutics. 2008;84:216–21. doi:10.1038/clpt.2008.30 

16. Smit E, Fidler J, West R. The role of desire, duty and intention in predicting attempts to quit 

smoking. Addiction. 2011;106(4):844–51. doi:10.1111/j.1360-0443.2010.03317.x 

17. Tidey JW, Rohsenow DJ. Intention to quit moderates the effect of bupropion on smoking 

urge. Nicotine & Tobacco Research. 2009 Mar;11(3):308–12. doi:10.1093/ntr/ntn032 

18. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the 

Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

Promotion, Office on Smoking and Health; 2000. 

19. Vangeli E, Stapleton J, Smit ES, Borland R, West R. Predictors of attempts to stop smoking 

and their success in adult general population samples: a systematic review. Addiction. 

2011;106:2110–21. doi:10.1111/j.1360-0443.2011.03565.x 

20. Zhou X, Nonnemaker J, Sherrill BH, Gilsenan AW, Coste F, West R. Attempts to quit 

smoking and relapse: factors associated with success or failure from the ATTEMPT cohort 

study. Addictive Behaviors. 2009;34(4):365–73. doi:10.1016/j.addbeh.2008.11.013 

21. McMenamin SB, Halpin HA, Bellows NM. Knowledge of Medicaid coverage and 

effectiveness of smoking treatments. American Journal of Preventive Medicine. 

2006;31(5):369–74. 

22. Orleans CT, Mabry PL, Abrams DB. Increasing tobacco cessation in America: a consumer 

demand perspective. American Journal of Preventive Medicine. 2010;38(3S):S303–6. doi: 

10.1016/j.amepre.2010.01.013 

23. Backinger CL, Thornton-Bullock A, Miner C, Orleans CT, Siener K, DiClemente CC, et al. 

Building consumer demand for tobacco-cessation products and services the national tobacco 

cessation collaborative’s consumer demand roundtable. American Journal of Preventive 

Medicine. 2010;38(3S):S307–11. doi:10.1016/j.amepre.2009.12.002 

24. Hyland A, Cummings MK. Using tobacco control policies to increase consumer demand for 

smoking cessation. American Journal of Preventive Medicine. 2010;38(3S):S347–50. 

doi:10.1016/j.amepre.2009.12.007 

25. Farrelly MC, Hussin A, Bauer UE. Effectiveness and cost effectiveness of television, radio 

and print advertisements in promoting the New York Smokers’ Quitline. Tobacco Control. 

2007 Dec;16(Suppl 1):i21–3. 

26. Hammond D, McDonald PW, Fong GT, Borland R. Do smokers know how to quit? 

Knowledge and perceived effectiveness of cessation assistance as predictors of cessation 

behaviour. Addiction. 2004 Aug;99(8):1042–8. 

27. Willems RA, Willemsen MC, Nagelhout GE, de Vries H. Understanding smokers’ 

motivations to use evidence-based smoking cessation aids. Nicotine & Tobacco Research. 

2013 Jan;15(1):167–76. doi:10.1093/ntr/nts104 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

30 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Outcome 1 

Increased Intention to Quit, Perceived Harm of Tobacco Use, and 

Awareness of and Support for Cessation Services 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.1.a Level of awareness of anti-tobacco 

media messages 

$$ 

3.1.b Level of receptivity to anti-tobacco 

media messages 

$$ 

3.1.c Level of perceived risk of tobacco 

products among tobacco users 

$$ 

3.1.d Proportion of tobacco users who 

intend to quit 

$ 

3.1.e Proportion of tobacco users who 

are aware of available cessation 

services 

$ 

3.1.fNR Total call volume to telephone 

quitline 

     

3.1.gNR Proportion of tobacco users who 

believe there are benefits to using 

evidence-based cessation services 

     

3.1.h Level of support for community 

policies that promote cessation 

$ * 

3.1.i Level of support for policies within 

health care settings that promote 

cessation 

$$$ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

 Denotes no rating information.
 

NR Denotes an indicator that is not rated (see Appendix C for an explanation).
 

*	 Denotes low reviewer response, defined as fewer than 75% of valid ratings on a criterion for an indicator. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

31 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.a 

Level of Awareness of Anti-Tobacco Media Messages
 

KOI 2005 3.8.1 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure Level of unaided, aided, and/or confirmed awareness of media messages among the 

target population 

Why this indicator is 

useful 

Evaluating awareness of messages is critical to understanding the behavioral effects of 

anti-tobacco advertising on target populations and should be used to guide health 

communication planning.1 Evidence shows that mass-reach health communication 

campaigns are effective in increasing tobacco-use cessation.1-5 

Example data 

source(s) 

Centers for Disease Control and Prevention (CDC) 2014 Tips From Former Smokers 

(Tips) Campaign, Pilot Campaign Survey 

New York Adult Tobacco Survey 

National Quitline Data Warehouse (NQDW) Intake Questionnaire, 2012 

Population group(s) General population 

Example survey Tips Pilot Campaign Survey 

question(s) Unaided Awareness: 

In the past month, do you remember seeing, hearing, or reading any TV, radio, 

newspaper, or online advertising about a [campaign describing the dangers of tobacco]? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

What can you tell me about this/these [advertisements]? Please describe for me anything
 

specific you saw, heard, or read in the [advertisements].
 

What [were] the [advertisements] about?
 

What was the name of the program mentioned in the [advertisements]? Is there anything 

else you can awareness?
 

Have you recently seen any antitobacco or antismoking ads on television [or other 

relevant medium of interest]? 

What happened in the ad(s)?6,7 

Aided Awareness: 

From CDC Tips: (Online survey) 

“Now, we would like you to view a series of television advertisements that have been 

shown in the U.S. When you are ready, please click on the link below to view the first 

advertisement. There are a total of XX ads to view. After you view each ad, there will be 

a few questions that ask about your opinions of the ad.” 

Have you seen this ad on television in the past 3 months that is, since [DATE]? 

1. Yes 

2. No 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

32 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

If yes:
 

In the past 3 months, how frequently have you seen this ad on television? (Rarely,
 

Sometimes, Often, Very Often)
 

Confirmed Awareness: 

From New York Adult Tobacco Survey (telephone survey): 

“Have you recently seen an anti-smoking ad on TV that shows [insert ad description
 

here]?”
 

“What happens in this ad?”
 

2012 NQDW Intake Questionnaire 

In the past three months, did you hear about 1-800-QUIT-NOW from any 

advertisements with smokers telling personal stories and tips about living with health 

problems? 

1. Yes 

2. No 

3. Unsure 

Comments	 There are three ways to measure individual-level awareness and recognition of 

advertisements: unaided awareness, aided awareness, and confirmed awareness. Aided 

awareness is also referred to as recognition or encoded exposure in the health 

communication research literature. Unaided awareness items provide little or no cues 

about the content of an advertisement and require the respondent to describe the details 

of an ad from memory. Aided awareness items consist of an interviewer providing 

respondents with a verbal description of an ad’s content in phone interviews, or 

respondents watching or listening to all or part of an advertisement during in-person or 

online interviews. The respondent then is asked if they recognize the ad. Confirmed 

awareness items provide a brief description of an ad (or show stills of an ad if the survey 

is conducted online) and then ask the respondent to provide additional details about the 

message. 

Aided awareness helps determine specific campaign and ad awareness,8 whereas 

unaided awareness allows for tracking which campaign messages are most prominent in 

the minds of the target population. For aided awareness items, evaluators may choose to 

include decoy responses to determine “yea-saying” bias. Research has questioned the 

marginal utility of confirmed awareness items compared to aided awareness measures, 

and given the extra respondent and interviewer burden open-ended confirmed awareness 

items confer, aided awareness measures may be preferable.9 The mode of survey 

administration is also important to consider when choosing awareness items. Online 

administration of surveys allows advertisements and other materials (e.g., Web site 

banner ads, television ads) to be shown directly to survey participants, rather than 

relying on crude interviewer descriptions of advertisements as in phone interviews. 

Examples of each type of measure are included in “Example Survey Question(s)” above. 

Programs may want to evaluate confirmed awareness of an advertisement by respondent 

smoking status (current, former, or never) and addiction level (e.g., light, moderate, or 

heavy) demographic and tobacco use characteristics because awareness levels may 

differ significantly among groups with different levels of addiction. In addition, 

frequency of exposure should be measured to allow greater variation in responses as 

well as provide for dose-response analyses. 

Evaluators should work closely with media campaign managers to 

(1) develop a separate series of questions for each main media message and 

(2) coordinate data collection with the timing of the media campaign.10 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

33 
 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

References 

1.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

2.	 The Guide to Community Preventive Services. Increasing tobacco use cessation: mass media campaigns when 

combined with other interventions. Available at: 

http://www.thecommunityguide.org/tobacco/cessation/massmediacampaigns.html. Last updated: October 25, 

2013. 

3.	 Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs— 

2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2014. 

4.	 Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane 

Database of Systematic Reviews. 2008;(1):CD004704. 

5.	 Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an 

integrative review. Tobacco Control. 2012;21:127–38. doi:10.1136/tobaccocontrol-2011-050345 

6.	 Davis KC, Farrelly MC, Duke J, Kelly L, Willett J. Antismoking media campaign and smoking cessation 

outcomes, New York State, 2003–2009. Preventing Chronic Disease. 2012; 9:E40. 

7.	 Davis KC, Crankshaw E, Farrelly MC, Niederdeppe J, Watson K. The impact of state tobacco control program 

funding cuts on teens’ exposure to tobacco control interventions: evidence from Florida. American Journal of 

Health Promotion. 2011 Jan-Feb;25(3):176–85. doi:10.4278/ajhp.090211-QUAN-59 

8.	 New York State Department of Health Tobacco Control Program. StatShot Vol. 5, No. 8; Oct 2012. New York 

State Adult Tobacco Survey, 2003–2011. Analysis conducted by RTI International. 

9.	 Southwell BG, Barmada CH, Hornik RC, Maklin DM. Can we measure encoded exposure? Evidence from a 

national campaign. Journal of Health Communication. 2002;7(5):445–453. 

10. Centers for Disease Control and Prevention. Designing and implementing an effective tobacco countermarketing campaign. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease 

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

Smoking and Health; 2003. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

34 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.b 

Level of Receptivity to Anti-Tobacco Media Messages
 

KOI 2005 3.8.2 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure	 Level of receptivity to media messages by the intended audience. Receptivity is 

generally defined as the extent to which people are willing to listen to a persuasive 

message. In tobacco control evaluation, however, the definition is narrower; receptivity 

is the extent to which people believe that the message was convincing, made them think 

about their behavior, and stimulated discussion with others.1 See “Comments” below for 

more information. 

Why this indicator is	 Message awareness is necessary but not sufficient to change knowledge, attitudes, and 

useful	 behavioral intentions. Media messages are effective only if they reach and resonate with 

the intended audience.2,3 Well-received messages help ensure campaign effectiveness.4-7 

Measures to gauge the perceived persuasiveness of messages, perceptions of the salience 

of the messages, and other general impressions about the campaign can be employed. A 

growing literature has established that measures of media message receptivity predict 

changes in attitudes, including negative feelings about smoking; increased perceived 

benefits of quitting; increased desire to quit; and increased intentions to quit.6-8 

Example data Centers for Disease Control and Prevention (CDC) 2012 Tips From Former Smokers 

source(s) (Tips) Campaign, Smoker Follow-up Questionnaire 

Population group(s) General population 

Example survey From CDC 2012 Tips Campaign, Smoker Follow-up Questionnaire 

question(s) Perceived ad effectiveness: 

These ads are worth remembering 

• Strongly disagree 

• Disagree 

• Neither agree nor disagree 

• Agree 

• Strongly agree 

These ads grabbed my attention 

• Strongly disagree 

• Disagree 

• Neither agree nor disagree 

• Agree 

• Strongly agree 

These ads are powerful 

• Strongly disagree 

• Disagree 

• Neither agree nor disagree 

• Agree 

• Strongly agree 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

35 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 better

GOAL AREA 3 

► Outcome 1 

low high 

These ads are informative 

• Strongly disagree 

• Disagree 

• Neither agree nor disagree 

• Agree 

• Strongly agree 

These ads are meaningful 

• Strongly disagree 

• Disagree 

• Neither agree nor disagree 

• Agree 

• Strongly agree 

Negative emotional reaction: 

“On a scale of 1 to 5, where 1 means ‘not at all’ and 5 means ‘very,’ please indicate how 

much these ads made you feel. . .” 

• Depressed 

• Afraid 

• Ashamed 

Motivational reaction: 

“On a scale of 1 to 5, where 1 means ‘not at all’ and 5 means ‘very,’ please indicate how 

much these ads made you feel. . .” 

• Motivated 

• Hopeful 

• Understood 

Comments	 Note that perceived effectiveness is a critical element of receptivity. Perceived 

effectiveness has been standardized and shown to be predictive of outcomes.6 Other 

receptivity measures, such as negative emotion and motivational reaction, tend to be 

more content-specific and may be useful depending on the specific content of an 

advertisement. 

Evaluators may want to assess media message receptivity by communication medium 

(e.g., television, Internet, social media, billboard, print). 

Evaluators should work closely with countermarketing campaign managers to 

(1) develop a separate series of questions for each main media message, 

(2) formatively test media messages, and 

(3) coordinate data collection with the timing of the media campaign.9 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

36 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

References 

1.	 Sly DF, Heald GR, Ray S. The Florida “truth” anti-tobacco media evaluation: design, first year results, and 

implications for planning future state media evaluations. Tobacco Control. 2001;10(1):9–15. 

doi:10.1136/tc.10.1.9 

2.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

3.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: The National 

Academies Press; 2007. 

4.	 McGuire WJ. Public communication as a strategy for inducing health-promoting behavioral change. Preventive 

Medicine. 1984;13(3):299–319. 

5.	 Kotler P, Armstrong G. Principles of marketing, 9th ed. Upper Saddle River, NJ: Prentice-Hall; 2001. 

6.	 Davis KC, Nonnemaker J, Duke J, Farrelly MC. Perceived effectiveness of cessation advertisements: the 

importance of audience reactions and practical implications for media campaign planning. Health 

Communication. 2013;28(5):461–72. doi:10.1080/10410236.2012.696535 

7.	 Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an 

integrative review. Tobacco Control. 2012;21:127–38. doi:10.1136/tobaccocontrol-2011-050345 

8.	 Dillard JP, Weber KM, Vail RG. The relationship between the perceived and actual effectiveness of persuasive 

messages: a meta-analysis with implications for formative campaign research. Journal of Communication. 

2007;57(4):613–31. doi: 10.1111/j.1460-2466.2007.00360.x 

9.	 Centers for Disease Control and Prevention. Designing and implementing an effective tobacco countermarketing campaign. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease 

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

Smoking and Health; 2003. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

37 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.c 

Level of Perceived Risk of Tobacco Products Among Tobacco Users
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure Tobacco users’ perceived direct and comparative risks of tobacco products 

Why this indicator is	 

useful	 

The tobacco industry continually introduces new tobacco products, including smokeless 

products, such as snus and dissolvable tobacco, and electronic nicotine delivery devices, 

including e-cigarettes;

1,2 these products are often perceived as less harmful by some 

current smokers and may be seen as an alternative to smoking cessation.3 One 

international study found that use of new tobacco products is most strongly associated 

with beliefs about the reduced harm of these products.4 Monitoring perceptions of risk 

from different product types can help illuminate the impact of these new products on 

cessation. 

Example data 

source(s)	 

National Adult Tobacco Survey (NATS), 2013–2014 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

Minnesota Adult Tobacco Survey (MATS), 2007 

Information available at: http://www.mntobacco.nonprofitoffice.com/ 

Population Assessment of Tobacco and Health (PATH) Study, Adult Extended 

Interview, 2012 

Information available at: https://pathstudyinfo.nih.gov/UI/FAQsResMobile.aspx 

Population group(s) General population 

Example survey 

question(s) 

From NATS 

How much do you think your risk of developing a smoking-related disease would 

decrease if you cut the amount that you smoke in half? Would you say... 

• Not at all 

• A little 

• Somewhat 

• A lot 

• DON’T KNOW/NOT SURE 

• REFUSED 

How harmful do you think cigar smoking is to a person’s health? 

• Not at all harmful 

• Moderately harmful 

• Very harmful 

• DON’T KNOW/NOT SURE 

• REFUSED 

How harmful do you think using smokeless tobacco is to a person’s health? 

• Not at all harmful 

• Moderately harmful 

• Very harmful 

• DON’T KNOW/NOT SURE 

• REFUSED 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

38 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

How harmful do you think using dissolvable tobacco is to a person’s health? 

•	 Not at all harmful 

•	 Moderately harmful 

•	 Very harmful 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

From MATS 

In your opinion, are any of the following products less harmful, more harmful, or just as 

harmful as smoking cigarettes? Smokeless tobacco such as snuff and chewing tobacco? 

•	 Less harmful 

•	 More harmful 

•	 Just as harmful 

•	 REFUSED 

•	 DON’T KNOW 

In your opinion, are any of the following products less harmful, more harmful, or just as 

harmful as smoking cigarettes? Electronic cigarettes? 

•	 Less harmful 

•	 More harmful 

•	 Just as harmful 

•	 REFUSED 

•	 DON’T KNOW 

From PATH 

I am going to read you a list of diseases that may or may not be caused by smoking 

cigarettes. Based on what you know or believe, does smoking cause... 

•	 Stroke in smokers? 

•	 Lung cancer in smokers? 

•	 Heart disease in smokers? 

•	 Blindness in smokers? 

•	 Peripheral vascular disease (poor circulation) in smokers? 

•	 Bladder cancer in smokers? 

•	 Mouth cancer in smokers? 

•	 Lung disease such as emphysema in smokers? 

•	 Lung disease in nonsmokers, from secondhand smoke? 

•	 Heart attack in nonsmokers from secondhand smoke? 

•	 Harm to fetuses (or unborn children) during pregnancy from secondhand 

smoke? 

– Yes 

– No 

– DON’T KNOW 

– REFUSED 

To what extent do you believe the nicotine in cigarettes to be the chemical that causes 

most of the cancer caused by smoking? 

•	 Not at all 

•	 A little 

•	 Somewhat 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

39 
 

 

 

 

 

 

 

 

 

 

 

 

Rating 

 better

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

•	 Very much 

•	 DON’T KNOW 

•	 REFUSED 

Is using [other tobacco product] less harmful, about the same, or more harmful than 

smoking cigarettes? 

•	 Less harmful 

•	 About the same 

•	 More harmful 

•	 DON’T KNOW 

•	 REFUSED 

Comments	 Measuring perceived risk among tobacco users is complicated by a number of factors, 

including type of risk assessed (e.g., personalized risk of harm from using a given 

tobacco product, relative risk of harm compared to other tobacco users and/or nontobacco users, comparative risks of using one type of product instead of another), length 

of time and intensity of tobacco use, cultural beliefs, and survey methods. Evaluators 

should carefully consider the purpose for collecting information and select the 

appropriate measure(s) to best inform decision making. For example, little is known 

about the perceived risk of different types of tobacco products, especially as new 

products emerge. Capturing this information over time may help inform program 

planning, especially if these risks can be linked to quit intentions, quit attempts, product 

preferences, and dual use. 

Strength of 

evaluation 

evidence 

Overall quality 

low high 

Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

References 

1.	 Carpenter CM, Connolly GN, Ayo-Yusuf OA, Wayne GF. Developing smokeless tobacco products for 

smokers: an examination of tobacco industry documents. Tobacco Control. 2009 Feb;18(1):54–9. 

doi:10.1136/tc.2008.026583 

2.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

3.	 Parascandola M, Augustson E, O’Connell ME, Marcus S. Consumer awareness and attitudes related to new 

potential reduced-exposure tobacco product brands. Nicotine & Tobacco Research. 2009;11(7):886–95. 

doi:10.1093/ntr/ntp082 

4.	 O’Connor R, McNeill A, Borland R, Hammond D, King B, Boudreau C, et al. Smokers’ beliefs about the 

relative safety of other tobacco products: findings from the ITC Collaboration. Nicotine & Tobacco Research. 

2007;9(10):1033–42. doi:10.1080/14622200701591583 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

40 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.d 

Proportion of Tobacco Users Who Intend to Quit
 

KOI 2005 3.8.3 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure Proportion of tobacco users who are considering stopping use of tobacco products 

Why this indicator is Evidence shows that intention to quit using tobacco is a predictor of actual quit attempts 

useful and successful quitting.1-7 

Example data 

source(s)	 

National Youth Tobacco Survey (NYTS): 2012 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

National Adult Tobacco Survey (NATS), 2013–2014 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2006–2007 

Information available at: http://riskfactor.cancer.gov/studies/tus-cps/ 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NYTS 

Are you seriously considering quitting cigarettes? 

• I do not smoke cigarettes 

• Yes, within the next 30 days 

• Yes, within the next 6 months 

• Yes, within the year 

• Yes, but not within the year 

• No, I am not thinking about quitting cigarettes 

Are you seriously considering quitting all tobacco products? 

• I do not use tobacco products 

• Yes, within the next 30 days 

• Yes, within the next 6 months 

• Yes, within the year 

• Yes, but not within the year 

• No, I am not thinking about quitting the use of all tobacco products 

From NATS 

Are you thinking about quitting cigarettes for good? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

How soon are you likely to quit smoking? Would you say... 

• Within the next 30 days 

• Within the next 6 months 

• Within the year 

• Longer than a year 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

41 
 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

From TUS-CPS 

Are you seriously considering quitting smoking within the next 6 months? 

•	 Yes 

•	 No 

•	 DON’T KNOW 

•	 REFUSED 

• NO RESPONSE 

Are you planning to quit within the next 30 days? 

•	 Yes 

•	 No 

•	 DON’T KNOW 

•	 REFUSED 

•	 NO RESPONSE 

Overall, on a scale from 1 to 10 where 1 is NOT AT ALL interested and 10 is 

EXTREMELY interested, how interested are you in quitting smoking? 

•	 1:10 Number 

•	 DON’T KNOW 

•	 REFUSED 

•	 NO RESPONSE 

Comments	 For dual/poly tobacco users, it is important to measure quitting intentions for all 

products used because intentions may vary across products. Tobacco users may quit one 

product but continue to use others. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Hyland A, Borland R, Li Q, Yong HH, McNeill A, Fong GT, et al. Individual-level predictors of cessation 

behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco 

Control. 2006;15(Suppl III):iii83–iii94. doi:10.1136/tc.2005.013516 

2.	 Perkins KA, Lerman C, Stitzer ML, Fonte CA, Briski JL, Scott JA, et al. Development of procedures for early 

screening of smoking cessation medications in humans. Clinical Pharmacology & Therapeutics. 2008;84:216– 

21. doi:10.1038/clpt.2008.30 

3.	 Smit ES, Fidler JA, West R. The role of desire, duty and intention in predicting attempts to quit smoking. 

Addiction. 2011;106(4):844–51. doi:10.1111/j.1360-0443.2010.03317.x 

4.	 Tidey JW, Rohsenow DJ. Intention to quit moderates the effect of bupropion on smoking urge. Nicotine & 

Tobacco Research. 2009 Mar;11(3):308–12. doi:10.1093/ntr/ntn032 

5.	 U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. 

Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

42 Tobacco Control Programs—2015 
 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

6.	 Vangeli E, Stapleton J, Smit ES, Borland R, West R. Predictors of attempts to stop smoking and their success in 

adult general population samples: a systematic review. Addiction. 2011;106:2110–21. doi:10.1111/j.1360­

0443.2011.03565.x 

7.	 Zhou X, Nonnemaker J, Sherrill BH, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: 

factors associated with success or failure from the ATTEMPT cohort study. Addictive Behaviors. 

2009;34(4):365–73. doi:10.1016/j.addbeh.2008.11.013 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

43 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.e 

Proportion of Tobacco Users Who Are Aware of Available Cessation 

Services 

KOI 2005 3.8.6, 3.8.7 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure	 Proportion of tobacco users who are aware of available evidence-based cessation 

services and whether the services are covered under their health insurance. Evidencebased services include individual counseling, group counseling, telephone counseling, 

mobile text-based cessation interventions, and Food and Drug Administration (FDA)­

approved pharmacotherapies.1,2 

Why this indicator is	 The existence and increased availability of evidence-based cessation services have a 

useful	 limited effect if tobacco users are not aware of these services.1,3–8 One study found that 

Medicaid enrollees who knew that their state program covered proven behavioral and 

pharmacologic treatments had higher likelihood of using these aids in their quit 

attempts.3 This issue will become increasingly important given expanded insurance 

coverage for cessation treatment under the Affordable Care Act.4 

Example data National Adult Tobacco Survey (NATS), 2009-2010
 source(s) Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/
 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

Are you aware of any telephone quitline services that are available to help you quit 

using tobacco? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Are you aware of any individual or group counseling services, other than quitlines, that 

are available to help you quit smoking cigarettes? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Now I am going to ask some questions about health insurance and quitting tobacco. Do 

you have any kind of health insurance, including prepaid plans such as HMOs or 

government plans such as Medicare or Medicaid? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Does your health insurance help pay for counseling or medications to help people stop 

smoking cigarettes? 

• Yes 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

44 Tobacco Control Programs—2015 
 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

•	 No 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

Does your health insurance help pay for counseling or medications to help people stop 

using tobacco products other than cigarettes? 

•	 Yes 

•	 No 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

Comments	 Similar questions could be asked of nonsmokers to gauge their awareness of evidencebased cessation services that could be used by family members and friends who are 

tobacco users. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure. 

www.thecommunityguide.org/tobacco/index.html. Last updated: June 12, 2014. 

3.	 McMenamin SB, Halpin HA, Bellows NM. Knowledge of Medicaid coverage and effectiveness of smoking 

treatments. American Journal of Preventive Medicine. 2006;31(5):369–74. 

4.	 Coates RJ, Ogden L, Monroe JA, Buehler J, Yoon PW, Collins JL; Centers for Disease Control and Prevention. 

Conclusions and future directions for periodic reporting on the use of adult clinical preventive services of public 

health priority—United States. Morbidity and Mortality Weekly Report. 2012 Jun 15;61 Suppl:73–8. NIH Stateof-the-Science conference statement on tobacco use: prevention, cessation, and control. Annals of Internal 

Medicine. 2006;145(11):839–44. 

5.	 Orleans CT, Mabry PL, Abrams DB. Increasing tobacco cessation in America: a consumer demand perspective. 

American Journal of Preventive Medicine. 2010;38(3S):S303–6. doi:10.1016/j.amepre.2010.01.013 

6.	 Backinger CL, Thornton-Bullock A, Miner C, Orleans CT, Siener K, DiClemente CC, et al. Building consumer 

demand for tobacco-cessation products and services: the national tobacco cessation collaborative’s consumer 

demand roundtable. American Journal of Preventive Medicine. 2010;38(3S):S307–11. 

doi:10.1016/j.amepre.2009.12.002 

7.	 Hyland A, Cummings MK. Using tobacco control policies to increase consumer demand for smoking cessation. 

American Journal of Preventive Medicine. 2010;38(3 Suppl):S347–50. doi:10.1016/j.amepre.2009.12.007 

8.	 Farrelly MC, Hussin A, Bauer UE. Effectiveness and cost effectiveness of television, radio and print 

advertisements in promoting the New York Smokers’ Quitline. Tobacco Control. 2007 Dec;16(Suppl 1):i21–3. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

45 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

Overall quality 

     

 better

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.fNR 

Total Call Volume to Telephone Quitline
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure Total number of calls to the quitline (not number of callers or unique individuals) 

Why this indicator is	 Mass-reach health communication interventions can be powerful tools for promoting 

useful	 and facilitating cessation, including promoting quitlines.1 Total call volume to telephone 

quitlines increases during emotionally evocative tobacco education media campaigns.

2,3 

Additionally, these increases in call volume have been shown to include priority 

populations, including African Americans; persons who predominantly speak Asian 

languages; and low-income smokers.4-7 

Example data CDC State Tobacco Activities Tracking and Evaluation (STATE) system—Quitline­ source(s) Service Utilization 

Information available at: http://www.cdc.gov/statesystem/ 

National Quitline Data Warehouse (NQDW), Quitline Services Survey, 2012 

Population group(s) Quitline service providers 

Example survey 

question(s) 

From NQDW 

How many total direct calls came in to the quitline? 

Note: Direct calls are your quitline’s total incoming calls, not referrals that generate an 

outbound call from the quitline. Please report on number of calls, not number of 

callers/unique individuals. This should include proxy callers, wrong numbers, prank 

calls, and other calls to the quitline that are not accounted for in these categories. 

Type of Call 

a. Calls answered live 

Number of Calls 

b. Calls went to voicemail 

c. Calls hung up or abandoned 

d. Other calls 

(e.g., listening to taped messages) 

e. Total direct calls 

(a+b+c+d) 

Comments	 To enhance utility of information for program improvement, evaluators may choose to 

analyze these data in total and by calls answered live by quitline staff, calls that went to 

voicemail, and all other calls. 

Rating Strength of 

evaluation 

evidence 

Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

46 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

References 

1.	 Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs— 

2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2014. 

2.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

3.	 Centers for Disease Control and Prevention. Impact of a national tobacco education campaign on weekly 

numbers of quitline calls and website visitors—United States, March 4–June 23, 2013. Morbidity and Mortality 

Weekly Report. 2013 Sep 20;62(37):763–7. 

4.	 Zhu SH, Gardiner P, Cummins S, Anderson C, Wong S, Cowling D, et al. Quitline utilization rates of AfricanAmerican and white smokers: the California experience. American Journal of Health Promotion. 2011;25(5 

Suppl):51S–58S. doi:10.4278/ajhp.100611-QUAN-185 

5.	 Rabius V, Wiatrek D, McAlister AL. African American participation and success in telephone counseling for 

smoking cessation. Nicotine & Tobacco Research. 2012;14(2):240–2. doi:10.1093/ntr/ntr129 

6.	 Zhu SH, Wong S, Stevens C, Nakashima D, Gamst A. Use of smokers’ quitline by Asian language speakers: 

results from 15 years of operation in California. American Journal of Public Health. 2010;100(5):846–52. 

doi:10.2105/AJPH.2009.168385 

7.	 Miller CL, Sedivy V. Using a quitline plus low-cost nicotine replacement therapy to help disadvantaged 

smokers to quit. Tobacco Control. 2009;18(2):144–9. doi:10.1136/tc.2008.026492 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

47 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.gNR 

Proportion of Tobacco Users Who Believe There Are Benefits to Using 

Evidence-Based Cessation Services 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure Proportion of tobacco users who believe evidence-based counseling and medications 

will help them successfully quit tobacco products 

Why this indicator is	 Although tobacco users improve their odds of successfully quitting when they use 

useful	 evidence-based cessation counseling and medications, the use of these treatments 

remains low.1-3 Approximately two-thirds to three-quarters of smokers who try to quit 

do not use any evidence-based cessation services.1 The use of these treatments among 

subpopulations varies according to personal beliefs, views toward doctors and other 

health care professionals, and knowledge of tobacco treatments.4 For example, one study 

found that hospitalized patients severely underestimate the effectiveness of medications 

and comprehensive cessation programs including counseling and medications.5 

Increasing tobacco users’ perceived effectiveness of evidence-based cessation services 

increases use of these services.6,7 

Example data No commonly used data sources were found. 

source(s) 

Population group(s) All tobacco users 

Example survey	 Modified from Juliano and Brandon8 to address a broader range of evidence-based 

question(s)	 cessation services: 

[Specific type of evidence-based cessation service] Increases my chances of quitting 

smoking 

• Completely unlikely 

• Moderately unlikely 

• Somewhat likely 

• Moderately likely 

• Completely likely 

[Specific type of evidence-based cessation service] Makes quitting smoking easier 

• Completely unlikely 

• Moderately unlikely 

• Somewhat likely 

• Moderately likely 

• Completely likely 

[Specific type of evidence-based cessation service] Reduces withdrawal 

• Completely unlikely 

• Moderately unlikely 

• Somewhat likely 

• Moderately likely 

• Completely likely 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

48 Tobacco Control Programs—2015 
 

low high 

Overall quality 

     

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Comments None 

Rating Strength of 

evaluation 

evidence 

Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

References 

1.	 Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs— 

2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2014. 

2.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

3.	 Ebbert J, Montori VM, Erwin PJ, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane 

Database of Systematic Reviews. 2011 Feb 16;(2):CD004306. 

4.	 Fu SS, Burgess D, van Ryn M, Hatsukami DK, Solomon J, Joseph AM. Views on smoking cessation methods 

in ethnic minority communities: a qualitative investigation. Preventive Medicine. 2007 Mar;44(3):235–40. 

5.	 Raupach T, Merker J, Hasenfuss G, Andreas S, Pipe A. Knowledge gaps about smoking cessation in 

hospitalized patients and their doctors. European Journal of Cardiovascular Prevention and Rehabilitation. 

2011 Apr;18(2):334–41. doi:10.1177/1741826710389370 

6.	 Hammond D, McDonald PW, Fong GT, Borland R. Do smokers know how to quit? Knowledge and perceived 

effectiveness of cessation assistance as predictors of cessation behaviour. Addiction. 2004 Aug;99(8):1042–8. 

7.	 Willems RA, Willemsen MC, Nagelhout GE, de Vries H. Understanding smokers’ motivations to use evidencebased smoking cessation aids. Nicotine & Tobacco Research. 2013 Jan;15(1):167–76. doi:10.1093/ntr/nts104 

8.	 Juliano LM, Brandon TH. Smokers’ expectancies for nicotine replacement therapy vs. cigarettes. Nicotine & 

Tobacco Research. 2004 Jun;6(3):569–74. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

49 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.h 

Level of Support for Community Policies that Promote Cessation
 

KOI 2005 3.8.5 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure	 Proportion of the population that supports community policies that promote cessation, 

such as restrictions on the use of tobacco products in public settings and restrictions on 

the sale and availability of tobacco products 

Why this indicator is	 Assessing public support for evidence-based practices, such as restrictions on the use of 

useful	 tobacco products in public settings and restrictions on the sale and availability of 

tobacco products, helps to clarify public awareness of environmental influences on 

tobacco use, monitor social norms, and determine whether efforts to combat pro-tobacco 

messaging are effective.1-7 Recent evidence also suggests that support for smokefree 

laws among smokers predicts future quitting.8 

Example data National Adult Tobacco Survey (NATS), 2009-2010 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

International Tobacco Control (ITC) Survey, 2012 

Information available at: http://www.itcproject.org/surveys 

HealthStyles, 2013
 

Information available at:
 

http://www.orau.gov/cdcynergy/soc2web/Content/activeinformation/resources/Healthsty 

les.pdf 

Population group(s) General population 

Example survey 

question(s) 

From NATS 

Should smoking indoors in restaurants...? 

• Always be allowed 

• Be allowed only at some times or in some places 

• Never be allowed 

• DON’T KNOW/NOT SURE 

• REFUSED 

Should smoking indoors in bars, casinos, or clubs...? 

• Always be allowed 

• Be allowed only at some times or in some places 

• Never be allowed 

• DON’T KNOW/NOT SURE 

• REFUSED 

Should tobacco use be completely banned on school grounds, including fields and 

parking lots, and at all school events, even for teachers and other adults? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

50 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

From ITC 

The following measures have been suggested to reduce smoking levels. Please tell me 

how you feel about each suggestion. Would you support or oppose a law that restricted 

the number of places where cigarettes could be purchased? 

•	 DON’T KNOW 

•	 NOT APPLICABLE 

•	 REFUSED 

•	 Oppose 

•	 Support 

•	 Strongly support 

•	 Strongly oppose 

From HealthStyles 

Do you think e-cigarettes should be allowed to be used in public areas where tobacco 

smoking is prohibited? 

•	 Yes 

•	 No 

•	 DON’T KNOW/NOT SURE 

Comments Evaluators may want to analyze the level of support for policies according to the 

tobacco use status of the respondent.
 

The example questions represent a sample of policies that promote cessation, not an 

exhaustive list. Similar questions could be asked of decision makers, opinion leaders, or
 

the public about conventional cigarettes as well as alternative products.
 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

2.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National 

Academies Press; 2007. 

3.	 U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. 

Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000. 

4.	 U.S. Department of Health and Human Services. Women and smoking: a report of the Surgeon General. 

Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon 

General; 2001. 

5.	 Howard KA, Rogers T, Howard-Pitney B, Flora JA, Norman GJ, Ribisl KM. Opinion leaders’ support for 

tobacco control policies and participation in tobacco control activities. American Journal of Public Health. 

2000;90(8):1283–7. 

6.	 Schmitt CL, Juster HR, Dench D, Willett J, Curry LE. Public and policy maker support for point-of-sale 

tobacco policies in New York. American Journal of Health Promotion. 2014 Jan-Feb;28(3):175–80. 

doi:10.4278/ajhp.121023-QUAN-514 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

51 
 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

7.	 Thomson GW, Wilson N. Public attitudes about tobacco smoke in workplaces: the importance of workers’ 

rights in survey questions. Tobacco Control. 2004;13(2):206–7. doi:10.1136/tc.2004.007492 

8.	 Nagelhout GE, Zhuang Y-L, Gamst A, Zhu S-H. Do smokers support smoke-free laws to help themselves quit 

smoking? Findings from a longitudinal study. Tobacco Control. Published online first 10 January 2014. 

doi:10.1136/tobaccocontrol-2013-051255 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

52 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 1 

Indicator 3.1.i 

Level of Support for Policies within Health Care Settings that Promote 

Cessation 

KOI 2005 3.8.8 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

What to measure Proportion of decision makers, including health administrators, insurers and purchasers, 

who support policies promoting cessation within health care settings (e.g., providing 

comprehensive coverage for proven behavioral and pharmacologic treatments to help 

people stop using tobacco products; implementing referral programs that link health care 

organizations, providers, and patients with tobacco quitlines ) 

Why this indicator is 

useful 

Measuring decision-maker support for policies that promote tobacco cessation may help 

to integrate cessation into the delivery of health care.1 Widespread implementation of 

health care systems-level policies that promote cessation has been shown to increase the 

number of successful quit attempts and decrease tobacco prevalence rates.1-4 

Example data 

source(s) 

Decision Maker or Opinion Leader Survey 

Population group(s) Decision makers 

Example survey Proven therapies for treatment of tobacco dependence, such as nicotine replacement 

question(s) therapy, telephone counseling, face-to-face counseling, and/or cessation group 

counseling, should be fully covered by health insurance plans. Do you... 

•	 Strongly agree 

•	 Agree 

•	 Disagree 

•	 Strongly disagree 

Comments The authors created this example question. It is not in any commonly used survey or 

other data source. The example questions could be asked of decision makers, opinion 

leaders, or the public. 

Rating 

Resources 

needed 

Strength of 

evaluation 

evidence Utility 

Face 

validity 

Accepted 

practice 

Overall quality 

$$$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, Li W. The effect of systematic clinical interventions 

with cigarette smokers on quit status and the rates of smoking-related primary care office visits. PLoS One. 

2012;7(7):e41649. doi:10.1371/journal.pone.0041649 

3.	 Centers for Disease Control and Prevention. Coverage for tobacco use cessation treatments. Atlanta, GA: 

Centers for Disease Control and Prevention; 2004. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

53 
 

 

 

GOAL AREA 3
 

► Outcome 1
 

4.	 Halpin HA, McMenamin SB, Shade SB. The demand for health insurance coverage for tobacco dependence 

treatments: support for a benefit mandate and willingness to pay. Nicotine & Tobacco Research. 

2007;9(12):1269–76. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

54 Tobacco Control Programs—2015 
 

 

 

GOAL AREA 3 

► Outcome 2 

Outcome 2 

Increased Availability and Expanded Coverage of Comprehensive 

Cessation Services 

Expanding cessation insurance coverage reduces cost and administrative barriers to cessation 

counseling and medications and increases the number of smokers who attempt to quit, who use 

evidence-based treatments, and who successfully quit tobacco use.1-5 The U.S. Public Health 

Service calls for all insurance plans to include comprehensive cessation coverage.3 

Comprehensive cessation coverage minimizes cost sharing and other barriers and includes all 

evidence-based cessation treatment—including individual, group, and telephone counseling— 

and all Food and Drug Administration (FDA)-approved cessation medications.1,5 Barriers to 

using evidence-based cessation services for patients trying to quit tobacco include requiring copayments, requiring prior authorization to access treatment, and limiting how long a patient can 

be treated or how many times per year a patient can access treatment.2,5-8 Expanding cessation 

insurance coverage has the potential to reduce tobacco-related population disparities.2-5 

The following indicators are associated with this outcome: 

► 3.2.a	 Proportion of the insured population with access to comprehensive cessation services 

►	 3.2.b Proportion of the insured population without health insurance barriers to accessing 

evidence-based cessation treatments 

References 

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

control programs—2014. Atlanta, GA: U.S. Department of Health and Human Services, 

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

and Health Promotion, Office on Smoking and Health; 2014. 

2. The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke 

exposure. Available at: http://www.thecommunityguide.org/tobacco/index.html. Last 

updated: June 12, 2014. 

3. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco 

use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; May 2008. 

4. Fiore MC, Keller PA, Curry SJ. Health systems changes to facilitate the delivery of tobacco 

dependence treatment. American Journal of Preventive Medicine. 2007;33(6 Suppl):349S– 

56S. 

5. American Lung Association. Helping smokers quit: tobacco cessation coverage 2012. 

Washington, DC: American Lung Association, 2012. Available at: 

http://www.lung.org/assets/documents/tobacco/helping-smokers-quit-2012.pdf . Accessed 

April 22, 2014. 

6. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, 

DC: National Academies Press; 2007. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

55 
GOAL AREA 3 

► Outcome 2 

7. Reda A, Kotz D, Evers S, van Schayck C. Healthcare financing systems for increasing the 

use of tobacco dependence treatment. Cochrane Database of Systematic Reviews. 

2012;(6):CD004305. 

8. NIH State-of-the-Science conference statement on tobacco use: prevention, cessation, and 

control. Annals of Internal Medicine. 2006;145(11):839–44. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

56 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 2 

Outcome 2

Increased Availability and Expanded Coverage of Comprehensive 

Cessation Services 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.2.a Proportion of the insured 

population with access to 

comprehensive cessation services 

† $ 

3.2.b Proportion of the insured 

population without health 

insurance barriers to accessing 

evidence-based cessation 

treatments 

$ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

† Denotes low agreement among reviewers, defined as less than 75% of valid ratings within ±1 point of the median 

for this indicator-specific criterion. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

57 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 2 

Indicator 3.2.a 

Proportion of the Insured Population with Access to Comprehensive 

Cessation Services 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 2 Increased availability and expanded coverage of comprehensive cessation services 

What to measure	 Proportion of insured population whose public and/or private insurance covers all 

recommended evidence-based cessation treatments. See “Comments” for clarification of 

“comprehensive cessation services.” 

Why this indicator is	 Health insurance coverage of evidence-based treatments including medications and 

useful	 counseling increases the use of effective treatments and successful quit attempts.1-7 

Evidence-based treatments have been shown to be both clinically effective and costeffective.1,2 

Example data American Lung Association (ALA), Tobacco Cessation Coverage 2012, Survey of State 

source(s)	 Medicaid, Department of Health and Quitline staff 

Information available at: http://www.lung.org/assets/documents/tobacco/helpingsmokers-quit-2012.pdf 

Population group(s) Health care administrators, insurers, and purchasers 

Example survey Of the 10 evidence-based recommended treatments, how many does your state Medicaid 

question(s) plan/state regulatory standard/state employee health plan/Essential Health Benefit 

cover? 

A. NRT gum 

B. NRT patch 

C. NRT nasal spray 

D. NRT lozenge 

E. NRT inhaler 

F. Varenicline (Chantix) 

G. Bupropion (Zyban) 

H. Group counseling 

I. Individual counseling 

J. Phone counseling
 

Response categories:

• Coverage only for pregnant women 

• Coverage varies by health plan 

• Coverage provided only under certain conditions 

• Data not reported 

Comments	 Comprehensive cessation services are currently defined as coverage of all evidencebased treatments recommended by the U.S. Public Health Service.1 Currently, these 

treatments include; Nicotine replacement therapy (NRT) gum, NRT patch, NRT nasal 

spray, NRT lozenge, NRT inhaler, Varencicline, Bupropion, group counseling, 

individual counseling, and telephone counseling. This definition may change over time 

as new treatments are developed. 

Capturing information regarding the scope and degree of coverage for target populations 

will help to identify gaps and assess where interventions are having the greatest impact. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

58 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

low high 

†

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 2 

For example, comprehensive cessation service coverage can be assessed for persons 

with private insurance or subpopulations of those covered by large employers in the 

state, the state Medicaid population, and/or persons covered under the state employee 

health plan. 

ALA systematically reviews public health insurance plans and state health insurance 

mandates, and summarizes which cessation treatments are covered. This information, 

combined with the denominator of insured population, can be used to calculate this 

indicator. 

Related Healthy People 2020 Objectives: TU-8 Increase comprehensive Medicaid 

insurance coverage of evidence-based treatment for nicotine dependency in states and 

the District of Columbia. 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 Centers for Disease Control and Prevention. Coverage for tobacco use cessation treatments. Atlanta, GA: 

Centers for Disease Control and Prevention; 2004. 

3.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National 

Academies Press; 2007. 

4.	 Centers for Disease Control and Prevention. State Medicaid coverage for tobacco-dependence treatments— 

United States, 2009. Morbidity and Mortality Weekly Report. 2010;59(41):1340–3. 

5.	 Hopkins DP, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG, Fielding JE, et al. Task Force on Community 

Preventive Services. American Journal of Preventive Medicine. 2001;20(2 Suppl):16–66. 

6.	 McMenamin SB, Halpin HA, Ganiats TG. Medicaid coverage of tobacco-dependence treatment for pregnant 

women: impact of the Affordable Care Act. American Journal of Preventive Medicine. 2012;43(4):e27–9. 

7.	 American Lung Association. Helping smokers quit: tobacco cessation coverage 2012. Available at: 

http://www.lung.org/assets/documents/tobacco/helping-smokers-quit-2012.pdf . 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

59 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

GOAL AREA 3 

► Outcome 2 

Indicator 3.2.b 

Proportion of the Insured Population Without Health Insurance Barriers to 

Accessing Evidence-Based Cessation Treatments 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 1 Increased availability and expanded coverage of comprehensive cessation services 

What to measure	 Proportion of the insured population without health insurance-related barriers to 

accessing evidence-based cessation services. See “Comments” for clarification of 

“health insurance-related barriers.” 

Why this indicator is	 Barriers to cessation treatment can exist even when insurance coverage is in place. 

useful	 Barriers for patients trying to quit tobacco include requiring co-payments, requiring 

prior authorization to access treatment or stepped care therapy, and limiting how long a 

patient can be treated or how many times per year a patient can access treatment.1-6 

Evidence demonstrates that removing these barriers to cessation treatment among 

Medicaid enrollees is associated with increased quit rates.7 

Example data American Lung Association (ALA), State Tobacco Cessation Coverage Database 

source(s) Information available at: http://www.lungusa2.org/cessation2/ 

Population group(s) Health care administrators, insurers, and purchasers 

Example survey Barriers to Cessation Coverage in the States: Yes/No to the following: 

question(s) • Lifetime limit on quit attempts 

• Annual limit on quit attempts 

• Prior authorization required 

• Stepped care therapy 

• Counseling required for medications 

• Limits on duration 

• Co-payments required 

Comments	 Health insurance-related barriers include provisions in coverage that pose barriers to 

accessing cessation treatments, such as co-payments, requirements for prior 

authorization, and limitations on the number and duration of treatments, which may 

reduce use of these treatments and therefore reduce cessation.8 

Determining which employers and/or health insurance organizations provide coverage 

for the state’s population is important to obtaining meaningful data regarding barriers to 

tobacco cessation services. Having this information at the individual health insurance 

plan level and by priority population, including specifically for tobacco users, could best 

aid in program and evaluation planning. However, systematically collecting this 

information is very difficult without existing partnerships with health care insurers and 

purchasers. States may choose to begin with the largest health plans, defined as those 

providing health insurance coverage to the largest proportion of individuals within a 

state. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$ 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

60 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 2 

References 

1.	 Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs— 

2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; October 2007. 

2.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National 

Academies Press; 2007. 

3.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

reducing out-of-pocket costs for evidence-based cessation treatments. Available at: 

http://www.thecommunityguide.org/tobacco/outofpocketcosts.html. Last updated: June 12, 2014. 

4.	 Reda A, Kotz D, Evers S, van Schayck C. Healthcare financing systems for increasing the use of tobacco 

dependence treatment. Cochrane Database of Systematic Reviews. 2012;(6):CD004305. 

5.	 NIH State-of-the-Science conference statement on tobacco use: prevention, cessation, and control. Annals of 

Internal Medicine. 2006;145(11):839–44. 

6.	 American Lung Association. Helping smokers quit: tobacco cessation coverage 2012. Available at: 

http://www.lung.org/assets/documents/tobacco/helping-smokers-quit-2012.pdf . 

7.	 Singleterry J, Jump Z, Lancet E, Babb S, MacNeil A, Zhang L. State medicaid coverage for tobacco cessation 

treatments and barriers to coverage - United States, 2008-2014. Morbidity Mortality Weekly Report. 2014: 

63(12):264-9. 

8.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

61 
 

 

 

GOAL AREA 3 

► Outcome 3 

Outcome 3 

Increased Health Care Systems Change to Promote and Support Cessation 

Integrated cessation interventions and systems-level strategies that incorporate tobacco 

dependence treatment into the delivery of health care lead to increasing rates of tobacco 

dependence treatment, quit attempts, and effective smoking cessation.

1-3 Approximately 80% of 

smokers visit a physician each year,4 but tobacco screening and assessment in the health care 

setting varies by smoker race/ethnicity, age, and insurance type.5 Full integration of tobacco 

dependence treatment into the clinical workflow increases the likelihood that health care 

providers will consistently screen patients for tobacco use and intervene with patients who use 

tobacco, thereby increasing rates of cessation.1,3,6,7 

Current clinical practice guidelines recommend that clinicians and health care delivery systems 

consistently identify and document tobacco use status for each patient using the 5 A’s model: 

(1) ask about tobacco use, (2) advise tobacco users to quit, (3) assess willingness to make a quit 

attempt, (4) assist in quit attempt, and (5) arrange for follow-up.1 Facilitating the 5A’s model 

through a provider reminder system can serve to institutionalize tobacco use and screening.1,2,8,9 

Finally, enacting tobacco-free policies on hospital and health care facility campuses can support 

cessation, especially among vulnerable populations, such as those at mental health facilities and 

substance abuse treatment centers.10 

The following indicators are associated with this outcome: 

►	 3.3.a Proportion of health care systems that have fully implemented current evidence-based 

cessation guidelines 

►	 3.3.b Proportion of the population that has been asked by a health care professional about 

tobacco use 

►	 3.3.c Proportion of tobacco users who have been advised to quit tobacco use by a health 

care professional 

►	 3.3.d Proportion of tobacco users who have been assessed regarding their willingness to 

make a quit attempt by a health care professional 

►	 3.3.e Proportion of tobacco users who have been assisted in quitting tobacco use by a 

health care professional 

►	 3.3.f Proportion of tobacco users for whom a health care provider has arranged for followup contact regarding a quit attempt 

► 3.3.g Proportion of health care facilities with comprehensive tobacco-free campus policies 

References 

1. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco 

use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; May 2008. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

62 Tobacco Control Programs—2015 
 

 

GOAL AREA 3 

► Outcome 3 

2. The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke 

exposure: provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: 

July 22, 2014. 

3. Fiore MC, Keller PA, Curry SJ. Health systems changes to facilitate the delivery of tobacco 

dependence treatment. American Journal of Preventive Medicine 2007;33(6 Suppl):349S– 

56S. 

4. Centers for Disease Control and Prevention. National Health Interview Survey. Available at: 

http://www.cdc.gov/nchs/nhis.htm. Accessed April 24, 2014. 

5. Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC. Tobacco use screening and 

counseling during physician office visits among adults—National Ambulatory Medical Care 

Survey and National Health Interview Survey, United States, 2005–2009. Morbidity and 

Mortality Weekly Report. 2012 Jun 15;61 Suppl:38–45. 

6. Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, Li W. The effect of systematic 

clinical interventions with cigarette smokers on quit status and the rates of smoking-related 

primary care office visits. PLoS ONE. 2012;7(7):e41649. doi:10.1371/journal.pone.0041649 

7. Rigotti NA. Integrating comprehensive tobacco treatment into the evolving US health care 

system. Archives of Internal Medicine. 2011;171(1):53–5. 

doi:10.1001/archinternmed.2010.491 

8. Schauer GL, Thompson JR, Zbikowski SM. Results from an outreach program for health 

systems change in tobacco cessation. Health Promotion Practice. 2012;13(5):657–65. 

doi:10.1177/1524839911432931 

9. Redmond LA, Adsit R, Kobinsky KH, Theobald W, Fiore MC. A decade of experience 

promoting the clinical treatment of tobacco dependence in Wisconsin. Wisconsin Medical 

Journal. 2010;109(2):71–8. 

10. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, 

DC: National Academies Press; 2007. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

63 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Outcome 3 

Increased Health Care Systems Change to Promote and Support Cessation 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.3.a Proportion of health care systems 

that have fully implemented 

current evidence-based cessation 

guidelines 

$$ 

3.3.b Proportion of the population that 

has been asked by a health care 

professional about tobacco use 

$ 

3.3.c Proportion of tobacco users who 

have been advised to quit tobacco 

use by a health care professional 

$ 

3.3.d Proportion of tobacco users who 

have been assessed regarding their 

willingness to make a quit attempt 

by a health care professional 

† $ 

3.3.e Proportion of tobacco users who 

have been assisted in quitting 

tobacco use by a health care 

professional 

$ 

3.3.f Proportion of tobacco users for 

whom a health care provider has 

arranged for follow-up contact 

regarding a quit attempt 

$ 

3.3.g Proportion of health care facilities 

with comprehensive tobacco-free 

campus policies 

$$$ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

†	 Denotes low agreement among reviewers, defined as less than 75% of valid ratings within ±1 point of the median 

for this indicator-specific criterion. 

†† 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

64 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Indicator 3.3.a 

Proportion of Health Care Systems that Have Fully Implemented Current

Evidence-Based Cessation Guidelines 

KOI 2005 3.9.1 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure	 Proportion of health care systems, which may include inpatient and outpatient hospitals 

and clinics, insurers, purchasers, and solo or groups of practitioners that have fully 

implemented Public Health Service Clinical Practice Guidelines.1 For a list of the 

guidelines, see “Comments” below. 

Why this indicator is	 Efforts by clinicians, health care systems, insurers, and purchasers of health insurance to 

useful	 integrate cessation interventions and systems-level strategies into the delivery of health 

care lead to increasing rates of tobacco dependence treatments delivered, quit attempts, 

and effective smoking cessation.1-6 System changes that remove barriers, such as the 

inclusion of electronic health record prompts and electronic referrals to follow-up 

quitline services, can help improve quality of care.7 

Example data Addressing Tobacco in Managed Care (ATMC), Survey of Health Plans, 1997–2002 

source(s) National Ambulatory Medical Care Survey (NAMCS), Electronic Health Records 

Survey, 2013 

Information available at: http://www.cdc.gov/nchs/ahcd.htm 

National Hospital Ambulatory Medical Care Survey (NHAMCS), 2013 Lookback 

Module 

Information available at: http://www.cdc.gov/nchs/ahcd/about_ahcd.htm 

National Survey of Substance Abuse Treatment Services (N-SSATS), 2012 

Questionnaire 

Information available at: http://www.icpsr.umich.edu/icpsrweb/ICPSR/series/58 

Population group(s) Health care administrators, insurers, and purchasers 

Example survey 

question(s) 

From ATMC 

With regard to the Agency for Healthcare Research and Quality (AHRQ) guidelines, has 

your plan implemented them: 

•	 Fully 

•	 Partially 

•	 The plan has not implemented the guidelines 

Mark all that apply 

Has your plan implemented systems for any of the following? 

•	 Documentation of patient smoking status in an administrative computer 

database 

•	 Documentation of patient smoking status in the medical record 

•	 Computerized clinic reminders to encourage providers to advise patients to quit 

•	 Provider training in effective smoking cessation interventions 

•	 Routine cessation advice/brief provider counseling of patients 

•	 Provider incentives that promote tobacco cessation assessment and intervention 

•	 Patient incentives for use of/adherence to recommended cessation treatment 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

65 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Are the providers in your plan required to carry out any of the following activities? 

•	 Ask new patients about their smoking status 

•	 Include smoking status as a vital sign (i.e., ask about and document smoking 

status at every visit) 

•	 Document smoking status in the patient’s medical record 

•	 Strongly advise all patients who smoke to quit 

•	 Assess willingness of patient to make a quit attempt 

•	 Refer the patient who smokes to intensive treatment when the physician 

considers it appropriate or the patient prefers it 

•	 Arrange for follow-up with patients who are trying to quit smoking 

•	 Ensure that support staff are trained to counsel patients about smoking 

cessation
 

•	 Have literature about smoking cessation and the health risks of smoking readily 

available in waiting rooms and exam rooms 

•	 Encourage parents who smoke to provide a smoke-free environment for their 

children at home and in day care 

•	 Other (please specify)______________________________________________ 

From NAMCS 

Please indicate whether the ambulatory reporting location has each of the computerized
 

capabilities listed below and how often these capabilities are used.
 

Recording patient smoking status?
 

•	 Yes, used routinely 

•	 Yes, but not used routinely 

•	 Yes, but turned off or not used 

•	 No 

•	 Unknown 

From NHAMCS (Lookback Module—Chart abstraction instrument) 

Smoke cigarettes? 

•	 Not current 

•	 Current 

• Unknown 

Health education/Counseling – 

Enter all health education or counseling ORDERED or PROVIDED at this visit. Mark 

(X) all that apply. 

•	 None 

• Smoking cessation 

Assessment and plan—Referral 

Mark (X) all that apply. 

•	 None 

•	 Smoking-cessation program 

From N-SSATS 

Which of the following services are provided by this facility at this location, that is, the 

location listed on the front cover? 

•	 Assessment and Pre-Treatment Services 

– Screening for tobacco use 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

66 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

•	 Pharmacotherapies 

–	 Nicotine replacement 

–	 Non-nicotine smoking/tobacco cessation medications (for example, Bupropion, 

Varenicline) 

Comments The Public Health Service Systems Strategies1 include the following: 

1. Implement a tobacco user identification system in every clinic. 

2. Provide education, resources, and feedback to promote provider intervention. 

3. Dedicate staff to provide tobacco dependence treatment, and assess the delivery of 

this treatment in staff performance evaluations. 

4. Promote hospital policies that support and provide tobacco dependence services. 

5. Include tobacco dependence treatments (both counseling and medication) 

identified as effective in this Guideline as paid or covered services for all 

subscribers or members of health insurance packages. 

Evaluators could conduct separate assessments for individual providers or groups that 

may not be nested within a larger health care system. Evaluators may want to assess 

implementation of cessation guidelines in different types of health care settings, such as 

hospitals, outpatient clinics, community health centers, and provider networks. 

Clarifying the scope of the assessment will be an important step in operationalizing the 

indicator. 

Provisions of the initial stages of the Centers for Medicare & Medicaid Services 

“Meaningful Use” initiative require electronic health records to capture identification of 

and intervention with patients who use tobacco, and require providers to report on these 

measures to receive financial rewards.8 These data can be leveraged for surveillance and 

evaluation of the implementation and outcomes of health systems change cessation 

interventions. 

Related Healthy People 2020 Objectives: TU-9 Increase tobacco screening in health 

care settings and TU-10 Increase tobacco cessation counseling in health care settings 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: July 22, 2014. 

3.	 Fiore MC, Keller PA, Curry SJ. Health system changes to facilitate the delivery of tobacco-dependence 

treatment. American Journal of Preventive Medicine. 2007;33(6S):S349–56. 

4.	 Partnership for Prevention. Healthcare provider reminder systems, provider education, and patient education: 

working with healthcare delivery systems to improve the delivery of tobacco-use treatment to patients—an 

action guide. The Community Health Promotion Handbook: Action Guides to Improve Community Health. 

Washington, DC: Partnership for Prevention; 2008. 

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67 
 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

5.	 Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane 

Database of Systematic Reviews. 2011 Dec 7;(12):CD008743. 

6.	 Conroy MB, Majchrzak NE, Silverman CB, Chang Y, Regan S, Schneider LI, et al. Measuring provider 

adherence to tobacco treatment guidelines: a comparison of electronic medical record review, patient survey, 

and provider survey. Nicotine & Tobacco Research. 2005;7(1):S35–S43. 

7.	 Adsit RT, Fox BM, Tsiolis T, Ogland C, Simerson M, Vind LM, et al. Using the electronic health record to 

connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop 

demonstration project. Translational Behavioral Medicine. 2014;1–9. doi:10.1007/s13142-014-0259-y 

8.	 Centers for Medicare & Medicaid Services. Meaningful Use. Available at: 

https://www.cms.gov/Regulations.../MU_Stage1_ReqOverview.pdf . Accessed June 2, 2014. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

68 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Indicator 3.3.b 

Proportion of the Population that Has Been Asked by a Health Care 

Professional about Tobacco Use 

KOI 2005 3.9.2 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure Proportion of the population that has been asked about their smoking status by a health 

care professional during the previous 12 months 

Why this indicator is	 All patients should be asked if they use tobacco and should have their tobacco use status 

important	 documented at every clinic visit.1 An estimated 80% of smokers visit a physician each 

year.2 Evidence shows that when patients are asked about their tobacco use by a health 

care professional and when that response is documented, both the rates and success of 

clinician interventions increase.1-8 Recent studies demonstrate that the rate of tobacco 

screening varies by patient race/ethnicity and insurance type.3 

Example data National Adult Tobacco Survey (NATS), 2009-2010 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Health Interview Survey (NHIS), 2014 

Information available at: 

http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm#2013_NHIS 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2009 

Information available at: http://www.cdc.gov/prams/AboutPRAMS.htm 

National Youth Tobacco Survey (NYTS), 2011 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

National Ambulatory Medical Care Survey (NAMCS), Patient Record Form, 2011 

Information available at: http://www.cdc.gov/nchs/ahcd.htm 

Population group(s) General population 

Example survey 

question(s) 

From NATS 

In the past 12 months, that is, since [DATE FILL], have you seen a doctor, dentist, 

nurse, or other health professional? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

In the past 12 months, that is, since [DATE FILL], did any doctor, dentist, nurse, or 

other health professional ask if you smoke cigarettes or use any other tobacco products? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

From NHIS 

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to 

you about your smoking? 

• Yes 

• No 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

69 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

•	 REFUSED 

•	 DON’T KNOW 

From PRAMS 

During any of your prenatal care visits, did a doctor, nurse, or other health care worker 

ask if you were smoking cigarettes? 

•	 No 

•	 Yes 

From NYTS 

During the past 12 months, did any doctor, dentist, or nurse ask you if you use tobacco 

of any kind? 

•	 I did not see a doctor, dentist, or nurse during the past 12 months 

•	 Yes 

•	 No 

From NAMCS (Patient Record Form) 

Health Education: Mark all ordered or provided at THIS visit: 

•	 Tobacco use/exposure 

Comments Indicator data can be collected and analyzed for subpopulations. For example, PRAMS 

includes items that assess tobacco use screening among pregnant women.
 

In addition to population survey data, these data could be collected as part of clinical
 

assessments,7 using patient visits as the denominator to measure the proportion of visits
 

in which a health care professional asked the patient about tobacco use.
 

Related Healthy People 2020 Objectives: TU-9 Increase tobacco screening in health 

care settings. 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 Centers for Disease Control and Prevention. National Health Interview Survey. Available at: 

http://www.cdc.gov/nchs/nhis.htm . Accessed April 24, 2014. 

3.	 Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC; Centers for Disease Control and Prevention. 

Tobacco use screening and counseling during physician office visits among adults—National Ambulatory 

Medical Care Survey and National Health Interview Survey, United States, 2005–2009. Morbidity and 

Mortality Weekly Report. 2012 Jun 15;61 Suppl:38–45. 

4.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: July 22, 2014. 

5.	 Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database of Systematic 

Reviews. 2012;6:CD005084. 

6.	 Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews. 

2008 Jan 23;(1). 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

70 Tobacco Control Programs—2015 
 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

7.	 Quinn VP, Hollis JF, Smith KS, Rigotti NA, Solberg LI, Hu W, et al. Effectiveness of the 5-As tobacco 

cessation treatments in nine HMOs. Journal of General Internal Medicine. 2008;24(2):149–54. 

doi:10.1007/s11606-008-0865-9 

8.	 Conroy MB, Majchrzak NE, Silverman CB, Chang Y, Regan S, Schneider LI, et al. Measuring provider 

adherence to tobacco treatment guidelines: a comparison of electronic medical record review, patient survey, 

and provider survey. Nicotine & Tobacco Research. 2005;7(1):S35–43 

. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

71 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Indicator 3.3.c 

Proportion of Tobacco Users Who Have Been Advised to Quit Tobacco 

Use by a Health Care Professional 

KOI 2005 3.9.3 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure Proportion of tobacco users who have been advised to quit tobacco use by a health care 

professional during the previous 12 months 

Why this indicator is	 Evidence shows that quit attempts and tobacco cessation rates increase when health care 

useful	 professionals advise their patients to stop using tobacco.1-6 Some populations, such as 

young adult smokers, are less likely to receive tobacco use counseling to quit from a 

health care provider.7 

Example data National Adult Tobacco Survey (NATS), 2009-2010 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2009 

Information available at: http://www.cdc.gov/prams/AboutPRAMS.htm 

National Youth Tobacco Survey (NYTS), 2011 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

National Health Interview Survey (NHIS), Adult Cancer Supplement, 2010 

Information available at: 

http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm#2013_NHIS 

National Ambulatory Medical Care Survey (NAMCS), Lookback Module, 2013 

Information available at: http://www.cdc.gov/nchs/ahcd/about_ahcd.htm 

National Hospital Ambulatory Medical Care Survey (NHAMCS), 2013 Lookback 

Module 

Information available at: http://www.cdc.gov/nchs/ahcd/about_ahcd.htm 

Population group(s) Current tobacco users and past-year smokers 

Example survey 

question(s) 

From NATS 

In the past 12 months, that is, since [DATE FILL], did any doctor, dentist, nurse, or 

other health professional advise you to quit smoking cigarettes or using any other 

tobacco products? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

From PRAMS 

During any of your prenatal care visits, did a doctor, nurse, or other health care worker 

advise you to stop smoking? 

• Yes 

• No 

• I had quit smoking before my first prenatal visit 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

72 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

Rating 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

From NYTS 

During the past 12 months, did any doctor, dentist, or nurse advise you not to use 

tobacco of any kind? 

•	 I did not see a doctor, dentist, or nurse during the past 12 months 

•	 Yes 

•	 No 

From NHIS 

In the PAST 12 MONTHS, has a medical doctor, dentist, or other health professional 

ADVISED you to quit smoking, or quit using other kinds of tobacco? 

•	 Yes 

•	 No 

•	 DON’T KNOW 

•	 REFUSED 

From NAMCS and NHAMCS 

Health education/Counseling –
 

Enter all health education or counseling ORDERED or PROVIDED at this visit. Mark
 

(X) all that apply. 

•	 None 

•	 Smoking cessation 

Comments Advising vulnerable subpopulations (e.g., pregnant women) to quit using tobacco is 

especially important.
 

In addition to population survey data, these data could be collected as part of clinical
 

assessments,8 using patient visits as the denominator to measure the proportion of visits
 

in which a health care professional advised the patient to quit tobacco.
 

Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: July 22, 2014. 

3.	 NIH State-of-the-Science conference statement on tobacco use: prevention, cessation, and control. Annals of 

Internal Medicine. 2006;145(11):839–44. 

4.	 Curry SJ, Sporer AK, Pugach O, Campbell RT, Emery S. Use of tobacco cessation treatments among young 

adult smokers: 2005 National Health Interview Survey. American Journal of Public Health. 2007;97(8):1464–9. 

5.	 Cokkinides VE, Ward E, Jemal A, Thun MJ. Under-use of smoking-cessation treatments: results from the 

National Health Interview Survey, 2000. American Journal of Preventive Medicine. 2005;28(1):119–22. 

6.	 Quinn VP, Hollis JF, Smith KS, Rigotti NA, Solberg LI, Hu W, et al. Effectiveness of the 5-As tobacco 

cessation treatments in nine HMOs. Journal of General Internal Medicine. 2008;24(2):149–54. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

73 
 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

7.	 Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC; Centers for Disease Control and Prevention. 

Tobacco use screening and counseling during physician office visits among adults—National Ambulatory 

Medical Care Survey and National Health Interview Survey, United States, 2005–2009. Morbidity and 

Mortality Weekly Report. 2012 Jun 15;61 Suppl:38–45. 

8.	 Conroy MB, Majchrzak NE, Silverman CB, Chang Y, Regan S, Schneider LI, et al. Measuring provider 

adherence to tobacco treatment guidelines: a comparison of electronic medical record review, patient survey, 

and provider survey. Nicotine & Tobacco Research. 2005;7(1):S35–S43. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

74 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rating 

low high 

 better

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Indicator 3.3.d 

Proportion of Tobacco Users Who Have Been Assessed by a Health Care 

Professional Regarding Their Willingness to Make a Quit Attempt 

KOI 2005 3.9.4 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure Proportion of tobacco users who have been evaluated by a health care professional 

regarding their willingness to quit tobacco use during the previous 12 months 

Why this indicator is Evidence suggests that once a tobacco-using patient is advised to quit, assessing that 

useful patient’s willingness to quit helps clinicians tailor the cessation counseling to the 

patient.1-4 

Example data National Adult Tobacco Survey (NATS), 2009-2010
 source(s) Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/
 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

The last time a health professional advised you to quit using tobacco, did they also ask if 

you wanted to try to quit? 

•	 Yes 

•	 No 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

Comments	 The example question could also be asked of young tobacco users. 

Evaluators might also wish to evaluate whether the physician inquired about the 

patient’s willingness to use assistance in quitting (e.g., calling a quitline, joining a group 

cessation program, using Food and Drug Administration [FDA]-approved 

pharmacotherapies). 

Assessment for vulnerable subpopulations, such as pregnant women, is especially 

important. 

Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

† $
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: July 22, 2014. 

3.	 Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database of Systematic 

Reviews. 2012;6:CD005084. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

75 
 

 

 

GOAL AREA 3
 

► Outcome 3
 

4.	 Curry SJ, Sporer AK, Pugach O, Campbell RT, Emery S. Use of tobacco cessation treatments among young 

adult smokers: 2005 National Health Interview Survey. American Journal of Public Health. 2007;97(8):1464–9. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

76 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Indicator 3.3.e 

Proportion of Tobacco Users Who Have Been Assisted in Quitting

Tobacco Use by a Health Care Professional 

KOI 2005 3.9.5 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure	 Proportion of tobacco users who have had a health care professional actively assist them 

in an attempt to quit tobacco use in the previous 12 months. Examples of assistance 

include prescribing Food and Drug Administration (FDA)-approved cessation 

medications, providing educational material, providing counseling or a counseling 

referral, and establishing a firm quit date. 

Why this indicator is There is strong evidence that clinician assistance in cessation leads to improved quit 

useful rates.1-4 

Example data National Adult Tobacco Survey (NATS), 2009-2010 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2009 

Information available at: http://www.cdc.gov/prams/AboutPRAMS.htm 

National Ambulatory Medical Care Survey (NAMCS), 2013 Lookback Module 

Information available at: http://www.cdc.gov/nchs/ahcd/ahcd_survey_instruments.htm 

National Hospital Ambulatory Medical Care Survey (NHAMCS), 2013 Lookback 

Module 

Information available at: http://www.cdc.gov/nchs/ahcd/about_ahcd.htm 

Survey of Dental Practice, 2010
 

Information available at:
 

http://www.healthindicators.gov/Resources/DataSources/SDP_229/Profile 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

The last time a health professional advised you to quit using tobacco, did they also offer 

any assistance, information, or additional advice to help you quit? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

The last time a health professional advised you to quit using tobacco, did they provide 

you with booklets, videos, website addresses, or other information to help you quit? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

The last time a health professional advised you to quit using tobacco, did they put you in 

contact with, or tell you how to contact, a telephone quitline, a class or program, or oneon-one counseling? 

• Yes 

• No 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

77 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

The last time a health professional advised you to quit using tobacco, did they help you 

set a specific date to quit using tobacco products? 

•	 Yes 

•	 No 

•	 DON’T KNOW/NOT SURE 

• REFUSED 

The last time a health professional advised you to quit using tobacco, did they 

recommend or prescribe nicotine patch, nicotine gum, lozenges, nasal spray, an inhaler, 

or pills such as Wellbutrin®, Zyban®, bupropion, Chantix®, or varenicline? 

•	 Yes 

•	 No 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

From PRAMS 

During any of your prenatal care visits, did a doctor, nurse, or other health care 

worker— 

•	 Spend time with you discussing how to quit smoking 

•	 Suggest that you set a specific date to stop smoking 

•	 Suggest you attend a class or program to stop smoking 

•	 Provide you with booklets, videos, or other materials to help you quit smoking 

on your own 

•	 Refer you to counseling for help with quitting 

•	 Ask if a family member or friend would support your decision to quit 

•	 Refer you to a national or state quit line 

•	 Recommend using nicotine gum 

•	 Recommend using a nicotine patch 

•	 Prescribe a nicotine nasal spray or nicotine inhaler 

•	 Prescribe a pill like Zyban® (also known as Wellbutrin® or bupropion) or 

Chantix® (also known as varenicline) to help you quit 

From NAMCS 

Health education/Counseling—Enter all health education or counseling ORDERED or 

PROVIDED at this visit. Mark (X) all that apply. 

• Smoking cessation 

Medications and Immunizations—Enter drugs that were ordered, supplied, administered 

or continued during this visit. Include prescription and over-the-counter drugs, 

immunizations, allergy shots, oxygen, anesthetics, chemotherapy, and dietary 

supplement. 

From NHAMCS 

Assessment and plan—Referral 

Mark (X) all that apply. 

•	 Nurse management 

•	 Nutritionist 

•	 Smoking-cessation program 

•	 Weight loss program 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

78 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

•	 Other physician, including primary care provider 

From Survey of Dental Practice 

Please use the following rating scale to answer the following question: 1 = Always, 2 = 

Usually, 3 = Sometimes, 4 = Rarely, 5 = Never. During the past week, how often did 

you or your dental team personally counsel patients who use tobacco on tobacco 

cessation? 

Comments	 The example survey questions could be asked of priority populations such as young 

tobacco users and pregnant women. 

In addition to population survey data, these data could be collected as part of clinical 

assessments,5 using patient visits as the denominator to measure the proportion of visits 

in which a health care professional assisted the patient in quitting tobacco (for example, 

by modifying the question from the American Dental Association Survey of Dental 

Practice available at; 

http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/10_sdpi.ashx ). Also, 

using electronic health record-based eReferrals for telephone quitline services can help 

to monitor the reach and effectiveness of health care system interventions to increase 

cessation. When capturing related information, evaluators may want to consider whether 

capturing all 5 A’s (ask, advise, assess, assist, and arrange) is necessary to answer key 

evaluation questions. 

Related Healthy People 2020 Objectives: TU-10 Increase tobacco cessation counseling 

in health care settings 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

Overall quality 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: July 22, 2014. 

3.	 Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC; Centers for Disease Control and Prevention. 

Tobacco use screening and counseling during physician office visits among adults—National Ambulatory 

Medical Care Survey and National Health Interview Survey, United States, 2005–2009. Morbidity and 

Mortality Weekly Report. 2012 Jun 15;61 Suppl:38–45. 

4.	 Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane 

Database of Systematic Reviews. 2011 Dec 7;(12):CD008743. 

5.	 Conroy MB, Majchrzak NE, Silverman CB, Chang Y, Regan S, Schneider LI, et al. Measuring provider 

adherence to tobacco treatment guidelines: a comparison of electronic medical record review, patient survey, 

and provider survey. Nicotine & Tobacco Research. 2005;7(1):S35–S43. 

Indicator 3.3.f 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

79 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

Proportion of Tobacco Users for Whom a Health Care Provider Has

Arranged for Follow-Up Contact Regarding a Quit Attempt 

KOI 2005 3.9.6 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure Proportion of tobacco users who have had a health care professional schedule follow-up 

contact to help them quit tobacco use during the past 12 months 

Why this indicator is	 Brief interventions may not be sufficient to help every patient quit successfully. 

useful	 Arranging for follow-up contact ensures continued cessation assistance and can increase 

the likelihood of a successful quit attempt.1,2 

Example data National Adult Tobacco Survey (NATS), 2009-2010
 source(s) Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/
 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

(The last time a health professional advised you to quit using tobacco,) did they schedule 

any follow-up contacts, either in person or by phone, or arrange for someone else to call 

you to see how your quit attempt was going? 

•	 Yes 

•	 No 

•	 DON’T KNOW/NOT SURE 

•	 REFUSED 

Comments	 The example survey question could be asked of priority populations, such as young 

tobacco users and pregnant women.
 

When capturing related information, evaluators may want to consider whether capturing
 

all five “A’s” (ask, advise, assess, assist, and arrange) is necessary to answer key
 

evaluation questions.
 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: 

provider reminders when used alone (inactive). Available at: 

http://www.thecommunityguide.org/tobacco/providerreminders_inactive.html. Last updated: July 22, 2014. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

80 Tobacco Control Programs—2015 
GOAL AREA 3
 

► Outcome 3
 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

81 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

GOAL AREA 3 

► Outcome 3 

Indicator 3.3.g 

Proportion of Health Care Facilities with Comprehensive Tobacco-Free 

Campus Policies 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 3 Increased health care systems change to promote and support cessation 

What to measure	 Proportion of health care facilities that implement 100% tobacco-free policies that (a) 

prohibit anyone from using any type of tobacco product at all times in all buildings and 

on health care facility grounds; (b) ban all tobacco industry marketing, sponsorship, and 

sale of products on health care facility grounds; and (c) provide cessation 

services/resources for health care facility patients and staff 

Why this indicator is	 Smoking restrictions decrease cigarette consumption and increase smoking cessation.1 

useful	 Efforts to prohibit tobacco product use in hospitals and health care facilities have been 

shown to protect patient health and reduce smoking among hospital employees.2-4 

Tobacco-free hospitals are also more likely to provide smoking cessation counseling to 

patients.6 Given that adults with some form of mental illness have a smoking rate 70% 

higher than adults with no mental illness,6 and quit rates among those with psychiatric 

diagnoses are markedly lower than rates among those without a diagnosis,7 ensuring 

tobacco-free campus policies at mental health facilities and substance abuse treatment 

centers and providing assistance to remain tobacco-free after discharge is an important 

step to decreasing tobacco-related morbidity and mortality among this vulnerable 

population.1 

Example data Policy tracking system 

source(s) Americans for Nonsmokers’ Rights (ANR) 

Information available at: http://no-smoke.org/ 

National Survey of Substance Abuse Treatment Services (N-SSATS), 2011 

Information available at: http://www.icpsr.umich.edu/icpsrweb/ICPSR/series/58 

Population group(s) Administrators of health care facilities 

Example survey 

question(s) 

From N-SSATS 

Which statement below BEST describes this facility’s smoking policy? MARK ONE 

ONLY. 

• Smoking is not permitted on the property or within any building 

• Smoking is permitted only outdoors 

• Smoking is permitted outdoors and in designated indoor area(s) 

• Smoking is permitted anywhere without restriction 

• Other (Specify:________________________) 

Comments Health care facilities include hospitals, clinics, nursing homes, mental health facilities, 

prenatal clinics, and substance abuse treatment centers, among others. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$
 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

82 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 3 

References 

1.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: The National 

Academies Press; 2007. 

2.	 Fee E, Brown TM. Hospital smoking bans and their impact. American Journal of Public Health. 

2004;94(2):185. 

3.	 National Cancer Institute. Population based smoking cessation: proceedings of a conference on what works to 

influence cessation in the general population. Tobacco Control Monograph No. 12. NIH Pub. No. 00-4892. 

Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer 

Institute; November 2000. 

4.	 Schultz AS, Finegan B, Nykiforuk CI, Kvern MA. A qualitative investigation of smoke-free policies on hospital 

property. Canadian Medical Association Journal. 2011 Dec 13;183(18):E1334–44. doi:10.1503/cmaj.110235 

5.	 Williams SC, Hafner JM, Morton DJ, Holm AL, Milberger SM, Koss RG, et al. The adoption of smoke-free 

hospital campuses in the United States. Tobacco Control. 2009 Dec;18(6):451–8. doi:10.1136/tc.2009.030494. 

6.	 Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18 years

with mental illness—United States, 2009–2011. Morbidity and Mortality Weekly Report. 2013;62(05):81–7. 

7.	 Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the US population. Tobacco Control. 2014 

Apr 17. doi:10.1136/tobaccocontrol-2013-051466. [Epub ahead of print] 

For Further Reading 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

83 
 

 

 

 

GOAL AREA 3 

► Outcome 4 

Outcome 4 

Increased Policy and Environmental Changes to Support Quitting, 

Strengthen Smokefree Laws, and Increase Tobacco Product Price 

Policy, systems, and environmental changes, such as increases in the purchase price of tobacco 

products and comprehensive smokefree laws, are the most efficient, effective ways to increase 

tobacco cessation.1-4 There is a strong, inverse relationship between cigarette price and 

consumption, particularly among price-sensitive populations, such as adolescents, young adults, 

and low-income smokers.5-9 Higher tobacco prices increase the probability that a current user 

will make a quit attempt.9

 Although substantial progress has been made in the adoption of 

comprehensive smokefree laws that prohibit smoking in all indoor areas of workplaces and 

public places, millions of Americans are not protected by such policies.10 A growing evidence 

base demonstrates that smokefree workplaces decrease the prevalence of adult smoking.11,12 

Retail tobacco sales and marketing increase unplanned cigarette purchases and the probability of 

smoking and may make it harder for smokers to quit.13-19 The 2009 Family Smoking Prevention 

and Tobacco Control Act expands the ability of state and local governments to adopt policies 

regulating the time, place, and manner of retail tobacco sales and marketing.20 

The following indicators are associated with this outcome: 

►	 3.4.a Proportion of jurisdictions with policies that regulate tobacco retail sales and 

marketing 

►	 3.4.b Proportion of jurisdictions with policies that regulate the extent and type of 

consumer-focused tobacco promotions 

►	 3.4.c Proportion of jurisdictions with comprehensive public policies for tobacco-free 

workplaces and other places 

► 3.4.d	 Proportion of tobacco users with smokefree home or vehicle rules 

► 3.4.e	 Amount of tobacco product taxes and fees 

► 3.4.f	 Tobacco product price 

References 

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

control programs—2014. Atlanta, GA: U.S. Department of Health and Human Services, 

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

and Health Promotion, Office on Smoking and Health; 2014. 

2. Centers for Disease Control and Prevention. State smoke-free laws for worksites, restaurants, 

and bars—United States, 2000–2010. Morbidity and Mortality Weekly Report. 

2011;60(15):472–5. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

84 Tobacco Control Programs—2015 
 

 

GOAL AREA 3 

► Outcome 4 

3. U.S. Department of Health and Human Services. How tobacco smoke causes disease: the 

biology and behavioral basis for smoking-attributable disease: a report of the Surgeon 

General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease 

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

Promotion, Office on Smoking and Health; 2010. 

4. U.S. Department of Health and Human Services. The health consequences of smoking: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human 

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

Prevention and Health Promotion, Office on Smoking and Health; 2004. 

5. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 

6. Hyland A, Bauer JE, Li Q, Abrams SM, Higbee C, Peppone L, et al. Higher cigarette prices 

influence cigarette purchase patterns. Tobacco Control. 2005;14(2):86–92. doi: 

10.1136/tc.2004.008730 

7. Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social 

disparities in adult smoking prevalence. American Journal of Preventive Medicine. 2009 

Apr;36(4):285–91. doi:10.1016/j.amepre.2008.11.013 

8. Messer K, Pierce JP, Zhu SH, Hartman AM, Al-Delaimy WK, Trinidad R, et al. The 

California Tobacco Control Program’s effect on adult smokers: (1) Smoking cessation. 

Tobacco Control. 2007;16(2):85–90. 

9. Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. 

Tobacco Control. 2011;20(3):235–8. doi:10.1136/tc.2010.039982 

10. Centers for Disease Control and Prevention. Vital signs: nonsmokers’ exposure to 

secondhand smoke—United States, 1999–2008. Morbidity and Mortality Weekly 

Report.2010;59(35):1141–6. 

11. Pierce JP, León ME on behalf of the IARC Handbook. Effectiveness of smoke-free policies. 

The Lancet Oncology. 2008;9(7):614–5. 

12. Hahn EJ, Rayens MK, Butler KM, Zhang M, Durbin E, Steinke D. Smoke-free laws and 

adult smoking prevalence. Preventive Medicine. 2008;47(2):206–9. 

doi:10.1016/j.ypmed.2008.04.009 

13. Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on 

impulse purchase. Addiction. 2007;103(2):322–8. 

14. Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and tobacco point of sale 

advertising: a potential barrier to smoking cessation. Tobacco Control. 2013 Nov;22(6):376– 

81. doi:10.1136/tobaccocontrol-2012-050427 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

85 
GOAL AREA 3 

► Outcome 4 

15. Burton S, Clark L, Jackson K. The association between seeing retail displays of tobacco and 

tobacco smoking and purchase: findings from a diary‐style survey. Addiction. 

2012;107(1):169–75. doi:10.1111/j.1360‐0443.2011.03584.x 

16. Carter OBJ, Mills BW, Donovan RJ. The effect of retail cigarette pack displays on unplanned 

purchases: results from immediate postpurchase interviews. Tobacco Control. 

2009;18(3):218–21. doi:10.1136/tc.2008.027870 

17. Hoek J, Gifford H, Pirikahu G, Thomson G, Edwards R. How do tobacco retail displays 

affect cessation attempts? Findings from a qualitative study. Tobacco Control. 

2010;19(4):334–7. doi:10.1136/tc.2009.031203 

18. Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic 

review. Nicotine & Tobacco Research. 2009;11(1):25–35. doi:10.1093/ntr/ntn003 

19. Germain D, McCarthy M, Wakefield M. Smoker sensitivity to retail tobacco displays and 

quitting: a cohort study. Addiction. 2010;105(1):159–63. doi:10.1111/j.1360­

0443.2009.02714.x 

20. Family Smoking Prevention and Tobacco Control Act, 21 U.S.C.A. §§ 387–387u (West 

2009); Pub. L. No. 111-31, 123 Stat. 1776 (2009); 21 C.F.R. §§ 1140.30, 1140.32 (2010) 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 4 

Outcome 4 

Increased Policy and Environmental Changes to Support Quitting,

Strengthen Smokefree Laws, and Increase Tobacco Product Price 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.4.a Proportion of jurisdictions with 

policies that regulate tobacco retail 

sales and marketing 

$$$ 

3.4.b Proportion of jurisdictions with 

policies that regulate the extent and 

type of consumer-focused tobacco 

promotions 

$$$$ 

3.4.c Proportion of jurisdictions with 

comprehensive public policies for 

tobacco-free workplaces and other 

places 

$$$$ 

3.4.d Proportion of tobacco users with 

smokefree home or vehicle rules 

$ 

3.4.e Amount of tobacco product taxes 

and fees 

$$ 

3.4.f Tobacco product price $ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

87 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

GOAL AREA 3 

► Outcome 4 

Indicator 3.4.a 

Proportion of Jurisdictions with Policies that Regulate Tobacco Retail 

Sales and Marketing 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 4 Policy and environmental changes to support quitting, strengthen smokefree laws, and 

increase tobacco product price 

What to measure Proportion of local jurisdictions with public policies that regulate time, place, and/or 

manner of retail tobacco sales and marketing 

Why this indicator is	 Tobacco advertising in stores, including large cigarette pack displays, increases 

useful	 unplanned cigarette purchases, increases the probability of smoking, and may make it 

harder for smokers to quit smoking.1-7 Studies have shown that the volume of in-store 

advertisements and the proportion of stores with sales promotions have increased more 

rapidly in neighborhoods with a higher proportion of African Americans than in other 

communities.8 Limiting tobacco retailer proximity to residential areas through licensing 

and/or local code restrictions may also aid cessation.9 

Example data Policy tracking system
 source(s) Americans for Nonsmokers’ Rights (ANR)
 

Information available at: http://www.no-smoke.org 

CDC State Tobacco Activities Tracking and Evaluation (STATE) system—LegislationAdvertising and Licensure Information available at: http://www.cdc.gov/statesystem/ 

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations. 

Example survey 

question(s) 

Not applicable 

Comments	 The 2009 Family Smoking Prevention and Tobacco Control Act gave the Food and 

Drug Administration the authority to regulate the manufacturing, marketing, and sale of 

tobacco products and allows states and localities to restrict or regulate the time, place, 

and manner (but not the content) of cigarette advertising and promotion (Pub. L. No. 

111-31, §203). 

Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. See the Center for Public Health Law and 

Tobacco Policy for an example Model Tobacco Product Display Ban Ordinance: 

http://publichealthlawcenter.org/sites/default/files/resources/nycenter-syntobproductdisplaybans-2010.pdf 

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances. In this way, the proportion of 

the population covered by such laws could be calculated. It may also be useful to gather 

details regarding any time, location, and medium restrictions included in the policies. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$
 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

88 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

References 

1.	 Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on impulse purchase. 

Addiction. 2007;103(2):322–28. 

2.	 Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and tobacco point of sale advertising: a 

potential barrier to smoking cessation. Tobacco Control. 2013 Nov;22(6):376–81. doi:10.1136/tobaccocontrol2012-050427 

3.	 Burton S, Clark L, Jackson K. The association between seeing retail displays of tobacco and tobacco smoking 

and purchase: findings from a diary‐style survey. Addiction. 2012;107(1):169–75. doi:10.1111/j.1360‐

0443.2011.03584.x 

4.	 Carter OBJ, Mills BW, Donovan RJ. The effect of retail cigarette pack displays on unplanned purchases: results 

from immediate postpurchase interviews. Tobacco Control. 2009;18(3):218–21. doi:10.1136/tc.2008.027870 

5.	 Hoek J, Gifford H, Pirikahu G, Thomson G, Edwards R. How do tobacco retail displays affect cessation 

attempts? Findings from a qualitative study. Tobacco Control. 2010;19(4):334–7. doi:10.1136/tc.2009.031203 

6.	 Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine & 

Tobacco Research. 2009;11(1):25–35. doi:10.1093/ntr/ntn003 

7.	 Germain D, McCarthy M, Wakefield M. Smoker sensitivity to retail tobacco displays and quitting: a cohort 

study. Addiction. 2010;105(1):159–63. doi: 10.1111/j.1360-0443.2009.02714.x 

8.	 Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8. 

doi:10.1136/tc.2007.022046 

9.	 Reitzel LR, Cromley EK, Li Y, Cao Y, Dela Mater R, Mazas CA, et al. The effect of tobacco outlet density and 

proximity on smoking cessation. American Journal of Public Health. 2011;101(2):315–20. 

doi:10.2105/AJPH.2010.191676 

For Further Reading 

Dachille K, Tobacco Control Legal Consortium. Regulating tobacco advertising and promotion: a “commerce 

clause” overview for state and local governments. 2010. Available at: 

http://publichealthlawcenter.org/sites/default/files/resources/tclc-fs-regadvert-2010.pdf 

Laird-Metke EP, Tobacco Control Legal Consortium. Regulating tobacco marketing: “commercial speech” 

factsheet for state and local governments. 2010. Available at: 

http://publichealthlawcenter.org/sites/default/files/resources/tclc-fs-speech-2010.pdf 

National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; June 2008. 

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low high 

 better

GOAL AREA 3 

► Outcome 4 

Indicator 3.4.b 

Proportion of Jurisdictions with Policies that Regulate the Extent and Type 

of Consumer-Focused Tobacco Promotions 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 4 Policy and environmental changes to support quitting, strengthen smokefree laws, and 

increase tobacco product price 

What to measure Proportion of local jurisdictions with public policies that regulate consumer-focused 

promotions, such as discounts, rebates, coupons, and buy-one-get-one-free offers 

Why this indicator is	 There is a causal relationship between tobacco promotion and increased tobacco use.1,2 

useful	 In 2011, almost $9.2 billion was spent on cigarette advertising and promotion 

expenditures, with approximately 85.1% of these expenditures directed at price 

promotions in the retail setting.3 A substantial increase in the percentage of stores 

offering price promotions for cigarettes has been documented over the past decade.4 

Recent studies show that price-related promotions are accelerating disproportionately 

among retailers in neighborhoods with lower socioeconomic status and higher 

proportions of racial and ethnic populations experiencing health disparities.5,6 Greater 

availability of cigarette promotions and lower cigarette prices are associated with 

decreased quit attempts among current smokers.7,8 

Example data Policy tracking system 

source(s) American Lung Association’s State Legislated Actions on Tobacco Issues (SLATI) 

Information available at: http://lungusa2.org/slati/about.php 

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations. 

Example survey 

question(s) 

Not applicable 

Comments Evaluators should determine the scope of policy standards before evaluating the 

presence/absence and reach of such policies. Strong policies that regulate the extent and 

type of consumer-focused tobacco promotions may include those that restrict the 

distribution or redemption of discount coupons for tobacco products, limit discounts and 

incentive programs offered by tobacco manufacturers to retailers, and prohibit buy-oneget-one-free and other value-added promotional discounts. See the Tobacco Control 

Legal Consortium’s report, Policy approaches to restricting tobacco product coupons 

and retail value-added promotions, for more information: 

http://publichealthlawcenter.org/sites/default/files/resources/tclc-guide-policyapproaches-pricing-cppw-2013.pdf. 

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances. In this way, the proportion of 

the population covered by such laws could be calculated. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$$ 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

90 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

References 

1.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

2.	 Pierce JP. Tobacco industry marketing, population-based tobacco control, and smoking behavior. American 

Journal of Preventive Medicine. 2007;33(6 Suppl):S327–34. 

3.	 Federal Trade Commission. Cigarette report for 2012. Washington, DC: Federal Trade Commission; 2015. 

4.	 Roeseler A, Feighery E, Cruz T. Tobacco marketing in California and implications for the future. Tobacco 

Control. 2010 Apr;19(Suppl 1):i21–9. doi:10.1136/tc.2009.031963 

5.	 Chuang Y, Cubbin C, Ahn D, Winkleby M. Effects of neighbourhood socioeconomic status and convenience 

store concentration on individual level smoking. Journal of Epidemiology and Community Health. 

2005;59(7):568–73. 

6.	 Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8. 

doi:10.1136/tc.2007.022046 

7.	 Feighery E, Rogers T, Ribisl KM. Tobacco retail price manipulation policy strategy summit proceedings. 

Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2009. 

8.	 Choi K, Hennrikus DJ, Forster JL, Moilanen M. Receipt and redemption of cigarette coupons, perceptions of 

cigarette companies and smoking cessation. Tobacco Control. 2013 Nov;22(6):418–22. 

doi:10.1136/tobaccocontrol-2012-050539 

For Further Reading 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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 better

GOAL AREA 3 

► Outcome 4 

Indicator 3.4.c 

Proportion of Jurisdictions with Comprehensive Public Policies for 

Tobacco-Free Workplaces and Other Places 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 4 Policy and environmental changes to support quitting, strengthen smokefree laws, and 

increase tobacco product price 

What to measure Proportion of local jurisdictions that have public policies requiring tobacco-free 

workplaces, including restaurants, bars, and other indoor public places1 

Why this indicator is	 Tobacco-free policies help establish nonsmoking environments as a social norm.2,3 A 

useful	 growing evidence base demonstrates that smokefree workplaces decrease the prevalence 

of adult smoking.4,5 One study comparing the cost-effectiveness of free nicotine 

replacement therapy (NRT) with a statewide smokefree workplace policy found the 

smokefree workplace policy to be approximately nine times more cost-effective.6 

Example data 

source(s) 

Policy tracking system 

Americans for Nonsmokers’ Rights 

Information available at: http://www.no-smoke.org 

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations. 

Example survey 

question(s) 

Not applicable 

Comments	 Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” comprehensive tobacco-free 

policies include those that apply to all public and private workplaces, restaurants, and 

bars at all times and do not include preemptions, opt-out provisions, or exemptions. See 

the Americans for Nonsmokers’ Rights Web site for additional information: 

http://www.no-smoke.org/ 

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances. In this way, the proportion of 

the population covered by such laws could be calculated. 

Related Healthy People 2020 Objectives: TU-12 Increase the proportion of persons 

covered by indoor worksite policies that prohibit smoking 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$$
 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

92 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

References 

1.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smokefree policies. Available at: http://www.thecommunityguide.org/tobacco/smokefreepolicies.html. Last updated: 

June 12, 2014. 

2.	 Hamilton WL, Biener L, Brennan RT. Do local tobacco regulations influence perceived smoking norms? 

Evidence from adult and youth surveys in Massachusetts. Health Education Research. 2008 Aug;23(4):709–22. 

doi:10.1093/her/cym054 

3.	 Francis JA, Abramsohn EM, Park HY. Policy-driven tobacco control. Tobacco Control. 2010 Apr;19(Suppl 

1):i16–20. doi:10.1136/tc.2009.030718 

4.	 Pierce JP, León ME on behalf of the IARC Handbook. Effectiveness of smoke-free policies. The Lancet 

Oncology. 2008;9(7):614–5. 

5.	 Hahn EJ, Rayens MK, Butler KM, Zhang M, Durbin E, Steinke D. Smoke-free laws and adult smoking 

prevalence. Preventive Medicine. 2008;47(2):206–9. doi:10.1016/j.ypmed.2008.04.009 

6.	 Ong MK, Glantz SA. Free nicotine replacement therapy programs vs implementing smoke-free workplaces: a 

cost-effectiveness comparison. American Journal of Public Health. 2005;95(6):969–75. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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► Outcome 4 

Indicator 3.4.d 

Proportion of Tobacco Users with Smokefree Home or Vehicle Rules
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 4 Policy and environmental changes to support quitting, strengthen smokefree laws, and 

increase tobacco product price 

What to measure Proportion of tobacco users who report having voluntary smokefree policy in their home 

or vehicles 

Why this indicator is	 Smokers who have implemented smokefree home rules are significantly more likely to 

useful	 make a quit attempt, be abstinent, and smoke fewer cigarettes per day.1-7 Although 

lower-income smokers4 and those with lower education levels5 are less likely to report 

smokefree home or vehicle rules, one study found that among those who report having 

them, successful quit rates are similar to smokers with higher incomes.4 

Example data National Adult Tobacco Survey (NATS), 2013–2014 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Youth Tobacco Survey (NYTS), 2011 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2006–2007 

Information available at: http://riskfactor.cancer.gov/studies/tus-cps/ 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

Not counting decks, porches, or garages, inside your home, is smoking... 

• Always allowed 

• Allowed only at some times or in some places 

• Never allowed 

• DON’T KNOW/NOT SURE 

• REFUSED 

Not counting motorcycles, in the vehicles that you or family members who live with you 

own or lease, is smoking... 

• Always allowed 

• Sometimes allowed in at least one vehicle 

• Never allowed in any vehicle 

• Respondent’s family does not own or lease a vehicle 

• DON’T KNOW/NOT SURE 

• REFUSED 

From NYTS 

Inside your home (not counting decks, garages, or porches), is smoking... 

• Always allowed 

• Allowed only at some times or in some places 

• Never allowed 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

In the vehicles that you and family members who live with you own or lease, is 

smoking... 

•	 Always allowed 

•	 Sometimes allowed 

•	 Never allowed 

From TUS-CPS 

Which statement best describes the rules about smoking in YOUR HOME? 

•	 No one is allowed to smoke anywhere 

•	 Smoking is allowed in some places or at some times 

•	 Smoking is permitted anywhere 

Comments	 Note that current evidence is specific to smokefree homes. As the use of noncombustible 

tobacco and nicotine-containing products increases, it will be important to examine the 

effects of broader home and vehicle tobacco-use rules. Evaluators could modify the 

example question to address tobacco-free policies inside vehicles. 

Related Healthy People 2020 Objectives: TU-14 Increase the proportion of smoke-free 

homes 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Mills AL, Messer K, Gilpen EA, Pierce JP. The effect of smoke-free homes on adult smoking behavior: a 

review. Nicotine & Tobacco Research. 2009:11(10):1131–41. doi:10.1093/ntr/ntp122 

2.	 Hyland A, Higbee C, Travers MJ, Van Deusen A, Bansal-Travers M, King B, et al. Smoke-free homes and 

smoking cessation and relapse in a longitudinal population of adults. Nicotine & Tobacco Research. 

2009;11(6):614–8. doi:10.1093/ntr/ntp022 

3.	 U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

smoke: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. 

4.	 Vijayaraghavan M, Messer K, White MM, Pierce JP. The effectiveness of cigarette price and smoke-free homes 

on low-income smokers in the United States. American Journal of Public Health. 2013 Dec;103(12):2276–83. 

doi:10.2105/AJPH.2013.301300 

5.	 Borland R, Yong HH, Cummings KM, Hyland A, Anderson S, Fong GT. Determinants and consequences of 

smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco 

Control. 2006;15:iii42–iii50. 

6.	 Messer K, Mills A, White MM, Pierce JP. The effect of smoke-free homes on smoking behavior in the U.S. 

American Journal of Preventive Medicine. 2008;35(3):210–6. 

7.	 King BA, Dube SR, Homa DM. Smoke-free rules and secondhand smoke exposure in homes and vehicles 

among US adults, 2009–2010. Preventing Chronic Disease. 2013 May 16;10:E79. doi:10.5888/pcd10.120218 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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► Outcome 4 

Indicator 3.4.e 

Amount of Tobacco Product Taxes and Fees
 

KOI 2005 3.12.1 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 4 Policy and environmental changes to support quitting, strengthen smokefree laws, and 

increase tobacco product price 

What to measure Per applicable individual unit of tobacco product that is sold, measure (1) excise tax, (2) 

sales tax, (3) applicable local fees, and (4) percentage of the total price attributable to 

taxes and fees 

Why this indicator is 

useful 

The level of excise tax on tobacco products is a reliable indicator of the success of a 

tobacco control program.1 Increasing tax on tobacco products increases the price of 

tobacco products, and higher tobacco prices are associated with overall reductions in 

tobacco use prevalence and tobacco consumption.2 These outcomes are, in part, 

achieved by promoting cessation and lowering consumption among tobacco users, 

especially price-sensitive populations (e.g., young people, ethnic or racial disparate 

populations).3-10 

Example data 

source(s) 

CDC State Tobacco Activities Tracking and Evaluation (STATE) system 

Information available at: http://www.cdc.gov/statesystem/ 

Campaign For Tobacco-Free Kids (CTFK) 

Information available at: 

http://www.tobaccofreekids.org/research/factsheets/pdf/0097.pdf 

State departments of revenue 

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring state and 

local excise tax on tobacco products. 

Example survey 

question(s) 

Not applicable 

Comments	 To understand the full impact of tobacco cost on consumer behavior, it is important to 

collect and analyze data on all tobacco products, including cigarettes, cigars, hookahs, 

snus, smokeless tobacco, loose tobacco (pipe and roll-your-own), bidis, kreteks, 

dissolvable tobacco, and electronic nicotine delivery devices. 

States and localities can independently track the price of tobacco products by collecting 

retail scanner data (data obtained from product bar codes), which provide information on 

product price, brand, and promotions. However, this type of data collection can be costprohibitive and does not capture data on all taxes and fees or costs associated with tax 

avoidance or tax evasion. 

Evaluators may also consider tax treaties between state governments and Native 

American Tribes where applicable. As the overall tax increases, tax avoidance via the 

purchase of reduced tax/tax-free products on tribal lands has been shown to increase.11 

Note: Indicator 3.4.e allows evaluators to understand the underlying contributors to the 

total price of tobacco products, whereas 3.4.f measures the actual price paid for tobacco 

products. 

Related Healthy People 2020 Objectives: TU-17 Increase the Federal and State tax on 

tobacco products. 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

96 Tobacco Control Programs—2015 
 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

References 

1.	 Centers for Disease Control and Prevention. Tobacco control state highlights 2010. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

2.	 International Agency for Research on Cancer (IARC). Effectiveness of tax and price policies for tobacco 

control: IARC handbook of cancer prevention, vol. 14. Lyon, France: IARC; 2011. 

3.	 Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National 

Academies Press; 2007. 

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

2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2007. 

5.	 Task Force on Community Preventive Services. The guide to community preventive services: tobacco use 

prevention and control. American Journal of Preventive Medicine. 2001;20(Suppl 2):1–88. 

6.	 Levy DT, Romano E, Mumford E. The relationship of smoking cessation to sociodemographic characteristics, 

smoking intensity, and tobacco control policies. Nicotine & Tobacco Research. 2005;7(3):387–96. 

7.	 Hyland A, Higbee C, Li Q, Bauer JE, Giovino GA, Alford T, et al. Access to low taxed cigarettes deters 

smoking cessation attempts. American Journal of Public Health. 2005;95(6):994–5. 

8.	 Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult 

smoking prevalence. American Journal of Preventive Medicine. 2009 Apr;36(4):285–91. 

doi:10.1016/j.amepre.2008.11.013 

9.	 Tauras JA. Public policy and smoking cessation among young adults in the United States. Health Policy. 

2004;68(3):321–32. 

10. Bandi P, Blecher E, Cokkinides V, Ross H, Jemal A. Cigarette affordability in the United States. Nicotine & 

Tobacco Research. 2013 Sep;15(9):1484–91. doi:10.1093/ntr/nts348 

11. Xu X, Malarcher A, O’Halloran A, Kruger J. Does every smoker bear the same cigarette tax? Addiction. 2014 

June 4. [Epub ahead of print] 

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97 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

Indicator 3.4.f 

Tobacco Product Price
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 4 Policy and environmental changes to support quitting, strengthen smoke freelaws, and 

increase tobacco product price 

What to measure Full price paid for a unit of tobacco product, including discounts and applicable taxes 

and fees 

Why this indicator is	 There is a strong, inverse relationship between cigarette price and consumption, 

useful	 particularly among price-sensitive populations (e.g., low socioeconomic status, young 

people).1-9 High tobacco prices increase the probability that a current user will make a 

quit attempt.9 

Example data National Adult Tobacco Survey (NATS), 2013-2014 

source(s) Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

Scanner data 

Retail observation or purchase survey 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

What price did you pay for the last carton of cigarettes you bought? 

____. Amount paid for last carton of cigarettes 

• DON’T KNOW/NOT SURE 

• REFUSED 

What price did you pay for the last pack of cigarettes you bought? 

____. Amount paid for last pack of cigarettes 

• DON’T KNOW/NOT SURE 

• REFUSED 

In the past 30 days, did you use coupons, rebates, buy 1 get 1 free, 2 for 1, or any other 

special promotions when you bought cigarettes? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Comments	 The tobacco industry uses price promotions (e.g., discount coupons for money off, buy 

one get one offers, promotional allowances paid directly to cigarette retailers or 

wholesalers) to mitigate the influence of taxes on price. Asking the public how much 

they paid for tobacco products can illuminate differences between advertised prices and 

actual price paid due to price promotions. 

States can track the price of tobacco products using retail scanner data that provide 

information on volume, price, brand, product type, package type, and promotions; 

however, scanner data are generally only available for a sample of stores in designated 

market areas that may not correspond with state borders. Additionally, scanner data are 

proprietary, costly to obtain, complex to analyze, and do not fully capture all taxes and 

fees or costs associated with tax avoidance or tax evasion. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

98 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 4 

States may use retail observation to capture price information with the benefits of 

flexibility in obtaining unique price data (e.g., advertised prices, tax stamps); specific 

price-promotional strategies; and compliance with certain policies, such as minimum 

price law. Additionally, evaluators may adjust the sampling frame and link observational 

data to census tract or other ecological data depending on study needs; however, it can 

be costly to collect observational data, difficult to ensure high inter-rater reliability, and 

challenging to develop and test new valid and reliable measures. 

Tracking the price of multiple types of tobacco products, including cigarettes, cigars, 

hookahs, snus, smokeless tobacco, loose tobacco (pipe and roll-your-own), bidis, 

kreteks, dissolvable tobacco, and electronic nicotine delivery systems, may help to 

provide important information for program planning and evaluation. 

Note: Indicator 3.4.e allows evaluators to understand the underlying contributors to the 

total price of tobacco products, whereas 3.4.f measures the actual price paid for tobacco 

products. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 NIH State-of-the-Science conference statement on tobacco use: prevention, cessation, and control. Annals of 

Internal Medicine. 2006;145(11):839–44. 

2.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

3.	 International Agency for Research on Cancer (IARC). Effectiveness of tax and price policies for tobacco 

control: IARC handbook of cancer prevention, vol. 14. Lyon, France: IARC; 2011. 

4.	 Hyland A, Bauer JE, Li Q, Abrams SM, Higbee C, Peppone L, et al. Higher cigarette prices influence cigarette 

purchase patterns. Tobacco Control. 2005;14(2):86–92. doi: 10.1136/tc.2004.008730 

5.	 White VM, Gilpin EA, White MM, Pierce JP. How do smokers control their cigarette expenditures? Nicotine & 

Tobacco Research. 2005 Aug;7(4):625–35. 

6.	 Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult 

smoking prevalence. American Journal of Preventive Medicine. 2009 Apr;36(4):285–91. 

doi:10.1016/j.amepre.2008.11.013. 

7.	 Messer K, Pierce JP, Zhu SH, Hartman AM, Al-Delaimy WK, Trinidad R, et al. The California Tobacco 

Control Program’s effect on adult smokers: (1) Smoking cessation. Tobacco Control. 2007;16:85–90. 

8.	 Bandi P, Blecher E, Cokkinides V, Ross H, Jemal A. Cigarette affordability in the United States. Nicotine & 

Tobacco Research. 2013 Sep;15(9):1484–91. doi: 10.1093/ntr/nts348. 

9.	 Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tobacco Control. 

2011;20(3):235–8. doi:10.1136/tc.2010.039982 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

99 
 

 

 

GOAL AREA 3 

► Outcome 5 

Outcome 5 

Reduced Tobacco Industry Influence 

The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the 

tobacco industry.1 In her final opinion on United States v. Philip Morris, U.S. District Judge 

Gladys Kessler concluded that the major tobacco companies are adjudicated racketeers that had 

“mounted a coordinated, well-financed, sophisticated public relations campaign to attack and 

distort the scientific evidence demonstrating the relationship between smoking and disease” (p. 

33-331).2 

Each day in the United States, the tobacco industry spends over $25 million to advertise and 

promote cigarettes, mostly at the point of sale.3 Although the Master Settlement Agreement 

(MSA) of 1998 (an arrangement in which the Attorneys General of 46 states, the District of 

Columbia, and five U.S. territories settled state lawsuits with the largest tobacco companies in 

the United States) helped restrict some types of cigarette and smokeless tobacco advertising, 

marketing, and promotion directed at youth, the tobacco industry continues to market its 

products aggressively.

4,5 The tobacco industry uses a “360-degree” strategy that encompasses 

multiple forms of media to market its products.5 Consumer-generated content on social media 

and tobacco sale Web sites have the potential to promote tobacco use.6-8 Moreover, a growing 

evidence base demonstrates that greater point of sale exposure to tobacco products and 

promotions is associated with decreased quit attempts among current smokers.9-15Exposure to 

smoking in the movies and on television increases the urge to smoke among adult tobacco 

users.16,17 The introduction of new tobacco products to the market might encourage continued 

nicotine dependence rather than cessation, distracting from cessation efforts.18-20 

The following indicators are associated with this outcome: 

► 3.5.a Extent and type of retail tobacco advertising 

► 3.5.b	 Extent and type of consumer-focused industry promotions 

► 3.5.c	 Extent and type of retailer-focused industry promotions 

► 3.5.d	 Extent of tobacco imagery in movies and television 

► 3.5.e	 Extent of pro-tobacco Internet presence 

►	 3.5.f Proportion of tobacco users reporting exposure to marketing and promotions for 

tobacco products (environmental cues) 

► 3.5.g Proportion of tobacco users who report unplanned purchases of tobacco products 

► 3.5.h	 Proportion of tobacco users who are aware of emerging tobacco products 

References 

1. U.S. Department of Health and Human Services. The health consequences of smoking—50 

years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Center for 

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

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

100 Tobacco Control Programs—2015 
 

 

 

GOAL AREA 3 

► Outcome 5 

2. U.S. v. Philip Morris, 449 F.Supp.2d 1. D.D.C. 2006. Amended Final Opinion. Available at: 

http://publichealthlawcenter.org/sites/default/files/resources/doj-final-opinion.pdf 

3. Federal Trade Commission. Cigarette report for 2012. Washington, DC: Federal Trade 

Commission; 2015. 

4. National Association of Attorneys General. MSA background. Washington, DC: National 

Association of Attorneys General; 2008. Available at: 

http://www.naag.org/naag/about_naag/naag-center-for-tobacco-and-publichealth.php?searched=MSA+background&advsearch=allwords&highlight=ajaxSearch_highli 

ght+ajaxSearch_highlight1+ajaxSearch_highlight2 

5. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 

6. Bromberg JE, Augustson EM, Backinger CL. Portrayal of smokeless tobacco in YouTube 

videos. Nicotine & Tobacco Research. 2012 Apr;14(4):455–62. 

7. Ribisl KM, Lee RE, Henriksen L, Haladjian HH. A content analysis of Web sites promoting 

smoking culture and lifestyle. Health Education & Behavior. 2003;30(1):64–78. 

8. Freeman B. New media and tobacco control. Tobacco Control. 2012;21(2):139–44. 

9. Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic 

review. Nicotine & Tobacco Research. 2009;11(1):25–35. doi:10.1093/ntr/ntn003 

10. Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on 

impulse purchase. Addiction. 2007;103(2):322–8. 

11. Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and tobacco point of sale 

advertising: a potential barrier to smoking cessation. Tobacco Control. 2013 Nov;22(6):376– 

81. doi:10.1136/tobaccocontrol-2012-050427 

12. Germain D, McCarthy M, Wakefield M. Smoker sensitivity to retail tobacco displays and 

quitting: a cohort study. Addiction. 2010;105(1):159–63. doi: 10.1111/j.1360­

0443.2009.02714.x 

13. Hyland A, Laux FL, Higbee C, Hastings G, Ross H, Chaloupka FJ, et al. Cigarette purchase 

patterns in four countries and the relationship with cessation: findings from the International 

Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15(Suppl III):iii59–64. 

doi:10.1136/tc.2005.012203 

14. Choi K, Hennrikus DJ, Forster JL, Moilanen M. Receipt and redemption of cigarette 

coupons, perceptions of cigarette companies and smoking cessation. Tobacco Control. 2013 

Nov;22(6):418–22. doi:10.1136/tobaccocontrol-2012-050539 

15. White VM, White MM, Freeman K, Gilpin EA, Pierce JP. Cigarette promotional offers: who 

takes advantage? American Journal of Preventive Medicine. 2006 Mar;30(3):225–31. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

101 
 

 

 

GOAL AREA 3 

► Outcome 5 

16. Centers for Disease Control and Prevention. Smoking in top-grossing movies—United 

States, 2010. Morbidity and Mortality Weekly Report. 2011;60(27):910–3. 

17. Jamieson PE, Romer D. Portrayal of tobacco use in prime-time TV dramas: trends and 

associations with adult cigarette consumption—USA, 1955–2010. Tobacco Control. 2014 

Apr 3 [Epub ahead of print]. doi:10.1136/tobaccocontrol-2012-050896 

18. Rees VW, Kreslake JM, Cummings KM, O’Connor RJ, Hatsukami DK, Parascandola M, et 

al. Assessing consumer responses to PREPs: a review of tobacco industry and independent 

research methods. Cancer Epidemiology, Biomarkers and Prevention. 2009 

December;18(12):3225–40. doi:10.1158/1055-9965.EPI-09-0946 

19. Parascandola M, Hurd AL, Augustson E. Consumer awareness and attitudes related to new 

potential reduced-exposure tobacco products. American Journal of Health Behavior. 2008 

Jul-Aug;32(4):431–7. 

20. McMillen R, Maduka J, Winickoff J. Use of emerging tobacco products in the United States. 

Journal of Environmental and Public Health. 2012;989474. doi:10.1155/2012/989474 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

102 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 5 

Outcome 5

Reduced Tobacco Industry Influence 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.5.a Extent and type of retail tobacco 

advertising 

$$$ 

3.5.b Extent and type of consumerfocused industry promotions 

† $$$ 

3.5.c Extent and type of retailer-focused 

industry promotions 

$$$ 

3.5.d Extent of tobacco imagery in 

movies and television 

† $$ 

3.5.e Extent of pro-tobacco Internet 

presence 

† $$$$ 

3.5.f Proportion of tobacco users 

reporting exposure to marketing 

and promotions for tobacco 

products (environmental cues) 

† $ 

3.5.g Proportion of tobacco users who 

report unplanned purchases of 

tobacco products 

† $$$ 

3.5.h Proportion of tobacco users who 

are aware of emerging tobacco 

products 

† $ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

† Denotes low agreement among reviewers, defined as less than 75% of valid ratings within ±1 point of the median 

for this indicator-specific criterion. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

103 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

GOAL AREA 3 

► Outcome 5 

Indicator 3.5.a 

Extent and Type of Retail Tobacco Advertising
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure Amount and type of tobacco advertising in and around retail outlets, including proximity 

of tobacco advertising to cessation products 

Why this indicator is	 Research demonstrates a causal relationship between exposure to retail tobacco 

useful	 advertising and tobacco initiation.1-4 Less is known about the impact of retail tobacco 

advertising on tobacco cessation, although one study suggests that residential proximity 

to tobacco retailers is associated with decreased long-term abstinence from tobacco 

products.5 Given that tobacco retailer concentration (and the accompanying tobacco 

advertising) is higher in lower socioeconomic neighborhoods and in neighborhoods with 

a higher proportion of African Americans,6,7 it will be important to consider whether 

lower rates of quitting success among these groups are associated with increased 

exposure to retail tobacco advertising. 

Example data Observation of tobacco advertising in retail outlets:8 Standardized Tobacco Assessment 

source(s) for Retail Settings (STARS) 

Information available at: http://www.sctcresearch.org
 

New York State’s Retail Advertising Tobacco Survey (RATS)
 

Information available at: http://www.health.ny.gov/prevention/tobacco_control/
 

docs/tobacco_marketing_exposure_rpt.pdf
 

CounterTobacco 

http://www.countertobacco.org 

Population group(s) Not applicable. This indicator is best measured by observation. 

Example survey Not applicable 

question(s) 

Comments	 The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) 

gave the Food and Drug Administration the authority to regulate the manufacturing, 

marketing, and sale of tobacco products and allow states and localities to restrict or 

regulate the time, place, and manner (but not the content) of cigarette advertising or 

promotions. 

Findings from this data have utility for monitoring compliance with existing laws or 

informing new policy; therefore, evaluators may choose to gather and report findings by 

type of retailer (e.g., grocery store, convenience store, gas station), by neighborhood 

characteristics (e.g., population density, median household income), and by affected 

population demographics. 

State-specific lists of licensed tobacco retailers will inform sampling strategies.9 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted

Utility practice 

$$$
 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

104 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 5 

References 

1.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

2.	 Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal study of exposure to retail cigarette 

advertising and smoking initiation. Pediatrics. 2010 Aug;126(2):232–8. 

3.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

4.	 Pierce JP. Tobacco industry marketing, population-based tobacco control and smoking behavior. American 

Journal of Preventive Medicine. 2007;33(6 Suppl):S327–34. 

5.	 Reitzel LR, Cromley EK, Li Y, Cao Y, Dela Mater R, Mazas CA, et al. The effect of tobacco outlet density and 

proximity on smoking cessation. American Journal of Public Health. 2011;101(2):315–20. 

doi:10.2105/AJPH.2010.191676 

6.	 Chuang YC, Cubbin C, Ahn D, Winkleby MA. Effects of neighbourhood socioeconomic status and 

convenience store concentration on individual level smoking. Journal of Epidemiology and Community Health. 

2005;59(7):568–73. doi:10.1136/jech.2004.029041 

7.	 Feighery EC, Schleicher NC, Boley Cruz T, Unger JB. An examination of trends in amount and type of 

cigarette advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008 

Apr;17(2):93–8. doi:10.1136/tc.2007.022046 

8.	 Lee JG, Henriksen L, Myers AE, Dauphinee AL, Ribisl KM. A systematic review of store audit methods for 

assessing tobacco marketing and products at the point of sale. Tobacco Control. 2014;23(2):98–106. 

doi:10.1136/tobaccocontrol-2012-050807 

9.	 Henriksen L. Monitoring retail tobacco marketing. Available at: 

http://www.ttac.org/resources/pdfs/092111_Monitoring_Impact_Netconference-handout.pdf. Accessed June 2, 

2014. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

105 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 better

GOAL AREA 3 

► Outcome 5 

Indicator 3.5.b 

Extent and Type of Consumer-Focused Industry Promotions
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

low high 

† 

Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$
 

Outcome 5 Reduced tobacco industry influence 

What to measure Level and type of consumer-focused tobacco industry promotions, such as discounts, 

rebates, coupons, and buy-one-get-one-free offers 

Why this indicator is Greater exposure to cigarette promotions and lower tobacco prices are associated with 

useful decreased quit attempts among current smokers.1-4 

Example data Observation of tobacco advertising in retail outlets: Standardized Tobacco Assessment 

source(s) for Retail Settings (STARS) 

Information available at: http://www.sctcresearch.org
 

New York State’s Retail Advertising Tobacco Survey (RATS)
 

Information available at: http://www.health.ny.gov/prevention/tobacco_control/
 

docs/tobacco_marketing_exposure_rpt.pdf
 

Scanner data 

Population group(s) Not applicable. This indicator is best measured by observation. 

Example survey Not applicable 

question(s) 

Comments	 Retail scanner data are generally only available for designated market areas that may not 

correspond with state borders. Additionally, scanner data can be costly to obtain and 

complex to analyze. 

States may also use retail observation to capture price information with the benefits of 

flexibility in obtaining unique promotional data (e.g., advertised discounts); specific 

price-promotional strategies; and compliance with certain policies, such as minimum 

price law. Additionally, evaluators may adjust the sampling frame and link observational 

data to census tract or other ecological data depending on study needs; however, it can 

be costly to collect observational data, difficult to ensure validity and reliability, and 

challenging to develop and test new valid and reliable measures. Suggested variables for 

retail observation include 

•	 tobacco product promotions (discounts, rebates, coupons, buy one get one free, 

bundles, gifts with purchase), 

•	 average number of tobacco promotions, and 

•	 percentage of tobacco retailers with promotions. 

Rating 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

106 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 5 

References 

1.	 Hyland A, Laux FL, Higbee C, Hastings G, Ross H, Chaloupka FJ, et al. Cigarette purchase patterns in four 

countries and the relationship with cessation: findings from the International Tobacco Control (ITC) Four 

Country Survey. Tobacco Control. 2006;15(Suppl III):iii59–64. doi:10.1136/tc.2005.012203 

2.	 Choi K, Hennrikus DJ, Forster JL, Moilanen M. Receipt and redemption of cigarette coupons, perceptions of 

cigarette companies and smoking cessation. Tobacco Control. 2013;22(6):418–22. doi:10.1136/tobaccocontrol2012-050539 

3.	 White VM, White MM, Freeman K, Gilpin EA, Pierce JP. (2006). Cigarette promotional offers: who takes 

advantage? American Journal of Preventive Medicine. 2006 Mar;30(3):225–31. 

4.	 Tauras JA, Peck RM, Chaloupka FJ. The role of retail prices and promotions in determining cigarette brand 

market shares. Review of Industrial Organization. 2006;28(3):253–84. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

107 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

GOAL AREA 3 

► Outcome 5 

Indicator 3.5.c 

Extent and Type of Retailer-Focused Industry Promotions
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure	 Level and type of retailer-focused tobacco industry promotions. These promotions 

include those where tobacco manufacturers provide retail and/or wholesale discounts on 

tobacco products or payments in return for prime advertising space. Retailer-focused 

promotions may include allowances paid to retailers, slotting fees, price discounts, and 

buy-downs paid to retailers rather than directly to consumers. 

Why this indicator is	 Since the 1998 Master Settlement Agreement, tobacco manufacturers have increasingly 

useful	 focused marketing resources on price promotions.1 In 2011, $9.2 billion was spent on 

cigarette advertising and promotions, with approximately $7.8 billion of these 

expenditures directed at price discounts paid to cigarette retailers or wholesalers to 

reduce the price of cigarettes.2 The tobacco industry uses merchant-directed industry 

promotions to counteract the impact of advertising restrictions.3 Retailers that participate 

in tobacco company incentive programs have more prominent placement of cigarettes 

and advertising.4 These price promotions may be contributing to tobacco-related 

disparities as research shows that price-related promotions are accelerating 

disproportionately among retailers in neighborhoods with lower socioeconomic status 

and higher proportions of racial and ethnic populations experiencing health disparities.5 

Studies demonstrate that point of sale exposure to products in the retail setting 

undermines quit attempts.6-9 

Example data 

source(s) 

Tobacco industry document reviews (e.g., Legacy Tobacco Documents Library) 

Information available at: http://legacy.library.ucsf.edu/ 

Retail observation 

Interviews with retailers 

Population group(s) Tobacco retailers 

Example survey 

question(s) 

Not applicable 

Comments	 There is little evidence linking retailer promotions to cessation or relapse. The majority 

of current evidence demonstrates that retailers with industry contracts for product 

placement have more consumer-focused promotions and tobacco displays, which has 

been shown to impact consumer behavior. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources

needed 

Face 

validity 

Accepted 

Utility practice 

$$$
 

References 

1.	 Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8. 

doi:10.1136/tc.2007.022046 

2.	 Federal Trade Commission. Cigarette report for 20121. Washington, DC: Federal Trade Commission; 2015. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

108 Tobacco Control Programs—2015
 
 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 5 

3.	 Lavack AM, Toth G. Tobacco point-of-purchase promotion: examining tobacco industry documents. Tobacco 

Control. 2006;15(5):377–84. 

4.	 Feighery EC, Ribisl KM, Schleicher NC, Clark PI. Retailer participation in cigarette company incentive 

programs is related to increased levels of cigarette advertising and cheaper cigarette prices in stores. Preventive 

Medicine. 2004;38(6):876–84. 

5.	 Bloom PN. Role of slotting fees and trade promotions in shaping how tobacco is marketed in retail stores. 

Tobacco Control. 2001 Dec;10(4):340–4. 

6.	 Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine & 

Tobacco Research. 2009;11(1):25–35. doi:10.1093/ntr/ntn003 

7.	 Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on impulse purchase. 

Addiction. 2007;103(2):322–8. 

8.	 Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and tobacco point of sale advertising: a 

potential barrier to smoking cessation. Tobacco Control. 2013 Nov;22(6):376–81. doi:10.1136/tobaccocontrol2012-050427 

9.	 Germain D, McCarthy M, Wakefield M. Smoker sensitivity to retail tobacco displays and quitting: a cohort 

study. Addiction. 2010;105(1):159–63. doi: 10.1111/j.1360-0443.2009.02714.x 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

109 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

† 

 better

GOAL AREA 3 

► Outcome 5 

Indicator 3.5.d 

Extent of Tobacco Imagery in Movies and Television
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure Proportion of movies that show tobacco use and/or tobacco products 

Why this indicator is	 Smoking in movies is a form of indirect marketing that normalizes tobacco use.1,2 

useful	 Studies have shown that portrayal of smoking in the movies or on television can elicit 

cravings for tobacco.3-7 Although the literature on the impact of smoking in movies and 

on television on cessation is more limited than evidence related to initiation, exposure to 

smoking cues has predicted increased craving and hindering the quitting process.3-7 

Although the Master Settlement Agreement (MSA) in 1998 prohibited paid placement 

of tobacco products in movies, the number of tobacco incidents in movies peaked in 

2005.2 By 2009, the number of incidents had been reduced by approximately half, the 

first time a decline of that magnitude and duration has been observed.2 

Example data Scene Smoking, “Thumbs Up! Thumbs Down!” sponsored by Breathe California of 

source(s) Sacramento-Emigrant Trails 

Information available at: http://www.scenesmoking.org/movie-search 

Population group(s) Not applicable. This indicator is best measured by observation. 

Example survey Not applicable 

question(s) 

Comments	 The extent of tobacco imagery in movies can be measured using a number of methods. 

The 2012 Surgeon General’s report describes several possible methods, including using 

content analysis to capture the prevalence of smoking in movies. Multiple variables may 

be measured, including type of movie in which tobacco appears (i.e., youth-rated 

movies), tobacco portrayal (characters using products vs. tobacco imagery), positive or 

negative framing of tobacco, and number of appearances of tobacco.8 

Assessing exposure to tobacco in movies and on television is challenging.9,10 Commonly 

used methods include using general self-reported exposure items, asking respondents to 

list their favorite actors and actresses and then linking this information with content 

analyses for pertinent movies, and asking respondents to identify movies that they have 

seen among a lengthy list of movies.8 Each of these methods raises the potential for bias. 

Given the complexity and cost of assessing exposure to tobacco in movies and on 

television, evaluators should consider methods most appropriate for their needs. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

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References 

1.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

2.	 Centers for Disease Control and Prevention. Smoking in top grossing movies—United States, 1991–2009. 

Morbidity and Mortality Weekly Report. 2010;59(32):1014–7. 

3.	 Sargent JD, Morgenstern M, Isensee B, Hanewinkel R. Movie smoking and urge to smoke among adult 

smokers. Nicotine & Tobacco Research. 2009 Sep;11(9):1042–6. doi:10.1093/ntr/ntp097 

4.	 Carter BL, Tiffany ST. Meta-analysis of cue-reactivity in addiction research. Addiction. 1999;94:327–40. 

5.	 Garcia-Rodriguez O, Pericot-Valverde I, Gutierrez-Maldonado J, Ferrer-Garcia M, Secades-Villa R. Validation 

of smoking-related virtual environments for cue exposure therapy. Addictive Behaviors. 2012;37(6):703–8. 

doi:10.1016/j.addbeh.2012.02.013 

6.	 Bradley BP, Mogg K, Wright T, Field M. Attentional bias in drug dependence: vigilance for cigarette-related 

cues in smokers. Psychology of Addictive Behaviors. 2003;17(1):66–72. 

7.	 Versace F, Robinson JD, Lam CY, Minnix JA, Brown VL, Carter BL, et al. Cigarette cues capture smokers’ 

attention: evidence from event-related potentials. Psychophysiology. 2010;47(3):435–41. 

8.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

9.	 Cruz TB. Monitoring the tobacco use epidemic IV. The vector: tobacco industry data sources and 

recommendations for research and evaluation. Preventive Medicine. 2009;48(1 Suppl):S24–34. 

10. Jamieson PE, Romer D. Portrayal of tobacco use in prime-time TV dramas: trends and associations with adult 

cigarette consumption—USA, 1955–2010. Tobacco Control. 2014 Apr 3 [Epub ahead of print]. 

doi:10.1136/tobaccocontrol-2012-050896 

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GOAL AREA 3 

► Outcome 5 

Indicator 3.5.e 

Extent of Pro-tobacco Internet Presence
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure Amount and type of pro-tobacco presence online, including corporate and brand Web 

sites, advertising, and social media. Content could include industry- and non-industry– 

sponsored Web sites or advertisements, pro-tobacco user-generated content, and retail 

Web sites that sell cigarettes online. 

Why this indicator is 

useful 

The tobacco industry is using a “360-degree” strategy that encompasses multiple forms 

of media to market its products.1 Although tobacco companies do not report 

expenditures for advertising their products online via banner advertisements or through 

social media marketing, these companies do maintain interactive Web sites.2-4 In 

addition, consumer-generated content on social media and tobacco sales Web sites has 

the potential to promote tobacco use indirectly.5-7 Understanding the extent of tobacco 

advertising in media will help to monitor the impact of regulations and provide 

additional information regarding the ways the tobacco industry targets populations at 

risk for health disparities. 

Example data 

source(s) 

Environmental scan of Internet search queries and social media Web sites for industry 

presence and pro-tobacco content; monitoring and content analysis of brand and 

corporate Web sites for messaging 

Internet search query and social media monitoring tools can be used for surveillance. To 

examine audience engagement with pro-tobacco content online, metrics for tobaccorelated posts on social media sites—such as the number of “likes” on Facebook, amount 

and type of Internet search queries, video views on YouTube, and followers on 

Twitter—are publicly available. Social media monitoring software (e.g., Radian6, 

Attensity, Buzzmetrics) summarizes trends in social media conversations and online 

earned media (e.g., blog posts) using keywords to monitor product and Web site 

mentions. 

Population group(s) Not applicable. This indicator is best measured by observation. 

Example survey 

question(s) 

Not applicable 

Comments Although Internet search query surveillance tools are readily available,1 social media 

monitoring programs are often proprietary and can be quite costly. The 2012 Surgeon 

General’s report concludes that the sheer number of Web pages that mention tobacco 

makes it very difficult to track comprehensively, and verifying that a Web site has been 

established by tobacco companies is extremely difficult.1 

Given the complexity and cost of assessing the amount and type of pro-tobacco presence 

online, evaluators should consider if and how this information may best be collected to 

meet program planning and evaluation needs. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$$
 

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References 

1.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

2.	 Federal Trade Commission. Cigarette report for 2007 and 2008. Washington, DC: Federal Trade Commission; 

2011. 

3.	 Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade Commission; 2013. 

4.	 Wackowski OA, Lewis MJ, Delnevo CD. Qualitative analysis of Camel Snus’ website message board—users’ 

product perceptions, insights and online interactions. Tobacco Control. 2011 Mar;20(2):e1. 

5.	 Bromberg JE, Augustson EM, Backinger CL. Portrayal of smokeless tobacco in YouTube videos. Nicotine & 

Tobacco Research. 2012 Apr;14(4):455–62. 

6.	 Ribisl KM, Lee RE, Henriksen L, Haladjian HH. A content analysis of Web sites promoting smoking culture 

and lifestyle. Health Education & Behavior. 2003;30(1):64–78. 

7.	 Freeman B. New media and tobacco control. Tobacco Control. 2012;21(2):139–44. 

8.	 Ayers JW, Ribisl K, Brownstein JS. Using search query surveillance to monitor tax avoidance and smoking 

cessation following the United States’ 2009 “SCHIP” cigarette tax increase. PLoS One. 2011;6(3):e16777. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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Indicator 3.5.f 

Proportion of Tobacco Users Reporting Exposure to Marketing and 

Promotions for Tobacco Products (Environmental Cues) 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure	 Proportion of tobacco users who report seeing tobacco advertisements or other protobacco content at the point of sale, in the media, in movies or on television, in e-mail, 

and on the Internet 

Why this indicator is	 The tobacco industry is using a “360-degree” strategy that encompasses multiple forms 

useful	 of media to market its products.1 Reducing exposure to tobacco advertising, promotions, 

and sponsorship may help decrease tobacco cravings, decrease unplanned tobacco 

purchases, and increase successful quit attempts.2-11 

Example data International Tobacco Control Policy Evaluation Study (ITC), 2008 

source(s)	 Information available at: http://www.itcproject.org/surveys 

National Youth Tobacco Survey (NYTS), 2011 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

Population group(s) All tobacco users 

Example survey 

question(s) 

From ITC 

In the last 6 months, have you noticed ... E-mail messages promoting cigarettes or 

tobacco products? 

• Yes 

• No 

• DON’T KNOW 

• NOT APPLICABLE 

• REFUSED 

• I never look at them 

In the last 6 months, have you noticed ... Internet sites promoting cigarettes or tobacco 

products? 

• Yes 

• No 

• DON’T KNOW 

• NOT APPLICABLE 

• REFUSED 

• I never look at them 

From NYTS 

When you go to a convenience store, supermarket, or gas station, how often do you see 

ads or promotions for cigarettes and other tobacco products? 

• Never 

• Rarely 

• Sometimes 

• Most of the time 

• Always 

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GOAL AREA 3 

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• I never go to a convenience store, supermarket, or gas station 

When you are using the Internet, how often do you see ads for tobacco products? 

•	 Never 

•	 Rarely 

•	 Sometimes 

•	 Most of the time 

•	 Always 

•	 I do not use the Internet 

When you read newspapers or magazines, how often do you see ads or promotions for 

cigarettes and other tobacco products? 

•	 Never 

•	 Rarely 

•	 Sometimes 

•	 Most of the time 

•	 Always 

•	 I do not read newspapers or magazine 

When you watch TV or go to the movies, how often do you see actors and actresses 

using cigarettes or other tobacco products? 

•	 Never 

•	 Rarely 

•	 Sometimes 

•	 Most of the time 

•	 Always 

•	 I do not watch TV or go to the movies 

Comments	 Evaluators may want to capture information from both current and former tobacco users. 

Additionally, experts have voiced concerns about self-report measures, in part, because 

individuals most receptive to tobacco marketing and promotions are most likely to 

report seeing them. Methods for decreasing this type of error would be to sample both 

tobacco and non-tobacco users and complement the information with more objective 

measures, such as retail observations. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

2.	 Centers for Disease Control and Prevention. Adult awareness of tobacco advertising, promotion, and 

sponsorship—14 countries. Morbidity and Mortality Weekly Report. 2012 May 25;61(20):365–9. 

3.	 Emery S, Kim Y, Choi YK, Szczypka G, Wakefield M, Chaloupka FJ. The effects of smoking-related television 

advertising on smoking and intentions to quit among adults in the United States: 1999–2007. American Journal 

of Public Health. 2012 Apr;102(4):751–7. 

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4.	 Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine & 

Tobacco Research. 2009;11(1):25–35. doi:10.1093/ntr/ntn003 

5.	 Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and tobacco point of sale advertising: a 

potential barrier to smoking cessation. Tobacco Control. 2013 Nov;22(6):376–81. doi:10.1136/tobaccocontrol2012-050427 

6.	 Germain D, McCarthy M, Wakefield M. Smoker sensitivity to retail tobacco displays and quitting: a cohort 

study. Addiction. 2010;105(1):159–63. doi: 10.1111/j.1360-0443.2009.02714.x 

7.	 Carter OBJ, Mills BW, Donovan RJ. The effect of retail cigarette pack displays on unplanned purchases: results 

from immediate postpurchase interviews. Tobacco Control. 2009;18(3):218–21. doi:10.1136/tc.2008.027870 

8.	 Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on impulse purchase. 

Addiction. 2007;103(2):322–8. 

9.	 Burton S, Clark L, Jackson K. The association between seeing retail displays of tobacco and tobacco smoking 

and purchase: findings from a diary‐style survey. Addiction. 2012;107(1):169–75. doi:10.1111/j.1360‐

0443.2011.03584.x 

10. Kim AE, Nonnemaker JM, Loomis BR, Shafer PR, Shaikh A, Hill E, et al. Influence of point-of-sale tobacco 

displays and graphic health warning signs on adults: evidence from a virtual store experimental study. American 

Journal of Public Health. 2014 May;104(5):888–95. 

11. Halonen JI, Kivimäki M, Kouvonen A, Pentti J, Kawachi I, Subramanian SV, et al. Proximity to a tobacco store 

and smoking cessation: a cohort study. Tobacco Control. 2014 Mar;23(2):146–51. 

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GOAL AREA 3 

► Outcome 5 

Indicator 3.5.g 

Proportion of Tobacco Users Who Report Unplanned Purchases of

Tobacco Products 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure Proportion of tobacco users who report an unplanned purchase of a tobacco product in 

the retail setting 

Why this indicator is 

useful 

Retail tobacco advertising, including cigarette displays, elicits emotional and physical 

reactions in current and former tobacco users that increase unplanned tobacco purchases 

and make successfully quitting tobacco harder.1-5 

Example data 

source(s) 

Population Assessment of Tobacco and Health (PATH), Baseline—Adult extended 

Interview, 2012 

Information available at: https://pathstudyinfo.nih.gov/UI/FAQsResMobile.aspx 

Population group(s) All tobacco users 

Example survey 

question(s) 

From PATH 

Since you quit using tobacco, has there been a time when seeing a tobacco product 

display or other signs that tobacco is sold there has given you an urge to buy tobacco? 

• Yes 

• No 

• DON’T KNOW 

• REFUSED 

Modified from Clattenburg et al.2

: 

Before you arrived at the store, did you plan on purchasing cigarettes? 

• Yes 

• No 

What if anything in this store prompted you to buy cigarettes? 

• Lower price 

• Special promotion/coupon 

• Tobacco advertising or display at the store 

• Other 

Comments	 Evaluators may want to capture information on impulse purchases made by former 

tobacco users as well as purchases made outside of the retail setting, such as online 

purchases triggered by electronic marketing. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$$
 

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GOAL AREA 3 

► Outcome 5 

References 

1.	 Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine & 

Tobacco Research. 2009;11(1):25–35. doi:10.1093/ntr/ntn003 

2.	 Clattenburg EJ, Elf JL, Apelberg BJ. Unplanned cigarette purchases and tobacco point of sale advertising: a 

potential barrier to smoking cessation. Tobacco Control. 2013 Nov;22(6):376–38. doi:10.1136/tobaccocontrol2012-050427 

3.	 Carter OBJ, Mills BW, Donovan RJ. The effect of retail cigarette pack displays on unplanned purchases: results 

from immediate postpurchase interviews. Tobacco Control. 2009;18(3):218–21. doi:10.1136/tc.2008.027870 

4.	 Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on impulse purchase. 

Addiction. 2007;103(2):322–8. 

5.	 Hoek J, Gifford H, Pirikahu G, Thomson G, Edwards R. How do tobacco retail displays affect cessation 

attempts? Findings from a qualitative study. Tobacco Control. 2010;19(4):334–7. doi:10.1136/tc.2009.03120 

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► Outcome 5 

Indicator 3.5.h 

Proportion of Tobacco Users Who Are Aware of Emerging Tobacco 

Products 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 5 Reduced tobacco industry influence 

What to measure	 Proportion of tobacco users who report being aware of emerging nicotine-containing 

products (e.g., dissolvable tobacco products, snus, electronic nicotine delivery systems 

such as e-cigarettes) 

Why this indicator is The tobacco industry examines and exploits consumer risk perceptions, responses to 

useful	 tobacco products, and product acceptability when marketing emerging tobacco 

products.1 Implied or suggested health benefits increase use among consumers with a 

concern about personal health, thereby encouraging maintained nicotine dependence 

rather than cessation.2,3 Awareness of emerging tobacco products is associated with 

increased use of these products among current smokers and should be monitored to track 

the impact of tobacco industry influence on cessation.4-6 

Example data International Tobacco Control Policy Evaluation Study (ITC), 2011 

source(s)	 Information available at: http://www.itcproject.org/surveys 

National Adult Tobacco Survey (NATS), 2013–2014 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/0 

National Youth Tobacco Survey (NYTS), 2013 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

HealthStyles Survey (2012) 

Information available at: 

http://www.cdc.gov/breastfeeding/data/healthstyles_survey/survey_2012.htm 

Population group(s) All tobacco users 

Example survey 

question(s) 

From ITC 

Have you ever heard of electronic cigarettes or e-cigarettes? 

• Yes 

• No 

• Not applicable 

• REFUSED 

• DON’T KNOW 

From NATS 

Have you ever heard of snus, such as Camel Snus or Marlboro Snus? Snus is a moist, 

smokeless tobacco usually sold in individual or pre-packaged small pouches that are 

placed under the lip against the gum. 

• Yes 

• No 

• DON’T KNOW 

• REFUSED 

Have you ever heard of a dissolvable tobacco product? Some examples of these product 

names are Ariva, Stonewall, Camel orbs, Camel sticks, or Camel strips. These products 

contain finely ground tobacco that are placed in the mouth or on the tongue and readily 

dissolve. 

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•	 Yes 

•	 No 

•	 DON’T KNOW 

• REFUSED 

Before today, had you ever heard of electronic cigarettes or e-cigarettes? 

•	 Yes 

•	 No 

•	 DON’T KNOW 

•	 REFUSED 

From NYTS 

Which of the following tobacco products have you ever heard of? 

•	 Roll-your-own cigarettes 

•	 Flavored cigarettes, such as Camel Crush 

•	 Bidis (small brown cigarettes wrapped in a leaf) 

•	 Clove cigars (kreteks) 

•	 Flavored little cigars (such as mint, clove, spice, alcohol (wine, cognac), candy, 

fruit, chocolate, or other sweets) 

•	 Smoking tobacco from a hookah or a waterpipe 

•	 Snus, such as Camel or Marlboro Snus 

•	 Dissolvable tobacco products, such as Ariva, Stonewall, Camel orbs, Camel 

sticks, or Camel strips 

•	 Electronic Cigarettes or E-cigarettes, such as Ruyan or NJOY 

•	 Some other new tobacco products not listed her 

•	 I have never heard of any of the products listed above or any new tobacco 

product 

From HealthStyles 

Which, if any, of the following products have you heard of? 

•	 Snus, such as Camel or Marlboro snus 

•	 Dissolvable tobacco products like Ariva, Stonewall, Camel orbs, Camel sticks, 

or Camel strips 

•	 Electronic cigarettes or E-cigarettes, such as Ruyan or NJOY 

•	 Flavored little cigars 

•	 Water pipes, also known as hookahs 

•	 Flavored cigarettes like Camel Crush 

•	 None of these 

Comments	 Emerging tobacco products are initially test marketed in specific geographic areas prior 

to broader distribution. The nonmenclature of emerging products changes rapidly. 

Evaluators may want to use information from rapid monitoring systems, such as the 

Tobacco Surveillance, Epidemiology and Evaluation (TSEEN) “New Product Watch,” 

to inform development of survey items. Where possible, evaluators can ask about 

specific brands or products entering the market. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

120 Tobacco Control Programs—2015 
 

low high 

†

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 5 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Rees VW, Kreslake JM, Cummings KM, O’Connor RJ, Hatsukami DK, Parascandola M, et al. Assessing 

consumer responses to PREPs: a review of tobacco industry and independent research methods. Cancer 

Epidemiology, Biomarkers and Prevention. 2009 December;18(12):3225–40. doi:10.1158/1055-9965.EPI-09­

0946 

2.	 Parascandola M, Hurd AL, Augustson E. Consumer awareness and attitudes related to new potential reducedexposure tobacco products. American Journal of Health Behavior. 2008 Jul-Aug;32(4):431–7. 

3.	 McMillen R, Maduka J, Winickoff J. Use of emerging tobacco products in the United States. Journal of 

Environmental and Public Health. 2012;989474. doi:10.1155/2012/989474 

4.	 Regan AK, Dube SR, Arrazola R. Smokeless and flavored tobacco products in the U.S.: 2009 Styles survey 

results. American Journal of Preventive Medicine. 2012;42(1):29–36. doi: 10.1016/j.amepre.2011.08.019 

5.	 Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. E-cigarette awareness, use, and harm 

perceptions in U.S. adults. American Journal of Public Health. 2012;102(9):1758–66. 

doi:10.2105/AJPH/2011.300526 

6.	 King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among 

U.S. adults, 2010–2011. Nicotine & Tobacco Research. 2013 Sep;15(9):1623–7. doi:10.1093/ntr/ntt013 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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GOAL AREA 3 

► Outcome 6 

Outcome 6 

Increased Quit Attempts and Attempts Using Evidence-Based Cessation 

Services 

Accelerating tobacco cessation rates has immediate population benefits, including decreased 

smoking-attributable deaths and increased health care savings.1 Attempting to quit is an essential 

step in the process of becoming tobacco-free.2 Stopping tobacco use entirely is often preceded by 

several quit attempts; increased numbers of quit attempts are associated with increased cessation 

and reduced overall smoking prevalence.3-5 

Although some smokers can quit without help, the probability of a quit attempt leading to 

sustained abstinence is increased by using evidence-based behavioral and pharmaceutical 

interventions.2 Two-thirds to three-quarters of smokers who try to quit do not use any evidencebased cessation counseling or medications, treatments that can substantially improve the odds of 

successfully quitting.6,7 Utilization of these treatments is particularly low among young adults,8 

individuals with low socioeconomic/education status, and those from racial and ethnic minority 

groups.2,7,9 Reducing barriers to accessing evidence-based cessation treatments, including 

language and cost barriers, could be expected to increase quit attempts using effective 

treatments, especially among populations with limited access to care.10,11 As new tobacco 

products enter the market, it is important to monitor whether tobacco users are quitting altogether 

or substituting one type of product for another. 

The following indicators are associated with this outcome: 

► 3.6.a Proportion of tobacco users who have made a quit attempt 

►	 3.6.b Proportion of tobacco users who have made a quit attempt using evidence-based 

strategies 

► 3.6.c	 Proportion of tobacco users who have used individual or group cessation counseling 

► 3.6.d	 Number of callers to telephone quitlines receiving assistance quitting tobacco 

►	 3.6.e Proportion of tobacco users who have used mobile telephone-based cessation services 

(other than quitline services) 

►	 3.6.f Proportion of tobacco users who have made a quit attempt by switching to a different 

tobacco product 

References 

1. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, 

DC: National Academies Press; 2007. 

2. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco 

use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; May 2008. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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► Outcome 6 

3. U.S. Department of Health and Human Services. The health consequences of smoking—50 

years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, Coordinating Center for 

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

Office on Smoking and Health; 2014. 

4. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 

5. Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit 

smoking and relapse: factors associated with success or failure from the ATTEMPT cohort 

study. Addictive Behaviors. 2009 Apr;34(4):365–73. doi:10.1016/j.addbeh.2008.11.013 

6. Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 

2001–2010. Morbidity and Mortality Weekly Report. 2011;60(44):1513–9. 

7. Shiffman S, Brockwell SE, Pillitteri JL, Gitchell JG. Use of smoking-cessation treatments in 

the United States. American Journal of Preventive Medicine 2008;34(2):102–11. 

doi:10.1016/j.amepre.2007.09.033 

8. Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic disparities in the 

use of nicotine replacement therapy for smoking cessation in an equal access health care 

system. American Journal of Health Promotion. 2005;20(2):108–16. 

9. Curry SJ, Sporer AK, Pugach O, Campbell RT, Emery S. Use of tobacco cessation 

treatments among young adult smokers: 2005 National Health Interview Survey. American 

Journal of Public Health. 2007;97(8):1464–9. 

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

control programs—2014. Atlanta, GA: U.S. Department of Health and Human Services, 

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

and Health Promotion, Office on Smoking and Health; 2014. 

11. Centers for Disease Control and Prevention. Quitting smoking among adults — United 

States, 2001–2010. Morbidity and Mortality Weekly Report. 2011;60(44):1513–9. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

123 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 6 

Outcome 6

Increased Quit Attempts and Attempts Using Evidence-Based Cessation 

Services 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.6.a Proportion of tobacco users who 

have made a quit attempt 

$ 

3.6.b Proportion of tobacco users who 

have made a quit attempt using 

evidence-based strategies 

$ 

3.6.c Proportion of tobacco users who 

have used individual or group 

cessation counseling 

$ 

3.6.d Number of callers to telephone 

quitlines receiving assistance 

quitting tobacco 

$ 

3.6.e NR Proportion of tobacco users who 

have used mobile telephone-based 

cessation services (other than 

quitline services) 

     

3.6.f Proportion of tobacco users who 

have made a quit attempt by 

switching to a different tobacco 

product 

† $ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

†	 Denotes low agreement among reviewers, defined as less than 75% of valid ratings within ±1 point of the median 

for this indicator-specific criterion. 

 Denotes no rating information. 

NR Denotes an indicator that is not rated (see Appendix C for an explanation). 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 6 

Indicator 3.6.a 

Proportion of Tobacco Users Who Have Made a Quit Attempt
 

KOI 2005 3.11.1, 3.11.2 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 6 Increased quit attempts and attempts using evidence-based cessation services 

What to measure Proportion of tobacco users who have stopped using tobacco for more than 1 day during 

the previous 12 months in an attempt to quit 

Why this indicator is	 Attempting to quit is an essential step in the process of becoming tobacco-free.1 

useful	 Stopping tobacco use entirely is often preceded by several quit attempts, with recent 

attempts strongly predicting future attempts.1-3 When considering population quit rates, 

it is necessary to understand both the number of quit attempts (includes the number of 

tobacco users who try to quit and the number of times they make a quit attempt) and the 

odds that tobacco users who try to quit will succeed in doing so.4,5 Evidence 

demonstrates variation in quit attempt rates by age, race/ethnicity, education level, 

socioeconomic status, and level of nicotine addiction.1-6 

Example data National Adult Tobacco Survey (NATS), 2013–2014 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Health Interview Survey (NHIS), 2014 

Information available at: http://www.cdc.gov/nchs/nhis.htm 

National Youth Tobacco Survey (NYTS), 2014Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

Population group(s) Current tobacco users and past-year smokers 

Example survey 

question(s) 

From NATS 

During the past 12 months, did you stop using all kinds of tobacco products for more 

than one day because you were trying to quit using tobacco? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

From NHIS 

During the past 12 months, have you stopped using ALL KINDS of tobacco products for 

more than one day because you were trying to quit using tobacco? 

“All kinds” means trying to quit using tobacco completely, including smoking 

cigarettes, smoking products other than cigarettes, and using smokeless tobacco 

products. 

• Yes 

• No 

• REFUSED 

• DON’T KNOW 

From NYTS 

During the past 12 months, how many times did you stop smoking for one day or longer 

because you were trying to quit smoking cigarettes for good? 

• I did not smoke during the past 12 months 

• I did not try to quit during the past 12 months 

• 1 time 

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GOAL AREA 3 

► Outcome 6 

•	 2 times 

•	 3 to 5 times 

•	 6 to 9 times 

• 10 or more times 

During the past 12 months, how many times have you stopped using all tobacco 

products for one day or longer because you were trying to quit all tobacco products for 

good? 

•	 I did not use tobacco products during the past 12 months 

•	 I did not try to quit during the past 12 months 

•	 1 time 

•	 2 times 

•	 3 to 5 times 

•	 6 to 9 times 

•	 10 or more times 

Comments	 Evaluators can ask about attempting to quit smoking cigarettes, attempting to quit other 

tobacco products, or attempting to quit all tobacco products. 

Related Healthy People 2020 Objectives: TU-4 Increase smoking cessation attempts by 

adult smokers and TU-7 Increase smoking cessation attempts by adolescent smokers. 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

3.	 Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: 

factors associated with success or failure from the ATTEMPT cohort study. Addictive Behaviors. 2009 

Apr;34(4):365–73. doi:10.1016/j.addbeh.2008.11.013 

4.	 Zhu SH, Lee M, Zhuang YL, Gamst A, Wolfson T. Interventions to increase smoking cessation at the 

population level: how much progress has been made in the last two decades? Tobacco Control. 2012;21:110–8. 

doi:10.1136/tobaccocontrol-2011-050371 

5.	 Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs— 

2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2014. 

6.	 Kahende JW, Malarcher AM, Teplinskaya A, Asman KJ. Quit attempt correlates among smokers by 

race/ethnicity. International Journal of Environmental Research and Public Health. 2011;8(10):3871–88. 

doi:10.3390/ijerph8103871 

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► Outcome 6 

7.	 Reid JL, Hammond D, Boudreau C, Fong GT, Siahpush M. Socioeconomic disparities in quit intentions, quit 

attempts, and smoking abstinence among smokers in four western countries: findings from the International 

Tobacco Control Four Country Survey. Nicotine & Tobacco Research. 2010;12(Suppl 1):S20–33. 

doi:10.1093/ntr/ntq051 

8.	 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001–2010. 

Morbidity and Mortality Weekly Report. 2011;60(44):1513–9. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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► Outcome 6 

Indicator 3.6.b 

Proportion of Tobacco Users Who Have Made a Quit Attempt Using 

Evidence-Based Strategies 

KOI 2005 3.11.3 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 6 Increased quit attempts and attempts using evidence-based cessation services 

What to measure	 Proportion of tobacco users who have stopped using tobacco for more than 1 day during 

the previous 12 months and used an evidence-based method for their most recent quit 

attempt. Examples of evidence-based cessation strategies include Food and Drug 

Administration (FDA)-approved pharmacotherapies, in-person individual counseling, 

counseling from telephone quitlines, mobile telephone-based cessation services, and 

stop-smoking classes. 

Why this indicator is	 Tobacco dependence is a chronic disease.1 Effective evidence-based treatments exist 

useful	 that significantly increase successful quit attempts and long-term abstinence rates across 

a broad range of populations.1-3 Randomized controlled trials demonstrate that 

pharmacotherapy and behavioral treatments improve cessation rates.4-7 Unfortunately, 

evidence-based tobacco cessation treatments are underused, especially among certain 

population groups, including young adults,8 individuals with low 

socioeconomic/education status, and racial and ethnic minority groups.1,4,8-11 

Example data National Adult Tobacco Survey (NATS), 2009-2010 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Youth Tobacco Survey (NYTS), 2013Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011 

Information available at: http://appliedresearch.cancer.gov/tus-cps/info.html 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

During the past 12 months, that is, since [DATE FILL], how many times have you 

stopped smoking for one day or longer because you were trying to quit smoking 

cigarettes for good? 

• Number of times 

• None 

• DON’T KNOW/NOT SURE 

• REFUSED 

[The last time you tried to quit smoking] Did you call a telephone quitline to help you 

quit? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

[The last time you tried to quit smoking] Did you use a class or program to help you 

quit? 

• Yes 

• No 

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GOAL AREA 3 

► Outcome 6 

• DON’T KNOW/NOT SURE 

• REFUSED 

[The last time you tried to quit smoking] Did you use one-on-one counseling from a 

health professional to help you quit? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Did you use any of the following medications: a nicotine patch, nicotine gum, nicotine 

lozenges, nicotine nasal spray, a nicotine inhaler, or pills such as Wellbutrin®, Zyban®, 

bupropion, Chantix®, or varenicline to help you quit? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

From NYTS 

During the past 12 months, did you do any of the following to help you quit using 

tobacco of any kind for good? (You can CHOOSE ONE ANSWER or MORE THAN 

ONE ANSWER) 

• I did not use tobacco of any kind during the past 12 months 

• I did not try to quit during the past 12 months 

• Attended a program in my school 

• Attended a program in the community 

• Called a telephone help line or telephone quit line 

• Used nicotine gum 

• Used nicotine patch 

• Used any medicine to help quit 

• Visited an Internet quit site 

• Used another method, such as hypnosis or acupuncture [not evidence-based] 

• Tried to quit on my own or quit “cold turkey” [not evidence-based] 

From TUS-CPS 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the past 12 

months—Did you use ANY of the following PRODUCTS: 

• A nicotine patch 

• A nicotine gum or nicotine lozenge 

• A nicotine nasal spray or nicotine inhaler 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the past 12 

months—Did you use ANY of the following PRODUCTS: 

• A prescription pill, called Chantix® or varenicline ? 

• A prescription pill, called Zyban®, bupropion, or Wellbutrin®? 

• Another prescription pill 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the past 12 

months. Did you use ANY of the following: 

• A telephone help line or quit line 

• One-on-one counseling 

• A stop smoking clinic, class, or support group 

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GOAL AREA 3 

► Outcome 6 

•	 Help or support from friends or family 

•	 Internet or web-based program 

•	 Books, pamphlets, videos, or other materials [not evidence-based] 

•	 Acupuncture or hypnosis [non-evidence-based] 

Comments	 The majority of tobacco users who successfully quit do so unaided.11 Although research 

on non-evidence-based strategies, such as acupuncture, hypnosis, and aversive smoking, 

have been mixed or inconclusive,12-15 capturing information on their use may help 

inform the provision of future cessation services and messaging. 

The proportion of tobacco users who have made a quit attempt and stopped using 

tobacco products for at least 1 day during the previous 12 months using a non-evidencebased cessation method, such as hypnosis, could be determined either by including nonevidence-based methods in the survey response options or by subtracting the number of 

smokers who said they used evidence-based methods from the total number of smokers 

who made quit attempts. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

3.	 Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs— 

2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2014. 

4.	 Shiffman S, Brockwell SE, Pillitteri JL, Gitchell JG. Use of smoking-cessation treatments in the United States. 

American Journal of Preventive Medicine. 2008;34(2):102–11. doi:10.1016/j.amepre.2007.09.033 

5.	 Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. 

Cochrane Database of Systematic Reviews. 2012;(10):CD008286. doi:10.1002/14651858.CD008286.pub2 

6.	 Kasza KA, Hyland, AJ, Borland R, McNeill AD, Bansal-Travers M, Fix BV, et al. Effectiveness of stopsmoking medications: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction. 

2013;108(1):193–202. 

7.	 Lai DTC, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database of 

Systematic Reviews. 2010;(1):CD006936. doi:10.1002/14651858.CD006936.pub2 

8.	 Curry SJ, Sporer AK, Pugach O, Campbell RT, Emery S. Use of tobacco cessation treatments among young 

adult smokers: 2005 National Health Interview Survey. American Journal of Public Health. 2007;97(8):1464–9. 

9.	 Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic disparities in the use of nicotine 

replacement therapy for smoking cessation in an equal access health care system. American Journal of Health 

Promotion. 2005;20(2):108–16. 

10. Milton MH, Maule CO, Yee SL, Backinger C, Malarcher AM, Husten CG. Youth tobacco cessation: a guide for 

making informed decisions. Atlanta, GA: Centers for Disease Control and Prevention; 2004. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 6 

11. Chapman S, MacKenzie R. The global research neglect of unassisted smoking cessation: causes and 

consequences. PLoS Medicine. 2010;7(2):e1000216. 

12. White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related therapies do not appear to help 

smokers who are trying to quit. Cochrane Database of Systematic Reviews. 2011;(1):CD000009. 

doi:10.1002/14651858.CD000009.pub3 

13. Barnes J, Dong CY, McRobbie H, Walker N, Mehta M, Stead LF. Does hypnotherapy help people who are 

trying to stop smoking. Cochrane Database of Systematic Reviews. 2010;(10):CD001008. doi: 

10.1002/14651858.CD001008.pub2. 

14. Hajek P, Stead LF. Aversive smoking for smoking cessation. Cochrane Database of Systematic Reviews. 

2001;(3):CD000546. doi:10.1002/14651858.CD000546.pub2 

15. Lindson-Hawley N, Aveyard P, Hughes JR. Reduction versus abrupt cessation in smokers who want to quit. 

Cochrane Database of Systematic Reviews. 2012;(11):CD008033. doi:10.1002/14651858.CD008033.pub3 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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GOAL AREA 3 

► Outcome 6 

Indicator 3.6.c 

Proportion of Tobacco Users Who Have Used Individual or Group 

Cessation Counseling 

KOI 2005 3.7.4 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 6 Increased quit attempts and attempts using evidence-based cessation services 

What to measure	 Proportion of tobacco users who have stopped using tobacco for more than 1 day during 

the previous 12 months and report using individual and/or group cessation counseling 

for their most recent quit attempt 

Why this indicator is	 Individual and group cessation counseling have been shown to increase tobacco 

useful	 abstinence rates across a broad range of populations.1-3 Unfortunately, evidence-based 

tobacco cessation treatments are underused, especially among certain population groups, 

including young adults,4 individuals with low socioeconomic/education status, and racial 

and ethnic minority groups.1,4,5 

Example data National Adult Tobacco Survey (NATS), 2009-2010 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

The Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011 

Information available at: http://appliedresearch.cancer.gov/tus-cps/info.html 

Pregnancy Risk Assessment Monitoring System (PRAMS), 2012, Standard 

QuestionsInformation available at: http://www.cdc.gov/prams/index.htm 

Population group(s) All tobacco users 

Example survey 

question(s) 

From NATS 

[The last time you tried to quit smoking] Did you use one-on-one counseling from a 

health professional to help you quit? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

From TUS-CPS 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the past 12 

months. Did you use ANY of the following: 

• One-on-one counseling 

• A stop smoking clinic, class, or support group 

From PRAMS 

During your most recent pregnancy, did you— 

• Attend a class or program to stop smoking 

• Go to counseling for help with quitting 

Comments Evaluators may want to analyze the use of individual and/or group counseling by current 

tobacco use status and by type and amount of individual and group counseling provided. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

132 Tobacco Control Programs—2015 
 

low high 

 better

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 6 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

2.	 Stead LF, Lancaster T. Do group-based smoking cessation programmes help people to stop smoking. Cochrane 

Database of Systematic Reviews. 2005;2:CD001007. doi:10.1002/14651858.CD001007.pub2 

3.	 Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of 

Systematic Reviews. 2005;2:CD001292 http://summaries.cochrane.org/CD001292/does-individually-deliveredcounselling-help-people-to-stop-smoking. doi:10.1002/14651858.CD001292.pub2 

4.	 Curry SJ, Sporer AK, Pugach O, Campbell RT, Emery S. Use of tobacco cessation treatments among young 

adult smokers: 2005 National Health Interview Survey. American Journal of Public Health. 2007;97(8):1464–9. 

5.	 Shiffman S, Brockwell SE, Pillitteri JL, Gitchell JG. Use of smoking-cessation treatments in the United States. 

American Journal of Preventive Medicine. 2008;34(2):102–11. doi:10.1016/j.amepre.2007.09.033 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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low high 

 better

GOAL AREA 3 

► Outcome 6 

Indicator 3.6.d 

Number of Callers to Telephone Quitlines Receiving Assistance Quitting 

Tobacco 

KOI 2005 3.7.1 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 6 Increased quit attempts and attempts using evidence-based cessation services 

What to measure	 The number of unique callers, calling for themselves, who received a quitline service for 

the first time during a particular quarter. Services include (1) counseling, (2) medication, 

(3) counseling and medication, and (4) self-help materials only. 

Why this indicator is Telephone quitlines are an important tool for linking tobacco users with cessation 

useful services.1,2 They have been shown to significantly increase both quitting and abstinence 

rates, with increasing number of calls leading to increased odds of quitting.1,3 

Example data National Quitline Data Warehouse (NQDW), Quitline Services Survey, 2011 

source(s)	 Information available at: http://www.naquitline.org/?page=NatDataWarehouse 

CDC State Tobacco Activities Tracking and Evaluation (STATE) system—Quitline— 

Services received 

Information available at: http://www.cdc.gov/statesystem/ 

Population group(s) Quitline service providers 

Example survey 

question(s) 

From NQDW, Quitline Services Questionnaire 

How many TOBACCO USERS who called or were referred to the quitline received the 

services listed below? 

• Self-help materials only with no counseling 

• Counseling provided (began at least one session) 

– Phone 

– Face-to-face, Individual/Group 

– Web 

– Other mechanism 

• Medication provided through the quitline 

Comments	 Evaluators may also want to collect information about the proportion of tobacco users in 

the state who have received counseling from the quitline.
 

Multiple types of information (e.g., caller demographics and location, call variability by
 

month and time of day, client satisfaction with quitline services) can be tracked through
 

quitline monitoring.
 

Coordinating multiple cessation services is an important way of increasing the use of
 

these services.4 Implementing referral linkages between health care providers and
 

telephone quitlines via a fax referral system, for example, has been shown to be a 

feasible, cost-effective way to increase the provision of cessation assistance and increase 

success in quitting.5-8
 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$ 

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GOAL AREA 3 

► Outcome 6 

References 

1.	 Stead LF, Perera R, Lancaster T. Telephone counseling for smoking cessation. Cochrane Database of 

Systematic Reviews. 2006;(9):CD002850. 

2.	 Borland R, Segan CJ. The potential of quitlines to increase smoking cessation. Drug and Alcohol Review. 

2006;25(1):73–8. 

3.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

4.	 Shelley D, Cantrell J. The effect of linking community health centers to a state-level smoker’s quitline on rates 

of cessation assistance. BMC Health Services Research. 2010;10:25. doi:10.1186/1472-6963-10–25 

5.	 Bentz CJ, Bayley KB, Bonin KE, Fleming L, Hollis JF, McAfee T. The feasibility of connecting physician 

offices to a state-level tobacco quit line. American Journal of Preventive Medicine. 2006;30(1):31–7. 

6.	 Warner DD, Land TG, Rodgers AB, Keithly L. Integrating tobacco cessation quitlines into health care: 

Massachusetts, 2002–2011. Preventing Chronic Disease. 2012;9:110343. 

doi:http://dx.doi.org/10.5888/pcd9.110343 

7.	 Borland R, Balmford J, Bishop N, Segan C, Piterman L, McKay-Brown L, et al. In-practice management versus 

quitline referral for enhancing smoking cessation in general practice: a cluster randomized trial. Family 

Practice. 2008;25(5):382–9. doi:10.1093/fampra/cmn046 

8.	 North American Quitline Consortium. NAQC Issue Paper: Increasing reach of tobacco cessation quitlines. 

2009. Available at: 

http://c.ymcdn.com/sites/www.naquitline.org/resource/resmgr/issue_papers/naqc_issuepaper_increasingre.pdf 

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low high 

     

 better

GOAL AREA 3 

► Outcome 6 

Indicator 3.6.e 

Proportion of Tobacco Users Who Have Used Mobile Telephone-Based 

Cessation Services (Other Than Quitline Services) 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 6 Increased quit attempts and attempts using evidence-based cessation services 

What to measure Proportion of tobacco users who have stopped using tobacco for more than one day 

during the previous 12 months and report using mobile telephone-based cessation 

services that include interactive features to deliver evidence-based information, 

strategies, and behavioral support directly to tobacco users interested in quitting. 

Why this indicator is 

useful 

Mobile telephone-based cessation services have been shown to significantly increase 

tobacco abstinence rates.1,2 

Example data 

source(s) 

Modified Question from the Tobacco Use Supplement to the Current Population Survey 

(TUS-CPS), 2010–2011 

Information available at: http://appliedresearch.cancer.gov/tus-cps/ 

Population group(s) All tobacco users 

Example survey 

question(s) From TUS-CPS 

Thinking back to the (LAST TIME/time) you tried to QUIT smoking in the past 12
 

months:
 

Did you use ANY of the following: 

(1) Yes 

(2) No 

• A telephone help line or quit line 

• One-on-one counseling 

• A stop smoking clinic, class, or support group 

• Help or support from friends or family 

• Internet or Web-based program 

• Cell phone-based program 

• Books, pamphlets, videos, or other materials 

• Acupuncture or hypnosis 

Comments	 Evaluators may want to analyze the use of mobile telephone-based cessation services by 

current tobacco use status and by type and amount of services received. For example, 

evaluators could capture whether message content was developed or adapted for specific 

populations and communities and/or whether the mobile telephone-based intervention 

was coordinated with additional interventions, such as Internet-based cessation services 

or provision of medications. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 6 

References 

1.	 The Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: mobile 

phone-based cessation interventions (abbreviated). Available at: 

www.thecommunityguide.org/tobacco/mobilephone.html. Last updated: December 9, 2013. 

2.	 Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for 

smoking cessation. Cochrane Database of Systematic Reviews. 2012 Nov 14;11:CD006611. 

doi:10.1002/14651858.CD006611.pub3 

3.	 Whittaker R, Borland R, Bullen C, Lin RB, McRobbie H, Rodgers A. Mobile phone-based interventions for 

smoking cessation. Cochrane Database of Systematic Reviews. 2009;(4):CD006611. 

doi:10.1002/14651858.CD006611.pub2 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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► Outcome 6 

Indicator 3.6.f 

Proportion of Tobacco Users Who Have Made a Quit Attempt by Switching 

to a Different Tobacco Product 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 6 Increased quit attempts and attempts using evidence-based cessation services 

What to measure Proportion of tobacco users who have stopped using their usual tobacco product for 

more than 1 day during the previous 12 months by switching to a different tobacco 

product. See “Comments” for additional clarification. 

Why this indicator is 

useful 

State actions such as increasing excise tax on certain tobacco products may prompt 

tobacco users to switch to other types of tobacco products.1,2 Investigating the 

relationship between product switching and quitting, particularly as new products enter 

the market, is important for understanding potential barriers to cessation and informing 

tobacco control policy. Current evidence from U.S. studies demonstrates that using 

products perceived as “less harmful” is not an effective cessation strategy and may lead 

to ongoing or increased use of cigarettes and other nicotine containing products.2-6 

Example data 

source(s) 

Population Assessment of Tobacco and Health (PATH) Baseline—Adult Extended 

Interview 

Information available at: https://pathstudyinfo.nih.gov/UI/FAQsResMobile.aspx 

The Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011 

Information available at: http://appliedresearch.cancer.gov/tus-cps/info.html 

Population group(s) All tobacco users 

Example survey 

question(s) 

From PATH 

Thinking back to the last time you tried to quit in the past 12 months, did you use: any 

different tobacco product, such as smokeless tobacco, snus, dissolvable tobacco, or ecigarettes to help you quit? Choose all that apply. 

• Cigarettes 

• E-cigarettes 

• Traditional cigars 

• Cigarillos 

• Filtered cigars 

• Pipe tobacco 

• Hookah 

• Snus pouches 

• Smokeless tobacco, like dip, chew, or snuff 

• Dissolvable tobacco 

• DON’T KNOW 

• REFUSED 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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†

 better

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 6 

[Do | Did] you use [e-cigarettes, cigars, pipes, hookah, smokeless tobacco, dissolvable 

tobacco] as a way of cutting down on your cigarette smoking? 

•	 Yes 

•	 No 

•	 DON’T KNOW 

•	 REFUSED 

[Do | Did] you use [e-cigarettes, cigars, pipes, hookah, smokeless tobacco, dissolvable 

tobacco] as an alternative to quitting tobacco altogether? 

•	 Yes 

•	 No 

•	 DON’T KNOW 

•	 REFUSED 

From TUS-CPS 

The (LAST TIME / time) you tried to QUIT smoking in the past 12 months: Did you do 

ANY of the following: 

•	 Try to quit by GRADUALLY cutting back on cigarettes? 

•	 Try to quit by SWITCHING to smokeless tobacco such as chewing tobacco, 

snuff, or snus? 

•	 Try to quit by SWITCHING to regular cigars, cigarillos, little filtered cigars, or 

pipes filled with tobacco? 

•	 Did you SWITCH to a “lighter” cigarette in order to TRY TO QUIT? 

•	 Did you SWITCH to menthol cigarettes in order to TRY TO QUIT? 

•	 Did you switch to non-menthol cigarettes in order to TRY TO QUIT? 

Comments	 Tobacco users may report switching to one or more different tobacco products in an 

attempt to quit. These different products may include emerging tobacco products, such 

as dissolvable tobacco products, snus, and electronic nicotine delivery systems such as 

e-cigarettes. Use of approved nicotine replacement therapies is not considered switching 

to a different tobacco product. Therefore, nicotine replacement therapies should not be 

included as a response option for survey questions measuring this indicator. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Huang, Taurus, Chaloupka. The impact of price and tobacco control policies on the demand for electronic 

nicotine delivery systems. Tobacco Control; forthcoming. 

2.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

3.	 U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and 

behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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GOAL AREA 3 

► Outcome 6 

4.	 Tomar SL, Fox BJ, Severson HH. Is smokeless tobacco use an appropriate public health strategy for reducing 

societal harm from cigarette smoking? International Journal of Environmental Research and Public Health. 

2009;6:10–24. doi:10.3390/ijerph6010010 

5.	 Zhu SH, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson JT, et al. Quitting cigarettes completely or 

switching to smokeless tobacco: do US data replicate the Swedish results? Tobacco Control. 2009;18(2):82–7. 

doi:10.1136/tc.2008.028209 

6.	 Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the 

missing link between youth prevention and adult cessation. Journal of Environmental and Public Health. 

2012;2012:1–9. doi:10.1155/2012/679134 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 7 

Outcome 7 

Increased Cessation of All Tobacco Products as Early in Life as Possible 

The risk and severity of tobacco-related morbidities are directly related to the duration and level 

of exposure to tobacco products.1-3 The earlier in life an individual successfully quits using 

tobacco products, the lower their likelihood of suffering tobacco-related disease.3

 Although 

quitting smoking at any age is beneficial, smokers who quit by the time they are 35 to 44 years of 

age avoid most of the risk of dying from a smoking-related disease.4 

The burden of death and disease from tobacco use in the United States is overwhelmingly caused 

by cigarettes and other combusted tobacco products.5 Long-term use of non-combustible tobacco 

products, such as smokeless tobacco, is also associated with increased individual and populationlevel risks.5, 6 These include direct health risks, such as increased oral, esophageal, and 

pancreatic cancers among smokeless tobacco users. Indirect risks from electronic nicotine 

delivery systems (e.g., electronic cigarettes, electronic hookah, and vape pens) also exist, such as 

the renormalization of public use of nicotine and sustained dual use of other tobacco products 

and cigarettes.5 Overall public health is harmed when the use of other tobacco products delays 

cessation among persons who would otherwise quit using tobacco altogether.2 

The following indicators are associated with this outcome: 

►	 3.7.a Proportion of former tobacco users with recent cessation success 

►	 3.7.b Proportion of tobacco users who have sustained abstinence from tobacco use 

►	 3.7.c Average age at which tobacco users successfully quit 

►	 3.7.d Proportion of former tobacco users who re-initiate regular tobacco use 

References 

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 

2. U.S. Department of Health and Human Services. How tobacco smoke causes disease: the 

biology and behavioral basis for smoking-attributable disease: a report of the Surgeon 

General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease 

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

Promotion, Office on Smoking and Health; 2010. 

3. U.S. Department of Health and Human Services. The health consequences of smoking: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human 

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

Prevention and Health Promotion, Office on Smoking and Health; 2004. 

4. Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, et al. 21stcentury hazards of smoking and benefits of cessation in the United States. New England 

Journal of Medicine. 2013;368(4):341–50. doi:10.1056/NEJMsa1211128 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

141 
 

 

GOAL AREA 3 

► Outcome 7 

5. U.S. Department of Health and Human Services. The health consequences of smoking—50 

years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, Coordinating Center for 

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

Office on Smoking and Health; 2014. 

6. National Cancer Institute and Centers for Disease Control and Prevention. Smokeless tobacco 

and public health: A global perspective. Bethesda, MD: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention and National Institutes of 

Health, National Cancer Institute. NIH Publication No. 14-7983; 2014. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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► Outcome 7 

Outcome 7 

Increased Cessation of All Tobacco Products as Early in Life as Possible 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.7.a Proportion of former tobacco users 

with recent cessation success 

$ 

3.7.b Proportion of tobacco users who 

have sustained abstinence from 

tobacco use 

$ 

3.7.c Average age at which tobacco users 

successfully quit 

$ 

3.7.d Proportion of former tobacco users 

who re-initiate regular tobacco use 

$ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

143 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 7 

Indicator 3.7.a 

Proportion of Former Tobacco Users with Recent Cessation Success
 

KOI 2005 3.13.2 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 7 Increased cessation of all tobacco products as early in life as possible 

What to measure Proportion of former tobacco users who last used tobacco 6 months to 1 year ago 

Why this indicator is It is important to measure the proportion of recent successful quit attempts to document 

useful progress toward increased permanent tobacco cessation.1 Many smokers make repeated 

quit attempts before achieving permanent cessation.2 

Example data Behavioral Risk Factor Surveillance System (BRFSS): Core Module, 2014Information 

source(s) available at: http://www.cdc.gov/brfss/ 

National Adult Tobacco Survey (NATS), 2013–2014 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Youth Tobacco Survey (NYTS), 2011
 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/
 

Population group(s) Former tobacco users 

Example survey 

question(s) 

From BRFSS and NATS 

Have you smoked at least 100 cigarettes in your entire life?μ 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you now smoke cigarettes every day, some days, or not at all? μ 

• Everyday 

• Some days 

• Not at all 

• REFUSED 

From NATS 

How long has it been since you completely stopped smoking cigarettes? 

• Day(s) 

• Week(s) 

• Month(s) 

• Year(s) 

• Date 

• Today 

• DON’T KNOW/NOT SURE 

• REFUSED 

Have you completely quit using all types of tobacco products, including cigarettes, 

smokeless tobacco, e-cigarettes, cigars, and pipes? 

• Yes 

• No 

• DON’T KNOW 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 7 

•	 REFUSED 

From NYTS 

About how many cigarettes have you smoked in your entire life? μ 

•	 I have never smoked cigarettes, not even one or two puffs 

•	 1 or more puffs but never a whole cigarette 

•	 1 cigarette 

•	 2 to 5 cigarettes 

•	 6 to 15 cigarettes (about 1/2 a pack total) 

•	 16 to 25 cigarettes (about 1 pack total) 

•	 26 to 99 cigarettes (more than 1 pack, but less than 5 packs) 

•	 100 or more cigarettes (5 or more packs) 

When you last tried to quit for good, how long did you stay off cigarettes? (PLEASE 

CHOOSE THE FIRST ANSWER THAT FITS) 

•	 I have never smoked cigarettes 

•	 I have never tried to quit 

•	 Less than a day 

•	 1 to 7 days 

•	 More than 7 days but less than 30 days 

•	 More than 30 days but less than 6 months 

•	 More than 6 months but less than 1 year 

•	 1 year or more 

μ Items used to determine smoking status 

Comments	 Evaluators may also want to report the percentage of ever smokers that have quit. This 

percentage is calculated by dividing the number of former smokers by the number of 

ever smokers. 

Related Healthy People 2020 Objective: TU-5 Increase recent smoking cessation 

success by adult smokers 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

Overall quality 

$
 

References 

1.	 Healthy People 2020. Tobacco use. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/ 

overview.aspx?topicid=41 

2.	 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001–2010. 

Morbidity and Mortality Weekly Report. 2011;44;1513–9. 

3.	 Lee C, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. American 

Journal of Public Health. 2007;97:1503–9. doi: 10.2105/AJPH.2005.083527 

4.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

145 
GOAL AREA 3 
 

► Outcome 7
 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

146 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 7 

Indicator 3.7.b 

Proportion of Tobacco Users Who Have Sustained Abstinence from 

Tobacco Use 

Indicator 3.7.b 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 7 Increased cessation of all tobacco products as early in life as possible 

What to measure Proportion of former tobacco users who have sustained abstinence from tobacco use for 

6 months or longer 

Why this indicator is	 Estimates suggest that about 50% of current smokers have made a quit attempt in the 

useful	 past year.1 However, only 5% sustain abstinence longer than a few weeks.2 Increasing 

recent smoking cessation success by adult smokers is a Healthy People 2020 objective.3 

The longer a person has gone without using a tobacco product, the more likely they are 

to remain abstinent.2 

Example data Behavioral Risk Factor Surveillance System (BRFSS): Core Module, 2014 

source(s)	 Information available at: http://www.cdc.gov/brfss/ 

National Health Interview Survey (NHIS): Adult Survey, 2014 

Information available at: http://www.cdc.gov/nchs/nhis.htm 

National Adult Tobacco Survey (NATS), 2013–2014
 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/
 

National Youth Tobacco Survey (NYTS), 2011
 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/
 

Population group(s) Former tobacco users 

Example survey 

question(s) 

From BRFSS 

How long has it been since you last smoked a cigarette, even one or two puffs? 

• Within the past month (less than 1 month ago) 

• Within the past 3 months (1 month but less than 3 months ago) 

• Within the past 6 months (3 months but less than 6 months ago) 

• Within the past year (6 months but less than 1 year ago) 

• Within the past 5 years (1 year but less than 5 years ago) 

• Within the past 10 years (5 years but less than 10 years ago) 

• 10 years or more 

• DON’T KNOW/NOT SURE 

• REFUSED 

From NHIS 

Have you smoked at least 100 cigarettes in your ENTIRE LIFE? μ 

• Yes 

• No 

• REFUSED 

• DON’T KNOW 

Do you NOW smoke cigarettes every day, some days, or not at all? μ 

• Every day 

• Some days 

• Not at all 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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GOAL AREA 3 

► Outcome 7 

• REFUSED 

• DON’T KNOW 

How long has it been since you quit smoking cigarettes? ______ 

From NATS 

How long has it been since you completely stopped smoking cigarettes? 

• Day(s) 

• Week(s) 

• Month(s) 

• Year(s) 

• Date 

• Today 

• DON’T KNOW/NOT SURE 

• REFUSED 

Have you completely quit using all types of tobacco products, including cigarettes, 

smokeless tobacco, e-cigarettes, cigars, and pipes? 

• Yes 

• No 

• DON’T KNOW 

• REFUSED 

From NYTS 

When was the last time you smoked a cigarette, even one or two puffs? (PLEASE 

CHOOSE THE FIRST ANSWER THAT FITS) 

• I have never smoked even one or two puffs 

• Earlier today 

• Not today but sometime during the past 7 days 

• Not during the past 7 days but sometime during the past 30 days 

• Not during the past 30 days but sometime during the past 6 months 

• Not during the past 6 months but sometime during the past year 

• 1 to 4 years ago 

• 5 or more years ago 

When you last tried to quit for good, how long did you stay off cigarettes? (PLEASE 

CHOOSE THE FIRST ANSWER THAT FITS) 

• I have never smoked cigarettes 

• I have never tried to quit 

• Less than a day 

• 1 to 7 days 

• More than 7 days but less than 30 days 

• More than 30 days but less than 6 months 

• More than 6 months but less than 1 year 

• 1 year or more 

μ Items used to determine smoking status 

Comments Evaluators could modify the example questions to measure sustained abstinence from all 

tobacco products and ask current smokers about their last quit attempt or longest quit 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

148 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

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GOAL AREA 3 

► Outcome 7 

attempt, since an increase in the duration of a quit attempt (even if the smoker begins 

smoking again) could indicate progress toward cessation. 

“Former smokers” can be derived by combining the variable of lifetime smoking (≥ 100

cigarettes) and current cigarette smoking (smoked zero cigarettes during the past 30 

days). See resources listed under “Further Reading” below for additional information 

regarding measurement. 

Related Healthy People 2020 Objective: TU-5.1 Increase recent smoking cessation 

success by adult smokers. 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001–2010. 

Morbidity and Mortality Weekly Report. 2011 Nov 11;60(44):1513–9. 

2.	 Hughes JR, Carpenter MJ, Naud S. Do point prevalence and prolonged abstinence measures produce similar 

results in smoking cessation studies? A systematic review. Nicotine & Tobacco Research. 2010 Jul;12(7):756– 

62. doi:10.1093/ntr/ntq078. 

3.	 Healthy People 2020. Tobacco use. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/ 

overview.aspx?topicid=41 

For Further Reading 

Hughes JR, Keely JP, Niaura RS, Ossip-Klein DJ, Richmond RL, Swan GE. Measures of abstinence in clinical 

trials: issues and recommendations. Nicotine & Tobacco Research. 2003;5(1):13–25. Erratum in: Nicotine & 

Tobacco Research. 2003;5(4):603. 

Kirchner TR, Shiffman S, Wileyto EP. Relapse dynamics during smoking cessation: Recurrent abstinence violation 

effects and lapse-relapse progression. Journal of Abnormal Psychology. 2012;121(1):187–97. doi:10.1037/a0024451 

Lee C, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. American 

Journal of Public Health. 2007;97:1503–9. doi: 10.2105/AJPH.2005.083527 

Messer K, Trinidad DR, Al-Delaimy WK, Pierce JP. Smoking cessation rates in the United States: a comparison of 

young adult and older smokers. American Journal of Public Health. 2008;98:317–22. 

doi:10.2105/AJPH.2007.112060 

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GOAL AREA 3 

► Outcome 7 

Indicator 3.7.c 

Average Age at Which Tobacco Users Successfully Quit
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 7 Increased cessation of all tobacco products as early in life as possible 

What to measure	 Average age at which former tobacco users successfully quit using tobacco products. 

“Successfully quit” is defined as sustained abstinence from tobacco use for 6 months or 

longer. 

Why this indicator is The risk and severity of tobacco-related morbidities are directly related to the duration 

useful	 and level of exposure to tobacco products.1-6 The earlier in life an individual 

successfully quits using tobacco products, the lower their likelihood of suffering a 

tobacco-related disease.3-7 

Example data National Adult Tobacco Survey (NATS), 2013–2014 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Health Interview Survey (NHIS), 2014 

Information available at: http://www.cdc.gov/nchs/nhis.htm 

Population Assessment of Tobacco and Health (PATH) Study, Individual Screener and 

Adult Extended Interview 

Information available at: https://pathstudyinfo.nih.gov/UI/FAQsResMobile.aspx 

Population group(s) Former tobacco users 

Example survey 

question(s) 

From NATS 

What is your age? 

___ Age in years 

• DON’T KNOW/NOT SURE 

• REFUSED 

About how long has it been since you completely quit using tobacco? 

• Date: 

• Today: 

• DON’T KNOW/NOT SURE 

• REFUSED 

From NHIS 

How old are you? 

• Age in years 

• REFUSED 

• DON’T KNOW 

How long has it been since you quit smoking cigarettes? 

• Day(s) 

• Week(s) 

• Month(s) 

• Year(s) 

• REFUSED 

• DON’T KNOW 

From PATH 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 7 

What is your date of birth? 

•	 MM/DD/YYYY 

•	 DON’T KNOW 

• REFUSED 

About how long has it been since you completely quit smoking cigarettes? 

•	 I___I___I DAYS 

•	 I___I___I MONTHS 

•	 I___I___I YEARS 

•	 DON’T KNOW 

•	 REFUSED 

About how long has it been since you last used [e-cigarette, cigar, pipe filled with 

tobacco, hookah, smokeless tobacco, dissolvable tobacco]? 

•	 I___I___I DAYS 

•	 I___I___I MONTHS 

•	 I___I___I YEARS 

•	 DON’T KNOW 

•	 REFUSED 

Comments Evaluators could also modify the example questions to measure sustained abstinence 

from all tobacco products.
 

Please note that measurable change to this indicator could take significant time to
 

achieve, making proximal measures more appropriate for short-term evaluation of
 

programmatic efforts.
 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and 

behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

2.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

3.	 U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon 

General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

Health; 2004. 

4.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

5.	 Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male 

British doctors. BMJ. 2004 Jun 26;328(7455):1519. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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► Outcome 7 

6.	 Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, et al. 21st-century hazards of 

smoking and benefits of cessation in the United States. New England Journal of Medicine. 2013 Jan 

24;368(4):341–50. doi: 10.1056/NEJMsa1211128 

7.	 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001–2010. 

Morbidity and Mortality Weekly Report 2011a;60(44):1513–9. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

152 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 7 

Indicator 3.7.d 

Proportion of Former Tobacco Users Who Re-Initiate Regular Tobacco Use 

KOI 2005	 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 7 Increased cessation of all tobacco products as early in life as possible 

What to measure Proportion of former tobacco users who re-initiate everyday or someday tobacco use 

after a sustained abstinence of 6 months or longer 

Why this indicator is	 The majority of tobacco users who make a quit attempt relapse within the first 8 days.1 

useful	 Estimates of sustained abstinence (longer than 6 months) vary by cessation intervention, 

product type, and level of use2 but have been found to be approximately 3% to 5% for 

daily smokers who have made unaided quit attempts.1,3 Capturing information about 

former tobacco users who re-initiate tobacco use is critical for guiding future cessation 

work.4 

Example data National Health Interview Survey (NHIS), 2012 

source(s) Information available at: 

http://www.cdc.gov/nchs/nhis/tobacco/tobacco_questions.htm#questions 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011 

Information available at: http://appliedresearch.cancer.gov/tus-cps/info.html 

Population Assessment of Tobacco and Health (PATH) Study, Individual Screener and 

Adult Extended Interview 

Information available at: https://pathstudyinfo.nih.gov/UI/FAQsResMobile.aspx 

Population group(s) Former tobacco users 

Example survey 

question(s) 

From NHIS 

How long has it been since you quit smoking cigarettes? 

Enter time period for time since quit smoking. 

• Day(s) 

• Week(s) 

• Month(s) 

• Year(s) 

• REFUSED 

• DON’T KNOW 

Do you NOW smoke cigarettes every day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• REFUSED 

• DON’T KNOW 

Do you NOW smoke tobacco products other than cigarettes every day, some days, 

rarely, or not at all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

153 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 7 

• REFUSED 

• DON’T KNOW 

Do you NOW use smokeless tobacco products every day, some days, rarely, or not at 

all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• REFUSED 

• DON’T KNOW 

From TUS-CPS 

During the PAST 12 MONTHS, what is the [LENGTH / LONGEST length: If D3 = 1, 

fill with “LENGTH;” ELSE fill with “LONGEST Length”] of time you stopped 

smoking because you were TRYING to quit smoking? 

(Do/Does) (you/name) now smoke cigarettes every day, some days, or not at all? 

During the past 12 MONTHS, what is the LONGEST length of time you stopped 

smoking//using [fill entry same as J4 fill— cigars/ pipes// smokeless tobacco] because 

you were TRYING to quit? 

(Do you/Does [name]) NOW (smoke/use) [fill entry in J1a] every day, some days or not 

at all? [J1a1-4 entries: smoke regular cigars, or cigarillos or little filtered cigars..../ 

smoke a regular pipe filled with tobacco.../ use a water pipe or hookah pipe filled with 

tobacco..../use smokeless tobacco.... ] 

• Every day 

• Some days 

• Not at all 

From PATH 

About how long has it been since you completely quit smoking cigarettes? 

• I___I___I DAYS 

• I___I___I MONTHS 

• I___I___I YEARS 

• DON’T KNOW 

• REFUSED 

About how long has it been since you last used [e-cigarette, cigar, pipe filled with 

tobacco, hookah, smokeless tobacco, dissolvable tobacco]? 

• I___I___I DAYS 

• I___I___I MONTHS 

• I___I___I YEARS 

• DON’T KNOW 

• REFUSED 

On how many of the past 30 days did you [smoke cigarettes, e-cigarette, cigar, pipe 

filled with tobacco, hookah, smokeless tobacco, dissolvable tobacco]? 

• |__|__| Days 

• DON’T KNOW 

• REFUSED 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

154 Tobacco Control Programs—2015 
 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 7 

Comments	 In addition to asking survey respondents whether they have re-initiated the specific type 

of tobacco products they formerly used, evaluators may want to determine whether 

respondents used different types of tobacco products during relapse. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. 

Addiction. 2004 Jan;99(1):29–38. 

2.	 Tindle HA, Shiffman S. Smoking cessation behavior among intermittent smokers versus daily smokers. 

American Journal of Public Health. 2011;101(7):e1–2. 

3.	 Caponnetto P, Keller E, Bruno CM, Polosa R. Handling relapse in smoking cessation: strategies and 

recommendations. Internal and Emergency Medicine. 2013 Feb;8(1):7–12. 

4.	 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and 

dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; May 2008. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

155 
 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

Outcome 8 

Reduced Tobacco-Use Prevalence and Consumption 

Cigarette smoking is the leading cause of preventable illness and death in the United States and 

has been causally linked to diseases of nearly all organs of the body.1,2 More than 20 million 

Americans have died as a result of smoking since the first Surgeon General’s report on smoking 

and health was released in 1964.2 Paralleling this enormous health and personal toll is the 

economic burden of tobacco use: the annual smoking-attributable economic costs in the United 

States estimated are approximately $300 billion.2 

Patterns of tobacco use are changing, with more intermittent use of cigarettes and an increase in 

use of other tobacco products.2 Although some smokers may attempt to use other tobacco 

products as an alternative to smoking cessation, research demonstrates that switching product 

types does not tend to lead to cessation but rather continued, concurrent use.3,4 Rapidly 

eliminating the use of cigarettes and all other tobacco products will dramatically reduce 

preventable death and disease.2 

The following indicators are associated with this outcome: 

►	 3.8.a Tobacco use prevalence 

►	 3.8.b Prevalence of tobacco use during pregnancy 

►	 3.8.c Per capita consumption of tobacco products 

►	 3.8.d Tobacco product preferences of tobacco users 

References 

1. U.S. Department of Health and Human Services. The health consequences of smoking: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human 

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

Prevention and Health Promotion, Office on Smoking and Health; 2004. 

2. U.S. Department of Health and Human Services. The health consequences of smoking—50 

years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Center for 

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

3. Parascandola M, Augustson E, O’Connell ME, Marcus S. Consumer awareness and attitudes 

related to new potential reduced-exposure tobacco product brands. Nicotine & Tobacco 

Research. 2009;11(7):886–95. doi:10.1093/ntr/ntp082 

4. Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national 

study. American Journal of Public Health. 2013 May;103(5):923–30. 

doi:10.2105/AJPH.2012.301070 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 8 

Outcome 8

Reduced Tobacco-Use Prevalence and Consumption 

Indicator Rating 

better 

Number Indicator 

Overall Quality 

low high 

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice 

3.8.a Tobacco use prevalence $ 

3.8.b Prevalence of tobacco use during 

pregnancy 

$ 

3.8.c Per capita consumption of tobacco 

products 

$$ 

3.8.d Tobacco product preferences of 

tobacco users 

† $ 

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

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

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

expert reviewers’ ratings regarding resources required to collect and analyze data to measure the indicator. 

† Denotes low agreement among reviewers, defined as less than 75% of valid ratings within ±1 point of the median 

for this indicator-specific criterion. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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GOAL AREA 3 

► Outcome 8 

Indicator 3.8.a 

Tobacco Use Prevalence
 

KOI 2005 3.14.1 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 8 Reduced tobacco-use prevalence and consumption 

What to measure	 For cigarettes: Proportion of adults aged 18 or older who have smoked at least 100 

cigarettes in their lifetime and who now report smoking cigarettes every day or some 

days 

For other tobacco products: Proportion of adults who have ever used a given tobacco 

product in their lifetime and who now report using the product every day or some days 

Why this indicator is	 Tobacco use remains the leading cause of preventable morbidity and mortality in the 

useful	 United States, resulting in more than 480,000 deaths each year.1 In 2013, an estimated 

17.8% of U.S. adults were current cigarette smokers.2 Of these, the majority, 78.4% 

(33million), smoked every day.3 One-half of all long-term smokers, especially those 

who begin smoking in adolescence, will eventually die from their tobacco use.3 

Although availability of epidemiologic data on cigarette smoking has grown 

exponentially since release of the first U.S. Surgeon General’s report on tobacco use.4 

Prevalence data on other tobacco products are available but limited,1 and additional 

information is needed regarding concurrent use of multiple tobacco products across the 

life course.6 Cross-sectional data show that usage patterns vary by age, gender, 

ethnicity/race, and socioeconomic status.7,8 Preventing and eliminating the use of all 

forms of tobacco as early in life as possible is the best strategy for decreasing 

preventable disease and death in the United States. 

Example data Behavioral Risk Factor Surveillance System (BRFSS): Core Module, 2011 and 2013 

source(s)	 Information available at: http://www.cdc.gov/brfss/ 

Youth Risk Behavior Surveillance System (YRBSS), 2015 

Information available at: http://www.cdc.gov/healthyyouth/yrbs/index.htm 

National Adult Tobacco Survey (NATS), 2013–2014 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Health Interview Survey (NHIS), 2014 

Information available at: http://www.cdc.gov/nchs/nhis.htm
 

National Youth Tobacco Survey (NYTS), 2011
 

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/
 

Population group(s) All tobacco users 

Example survey 

question(s) 

From BRFSS and NATS: 

Have you smoked at least 100 cigarettes in your entire life? 

• Yes 

• No 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you now smoke cigarettes every day, some days, or not at all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

158 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at 

all? 

• Every day 

• Some days 

• Not at all 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you now smoke cigars, cigarillos, or little filtered cigars every day, some days, 

rarely, or not at all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you now smoke a regular pipe filled with tobacco every day, some days, rarely, or 

not at all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you now use chewing tobacco, snuff, or dip every day, some days, rarely, or not at 

all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• DON’T KNOW/NOT SURE 

• REFUSED 

Do you now use electronic cigarettes everyday, some days, rarely, or not at all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• DON’T KNOW/NOT SURE 

• REFUSED 

From YRBSS 

Have you ever tried cigarette smoking, even one or two puffs? 

• Yes 

• No 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

159 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

During the past 30 days, on how many days did you smoke cigarettes? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

Have you ever used an electronic vapor product? 

• Yes 

• No 

During the past 30 days, on how many days did you use an electronic vapor product? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

From NHIS 

Do you NOW smoke cigarettes every day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• REFUSED 

• DON’T KNOW 

Do you NOW smoke tobacco products other than cigarettes every day, some days, 

rarely, or not at all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• REFUSED 

• DON’T KNOW 

Do you NOW use smokeless tobacco products every day, some days, rarely, or not at 

all? 

• Every day 

• Some days 

• Rarely 

• Not at all 

• REFUSED 

• DON’T KNOW 

Have you ever used an e-cigarette, even one time? 

• Yes 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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GOAL AREA 3 

► Outcome 8 

• No 

• REFUSED 

• DON’T KNOW 

Do you now use e-cigarettes every day, some days, or not at all? 

• Every day 

• Some days 

• Not at all 

• REFUSED 

• DON’T KNOW 

From NYTS 

During the past 30 days, on how many days did you smoke cigarettes? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

During the past 30 days, on how many days did you smoke cigars, cigarillos, or little 

cigars? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

During the past 30 days, on how many days did you smoke tobacco in a pipe? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip? 

• 0 days 

• 1 or 2 days 

• 3 to 5 days 

• 6 to 9 days 

• 10 to 19 days 

• 20 to 29 days 

• All 30 days 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

161 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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GOAL AREA 3 

► Outcome 8 

During the past 30 days, on how many days did you smoke cigarettes? 

•	 0 days 

•	 1 or 2 days 

•	 3 to 5 days 

•	 6 to 9 days 

•	 10 to 19 days 

•	 20 to 29 days 

•	 All 30 days 

During the past 30 days, which of the following products have you used at least one 

day? 

•	 Roll-your-own cigarettes 

•	 Bidis (small brown cigarettes wrapped in a leaf) 

•	 Clove cigarettes (kreteks) 

•	 Smoking tobacco from hookah or a waterpipe 

•	 Snus, such as Camel or Marlboro Snus 

•	 Dissolvable tobacco products, such as Ariva, Stonewall, Camel orbs, Camel 

sticks, Marlboro sticks, or Camel strips 

•	 Electronic cigarettes or E-cigarettes, such as Ruyan or NJOY 

•	 Some other new tobacco product not listed here 

•	 I have not used any of the products listed above or any new tobacco product 

during the past 30 days 

Comments	 In addition to capturing tobacco prevalence, evaluators may also want to assess average 

number of tobacco products used per day to estimate tobacco use intensity. This 

information can be useful in considering population-attributable risk and guiding 

cessation-related strategies. 

Related Healthy People 2020 Objective: TU-1 Reduce tobacco use by adults and TU-2 

Reduce tobacco use by adolescents. 

Information available at: http://www.healthypeople.gov/2020/default.aspx 

Rating Strength of 

evaluation 

evidence 

Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

Overall quality 

$
 

References 

1.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

2. Centers for Disease Control and Prevention. Current cigarette smoking among adults—United States, 2005–2013. 

Morbidity and Mortality Weekly Report. 2014;63(47):1108–12. 

3.	 U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and 

behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

162 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

4.	 Surgeon General’s Advisory Committee on Smoking and Health United States. Public Health Service. Office of 

the Surgeon General. Smoking and health: report of the advisory committee to the Surgeon General of the 

public health service. Public Health Service Publication No. 1103; 1964. 

5.	 Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the 

missing link between youth prevention and adult cessation. Journal of Environmental and Public Health. 2012; 

1–9. doi:10.1155/2012/679134 

7.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

8.	 Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity. Atlanta: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

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

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

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GOAL AREA 3 

► Outcome 8 

Indicator 3.8.b 

Prevalence of Tobacco Use During Pregnancy
 

KOI 205 3.14.2 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 8 Reduced tobacco-use prevalence and consumption 

What to measure Proportion of pregnant women who used tobacco during pregnancy or resume smoking 

within 6 months after giving birth 

Why this indicator is	 Smoking is associated with a variety of complications before, during, and after 

useful	 pregnancy, including infertility, ectopic pregnancy, placental complications, preterm 

delivery, stillbirth, neonatal and perinatal mortality, and low birth weight.1-3 Evidence 

shows that health promotion efforts and referral to effective cessation interventions 

reduce maternal smoking prevalence during pregnancy.

4,5 Women who continue to 

smoke into their third trimester are more likely to have low socioeconomic status and to 

enter prenatal care late.4 Studies suggest that use of other tobacco products, including 

smokeless tobacco and snuff, may adversely affect pregnancy outcomes as well,6-11 

likely due to specific actions of nicotine.3 

Example data 

source(s) 

Birth certificate data
 

CDC Pregnancy Risk Assessment Monitoring System (PRAMS), Core Questions, 2009–
 

2012
 

Information available at: http://www.cdc.gov/prams/Questionnaire.htm#p3
 

National Health Interview Survey (NHIS), Sample Adult Diet and Nutrition
 

Supplement, 2010
 

Information available at: http://www.cdc.gov/nchs/nhis.htm
 

Population group(s) Pregnant women 

Example survey 

question(s) 

Birth certificate data are available from states’ vital statistics data. 

From PRAMS 

In the last 3 months of your pregnancy, how many cigarettes did you smoke on an 

average day? 

• 41 cigarettes or more 

• 21 to 40 cigarettes 

• 11 to 20 cigarettes 

• 6 to 10 cigarettes 

• 1 to 5 cigarettes 

• Less than 1 cigarette 

• I didn’t smoke then 

How many cigarettes do you smoke on an average day now? (A pack has 20 cigarettes.) 

• 41 cigarettes or more 

• 21 to 40 cigarettes 

• 11 to 20 cigarettes 

• 6 to 10 cigarettes 

• 1 to 5 cigarettes 

• Less than 1 cigarette 

• I didn’t smoke then 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

164 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

From NHIS 

Have you given birth to a live born infant within the past 5 years? 

•	 Yes 

•	 No 

•	 REFUSED 

• DON’T KNOW 

Did you smoke cigarettes at any time during your pregnancy with your last child? 

•	 Yes 

•	 No 

•	 REFUSED 

•	 DON’T KNOW 

Comments	 Using birth certificate data may lead to underestimates of smoking rates during 

pregnancy due to variations in birth certificate forms as well as underreporting.2 

Surveys, such as PRAMS, may also be subject to underreporting bias.3 

To gather more complete data on tobacco use, evaluators can also ask questions about 

the use of other tobacco products, such as cigars, smokeless tobacco, and loose tobacco. 

Because most mothers resume smoking within 18 months of delivery,4,5 evaluators may 

also choose to measure the proportion of women who use tobacco in the postpartum 

period (6 months after giving birth). In addition to the increased morbidity and mortality 

risks for the mothers, children exposed to secondhand smoke are at increased risk for 

sudden infant death syndrome (SIDS), acute respiratory infections, ear infections, and 

more severe asthma.1,2,12 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and 

behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

2.	 U.S. Department of Health and Human Services. Women and smoking: a report of the Surgeon General. 

Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon 

General; 2001. 

3.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

4.	 Tong VT, England LJ, Dietz PM, Asare LA. Smoking patterns and use of cessation interventions during 

pregnancy. American Journal of Preventive Medicine. 2008;35(4):327–33. doi:10.1016/j.amepre.2008.06.033 

5.	 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH report: 

substance use among women during pregnancy and following childbirth. Rockville, MD: Substance Abuse and 

Mental Health Services Administration, Office of Applied Studies; May 21, 2009. 

6.	 Gupta PC, Sreevidya S. Smokeless tobacco use, birth weight, and gestational age: population based prospective 

cohort study of 1217 women in Mumbai, India. BMJ. 2004;328:1538. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

165 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

7.	 Gupta PC, Subramoney S. Smokeless tobacco use and risk of stillbirth: a cohort study in Mumbai, India. 

Epidemiology. 2006;17:47–51. 

8.	 England LJ, Levine RJ, Mills JL, Klebanoff MA, Yu KF, Cnattingius S. Adverse pregnancy outcomes in snuff 

users. American Journal of Obstetrics and Gynecology. 2003;189:939–43. 

9.	 Wikström AK, Cnattingius S, Galanti MR, Kieler H, Stephansson O. Effect of Swedish snuff (snus) on preterm 

birth. BJOG. 2010 Jul;117(8):1005–10. doi:10.1111/j.1471-0528.2010.02575.x 

10.	 Baba S, Wikström AK, Stephansson O, Cnattingius S. Changes in snuff and smoking habits in Swedish 

pregnant women and risk for small for gestational age births. BJOG. 2013 Mar;120(4):456–62. 

doi:10.1111/1471-0528.12067 

11.	 U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

smoke: a report of the Surgeon General—Executive Summary. U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006.

12.	 Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the US population. Tobacco Control. 2014 

Apr 17. doi:10.1136/tobaccocontrol-2013-051466. [Epub ahead of print] 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

166 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

 better

 

 

 

GOAL AREA 3 

► Outcome 8 

Indicator 3.8.c 

Per Capita Consumption of Tobacco Products
 

KOI 2005 3.14.4 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 8 Reduced tobacco-use prevalence and consumption 

What to measure Number of tobacco products sold per adult aged 18 years or older in the state, by type 

Why this indicator is	 Decreases in overall tobacco consumption are associated with the success of a 

useful	 comprehensive tobacco control program.1-5 However, tax disparities and variations in 

tobacco industry promotion for different tobacco products can lead to shifts in productspecific consumption.6,7 Capturing overall tobacco consumption and key productspecific consumption levels can provide important tobacco control planning and 

program improvement information. 

Example data Excise tax data from the U.S. Department of Treasury’s Alcohol and Tobacco Tax and 

source(s) Trade Bureau 

State departments of revenue 

The Tax Burden on Tobacco 

Available at: https://chronicdata.cdc.gov/Policy/The-Tax-Burden-on-Tobacco-Volume49-1970-2014/7nwe-3aj9 

Population group(s) This indicator is best measured by examining tax records to assess state tobacco sales. 

Population survey methods include asking items of all tobacco users. 

Example survey Not Applicable 

question(s) 

Comments	 The two standard approaches for measuring consumption are (1) estimating 

consumption based on tobacco excise tax data and (2) surveying a representative sample 

of the public and asking questions about personal consumption levels. The U.S. 

Department of Agriculture, which previously provided estimates based on tax data, 

stopped reporting on tobacco consumption in 2007. The Centers for Disease Control and 

Prevention (CDC) now uses excise tax data from the U.S. Department of Treasury’s 

Alcohol and Tobacco Tax and Trade Bureau to estimate consumption. 

Evaluators need to measure statewide consumption of cigarettes, smokeless tobacco, and 

other tobacco products separately. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$$
 

References 

1.	 U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2014. 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

167 
 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

2.	 Al-Delaimy WK, Pierce JP, Messer K, White MM, Trinidad DR, Gilpin EA. The California Tobacco Control 

Program’s effect on adult smokers: (2) Daily cigarette consumption levels. Tobacco Control. 2007;16:91–5. 

doi:10.1136/tc.2006.017061 

3.	 Farrelly MC, Pechacek TF, Chaloupka FJ. The impact of tobacco control expenditures on aggregate cigarette 

sales: 1981–2000. Journal of Health Economics. 2003;22(5):843–59. Erratum in: Journal of Health Economics. 

2004;23(2):419. 

4.	 Lightwood J, Glantz S. Effect of the Arizona tobacco control program on cigarette consumption and healthcare 

expenditures. Social Science and Medicine. 2011;72(2):166–72. doi:10.1016/j.socscimed.2010.11.015 

5.	 Orzechowski and Walker. Tax burden on tobacco, historical compilation, Vol 46. Arlington, VA: Orzechowski 

and Walker; 2011. 

6.	 Centers for Disease Control and Prevention. Consumption of cigarettes and combustible tobacco—United 

States, 2000–2011. Morbidity and Mortality Weekly Report. 2012;61(30);565–9. 

7.	 Delnevo CD, Wackowski OA, Giovenco DP, Manderski MT, Hrywna M, Ling PM. Examining market trends in 

the United States smokeless tobacco use: 2005–2011. Tobacco Control. 2014 Mar;23(2):107–12. 

doi:10.1136/tobaccocontrol-2012-050739 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

168 Tobacco Control Programs—2015 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

Indicator 3.8.d 

Tobacco Product Preferences of Tobacco Users
 

KOI 2005 New 

Goal area 3 Promoting Quitting Among Adults and Young People 

Outcome 8 Reduced tobacco-use prevalence and consumption 

What to measure Type and brand of tobacco products used by respondents in the past 30 days 

Why this indicator is	 Research suggests a link between exposure to tobacco advertising and brand 

useful	 preference.1,2 Knowing brand and product preferences of tobacco users across the life 

course can help inform the development of effective tobacco control interventions and 

also provide insight into the influence of the tobacco industry’s marketing practices.

3,4 

The tobacco industry disproportionately targets certain populations and communities.5 

For example, evidence shows increased menthol cigarette marketing at the point of sale 

in lower income and African American communities.6,7 Additionally, the tobacco 

industry has begun marketing alternative tobacco products with claims that they are less 

harmful or less addictive than cigarettes, and there is concern that smokers may use 

these products as an alternative to cessation.8 Although these messages may appeal to 

smokers, research demonstrates that switching product type does not lead to cessation.8,9 

Example data National Adult Tobacco Survey (NATS), 2009-2010 and 2013–2014 

source(s)	 Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/ 

National Youth Tobacco Survey (NYTS), 2011 

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm 

National Survey on Drug Use and Health (NSDUH), 2011 

Information available at: http://www.samhsa.gov/data/NSDUH.aspx 

Population group(s) Current tobacco users 

Example survey 

question(s) 

From NATS 2009-2010 

During the past 30 days, that is since ______, what brand of cigarettes did you buy most 

often?
 

During the past 30 days, that is since ______, what brand of cigarettes did you smoke
 

most often?
 

During the past 30 days, that is since ______, what brand of smokeless tobacco did you
 

use most often?
 

From NATS 2013–2014 

At any time during the past 12 months, did you completely switch from smoking 

traditional cigarettes to using electronic or e-cigarettes?
 

At any point during the past 12 months, did you completely switch from smoking 

cigarettes to using a smokeless tobacco product, such as chewing tobacco, dip, snuff, or
 

snus?
 

From NYTS 

During the past 30 days, which of the following tobacco products did you use on at least 

one day? (CHOOSE ALL THAT APPLY) 

• Roll-your-own cigarettes 

• Flavored cigarettes, such as Camel Crush 

• Clove cigars 

• Flavored little cigars 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

169 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

low high 

†

 better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GOAL AREA 3 

► Outcome 8 

•	 Smoking tobacco from a hookah or a waterpipe 

•	 Snus, such as Camel or Marlboro Snus 

•	 Dissolvable tobacco products, such as Ariva, Stonewall, Camel orbs, Camel 

sticks, or Camel strips 

•	 Electronic cigarettes or E-cigarettes, such as Ruyan or NJOY 

•	 Some other new tobacco products not listed here 

•	 I have not used any of the products listed above or any new tobacco product 

Comments	 In addition to monitoring trends in type and brand preferences among tobacco users, 

evaluators may want to identify recent product type and brand changes as well as 

reasons for preference changes. Capturing this additional information may aid in the 

interpretation of cross-sectional data and help to link product preference information 

with other cessation-related behaviors. Ideally, changes in product preferences and 

subsequent effects on quit attempts/dual use/ continued use should be assessed using 

longitudinal data systems. 

Rating Strength of 

evaluation 

evidence 

Overall quality Resources 

needed 

Face 

validity 

Accepted 

Utility practice 

$
 

References 

1.	 National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control 

Monograph No. 19. NIH Publication No. 07-6242. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; June 2008. 

2.	 Wakefield M, Ruel E, Chaloupka F, Slater S, Kaufmann N. Association of point-of-purchase tobacco 

advertising and promotions with choice of usual brand among teenage smokers. Journal of Health 

Communication. 2002;7(2):113–21. 

3.	 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

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

on Smoking and Health; 2012. 

4.	 Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the 

missing link between youth prevention and adult cessation. Journal of Environmental and Public Health. 2012; 

1–9. doi:10.1155/2012/679134 

5.	 Widome R, Brock B, Noble P, Forster JL. The relationship of neighborhood demographic characteristics to 

point-of-sale tobacco advertising and marketing. Ethnicity and Health. 2013;18(2):136–51. 

doi:10.1080/13557858.2012.701273 

6.	 Seidenberg AB, Caughey RW, Rees VW, Connolly GN. Storefront cigarette advertising differs by community 

demographic profile. American Journal of Health Promotion. 2010;24(6):e26–31. doi:10.4278/ajhp.090618­

QUAN-196 

7.	 Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted advertising, promotion, and price for 

menthol cigarettes in California high school neighborhoods. Nicotine & Tobacco Research. 2012;14(1):116–21. 

doi:10.1093/ntr/ntr122 

8.	 Parascandola M, Augustson E, O’Connell ME, Marcus S. Consumer awareness and attitudes related to new 

potential reduced-exposure tobacco product brands. Nicotine & Tobacco Research. 2009;11(7):886–95. 

doi:10.1093/ntr/ntp082 

9.	 Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. American 

Journal of Public Health. 2013 May;103(5):923–30. doi:10.2105/AJPH.2012.301070 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

170 Tobacco Control Programs—2015 
GOAL AREA 3
 

► Outcome 8
 

CHAPTER 2 ► Goal Area 3: Promoting Quitting Among Adults and Young People 

171 

Appendices and Glossary
 

 

 

 

 

APPENDIX A
 

National Tobacco Control Program 

An Overview 

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

(OSH) created the National Tobacco Control Program (NTCP) in 1999 to encourage 

coordinated, national efforts to reduce tobacco-related diseases and deaths. The program 

provides funding and technical support to state and territorial health departments. 

NTCP funds 

►	 all 50 states, 

►	 the District of Columbia, 

►	 eight U.S. territories/jurisdictions, 

►	 eight tribal support centers, and 

►	 several national networks that provide technical assistance to increase tobacco control and 

prevention capacity and infrastructure to address health disparities. 

NTCP-funded programs are working to achieve the objectives outlined in OSH’s Best Practices 

for Comprehensive Tobacco Control Programs.

1 

The four goals of NTCP are to 

►	 prevent initiation among youth and young adults, 

►	 eliminate exposure to secondhand smoke, 

►	 promote quitting among adults and youth, and 

►	 identify and eliminate tobacco-related disparities among population groups, 

The four components of NTCP are 

►	 population-based community interventions, 

►	 countermarketing, 

►	 program policy/regulation, and 

►	 surveillance and evaluation. 

For more information on the NTCP, go to: 

http://www.cdc.gov/tobacco/tobacco_control_programs/ntcp/ . Several resources for effective 

tobacco control programs are also available on the Web site, including the following: 

►	 Best Practices for Comprehensive Tobacco Control Programs-20141 

►	 Designing and Implementing an Effective Tobacco Counter-Marketing Campaign2 

APPENDIX A 

175 
 

 

 

► Surgeon General Reports related to tobacco prevention and control3-8 

► The Guide to Community Preventive Services: Tobacco Use Prevention and Control9 

References 

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

control programs—2014. Atlanta, GA: U.S. Department of Health and Human Services, 

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

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

2. Centers for Disease Control and Prevention. Designing and implementing an effective 

tobacco counter-marketing campaign (1st ed.). Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Center for 

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

October 2003. 

3. U.S. Department of Health and Human Services. The health consequences of smoking—50 

years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 

2014. 

4. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 

5. U.S. Department of Health and Human Services. The health consequences of smoking: a 

report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human 

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

Prevention and Health Promotion, Office on Smoking and Health; 2004. 

6. U.S. Department of Health and Human Services. Women and smoking: a report of the 

Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public 

Health Service, Office of the Surgeon General; 2001. 

7. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the 

Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers 

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

Health Promotion, Office on Smoking and Health; 2000. 

8. U.S. Department of Health and Human Services. Tobacco use among U.S. racial/ethnic 

minority groups—African Americans, American Indians and Alaska Natives, Asian 

Americans and Pacific Islanders, and Hispanics: a report of the Surgeon General. Atlanta, 

GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

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

on Smoking and Health; 1998. 

9. Task Force on Community Preventive Services. The guide to community preventive 

services: tobacco use prevention and control. American Journal of Preventive Medicine. 

2001;20(Suppl 2):1–88. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

176 Tobacco Control Programs—2015 
APPENDIX B
 

Expert Panel Members 

We thank the following panel of expert members (in alphabetical order) who rated the indicators. 

Without their generosity in sharing their expertise and donating their time, this publication would 

not have been possible. 

Linda Bailey, MHS, JD 

President and CEO 

North American Quitline Consortium 

Carsten Baumann, MA 

Owner 

Carsten Consulting Services LLC 

External Evaluation Director 

Colorado Department of Public Health and Environment 

Frank Chaloupka, PhD 

Distinguished Professor of Economics 

Institute for Health Research and Policy 

University of Illinois at Chicago 

Michael Cummings, PhD, MPH 

Professor of Psychiatry and Behavioral Sciences 

Co-Director of the Tobacco Policy and Control Program 

College of Medicine 

Medical University of South Carolina 

Michael Fiore, MD, MPH, MBA 

Professor and Director of Medicine 

Center for Tobacco Research and Intervention 

University of Wisconsin School of Medicine and Public Health 

Jonathan Foulds, PhD 

Professor 

Division of Health Services Research 

Public Health Sciences and Psychiatry 

Penn State College of Medicine 

Corinne Husten, MD, MPH 

Senior Medical Advisor 

Center for Tobacco Products 

Food and Drug Administration 

APPENDIX B 

177 
 

Andrew Hyland, PhD 

Chair 

Department of Health Behavior 

Division of Cancer Prevention & Population Sciences 

Roswell Park Cancer Institute 

Director 

New York State Smokers’ Quitline 

Research Professor 

Department of Social and Preventive Medicine 

University at Buffalo 

State University of New York 

Mark Paskowsky, MPP 

Director of Surveillance and Evaluation 

Massachusetts Tobacco Cessation and Prevention Program 

Massachusetts Department of Public Health 

Kurt Ribsl, PhD 

Professor 

Department of Health Behavior 

UNC Gillings School of Global Public Health 

University of North Carolina at Chapel Hill 

Stacey Schubert, MPH 

Health Promotion and Chronic Disease Prevention Section 

Oregon Public Health Division 

Donna Warner, MBA, MA 

Managing Member 

Multi-State Collaborative for Health Systems Change to Address Tobacco Use 

Shu-Hong Zhu, PhD 

Professor of Family and Preventive Medicine 

UC San Diego 

Principal Investigator 

California Smokers’ Helpline and the Center for Tobacco Cessation 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

178 Tobacco Control Programs—2015 
Outcome Indicator Workgroup
 

We thank the following individuals for their assistance in preparing and reviewing this 

publication. 

From the Office on Smoking and Health, National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and Prevention: 

► Stephen Babb, MPH 

► Susan Brown, MPH 

► Jami Fraze, PhD 

► Erika Fulmer, MHA 

► Ahmed Jamal, MBBS 

► Christopher Jones, PhD, LCSW 

► Nicole Kuiper, MPH 

► Rene Lavinghouze, MA 

► Ann Malarcher, PhD 

► Boris Volkov, PhD 

From RTI International: 

► Todd Rogers, PhD 

► LaShawn Curtis, DrPH 

► Laurel Curry, MPH 

► Sandhya Joshi, BA 

APPENDIX B 

179 

 

 

 

 

APPENDIX C
 

Selecting and Rating the Indicators 

The Centers for Disease Control and Prevention (CDC) began producing this publication by first 

reviewing the indicators included in Goal 3: Promoting Quitting Among Adults and Young 

People from the Key Outcome Indicators for Evaluating Comprehensive Tobacco Control 

Programs published in 2005 (KOI 2005). The 2005 guide was developed by updating previously 

published logic models for three of the four goal areas of the National Tobacco Control Program 

(NTCP): 

► Preventing initiation of tobacco use among young people. 

► Eliminating nonsmokers’ exposure to secondhand smoke. 

► Promoting quitting among adults and young people. 

Initial Outcome Indicator Development 

KOI 2005 used an extensive review of published and fugitive literature to select candidate 

indicators for the outcome components of each NTCP goal area’s logic model. Once selected, the 

scientific evidence was then reviewed to determine whether an association existed between the 

candidate indicators and the outcome components in the NTCP logic models. 

Candidate indicators that demonstrated an association were included in further development, 

including the selection of example data sources and survey questions for each indicator. The 

selection of example data sources was focused on choosing data sources that were readily 

available to state tobacco control programs. 

Candidate indicators with example data sources and survey questions then were submitted to an 

external review panel for rating across several criteria. Reviewer responses were analyzed and 

augmented with information from an independent literature review conducted by the Battelle 

Centers for Public Health Research and Evaluation under contract to CDC. (See KOI 2005, 

Appendix B for a detailed description of the methods.) 

Updating Goal 3 Outcome Indicators 

Revising the Candidate List of Indicators 

In 2012, an initial step taken to update the Goal 3 indicators was to review the relevant tobacco 

literature published since the release of KOI 2005. During this review, we sought to determine 

whether the scientific evidence continued to support associations between individual indicators 

and outcome components in the NTCP Goal 3 logic model and to determine whether the 

evolution of science and practice created gaps in the logic model requiring development of new 

outcome indicators. The process included careful examination of seminal tobacco control 

documents, including Surgeon General reports, National Cancer Institute (NCI) Monographs, 

APPENDIX C 

181 
 

 

 

Clinical Guidelines and Institute of Medicine reports published from 2005 to 2012. We also 

conducted targeted literature searches via PubMed. 

The 2012 literature review identified the need for additional and more nuanced indicators related 

expanding health coverage for comprehensive cessation services, reducing tobacco industry 

influence, and increasing environmental changes to support quitting. The Affordable Care Act 

created opportunities to expand coverage of evidence-based tobacco use cessation treatments 

while the issue of tobacco industry influence became more salient with the passage of the Family 

Smoking Prevention and Tobacco Control Act (Tobacco Control Act) in 2009. 

Information from the literature review was used to modify the existing Goal 3 logic model and 

indicator list. Ultimately, 24 new candidate indicators were added to the Goal 3 list, and 10 

indicators from KOI 2005 were removed. Revised materials included the revised Goal 3 logic 

model, a draft list of candidate indicators, and brief indicator profiles with example data sources 

and survey questions similar to those developed for KOI 2005. 

Rating the Indicators 

Replicating the original indicator development process, we assembled a panel of experts (listed 

in Appendix B) to rate the final set of candidate indicators for Goal Area 3. Of the 21 invited 

experts, 13 agreed to participate and completed the indicator review. The experts assessed the 

indicators against several criteria and suggested data sources useful for measuring these 

indicators. 

Expert panelists were asked to rate each of the candidate indicators separately according to 

several criteria (see expert panel review instructions and review form on page X of this 

appendix). 

In addition, we asked the expert raters to 

►	 comment on the data sources and survey questions that CDC had selected for each proposed 

indicator, 

►	 suggest alternative data sources and questions, 

►	 suggest additional or alternative supporting references, and 

►	 suggest additional indicators that would be useful for evaluation of comprehensive state
 

tobacco control programs. 

Each expert used a separate rating form for each indicator (see end of this appendix for a reprint 

of the rating form and rater instructions). 

Revising the Indicator Profiles 

Concurrent with external review, OSH staff worked to develop complete profiles for each 

candidate indicator. This included systematically updating example data sources and survey 

questions, which involved searching current and past (1999–2014) national data sources 

including federal sources, such as the National Adult Tobacco Survey (NATS), National Youth 

Tobacco Survey (NYTS), STATE System, CDC OSH News Media Surveillance System, Youth 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

182 Tobacco Control Programs—2015 
 

 

 

Risk Behavior Survey (YRBS), School Health Profiles, National Survey on Drug Use and Health 

(NSDUH) (Substance Abuse and Mental Health Services Administration [SAMHSA]), Synar 

reports, and Federal Trade Commission reports; and non-federal sources, including Legacy 

Media Tracking Survey, Center for Responsive Politics, National Institute on Money in State 

Politics, and state tobacco control program evaluation reports. 

Rationale statements and supporting references for each candidate indicator were updated using 

the 2012 literature review as well as topic-specific PubMed searches for more recent evidence 

published since 2012. 

Considering Stakeholder Input: Updating Outcome Indicators 

Analysis and Synthesis of Data from the Expert Reviews 

After CDC received the completed rating forms from the experts, all criteria ratings and written 

comments were entered into an electronic file. We adjusted for multiple responses, skipped 

items, and coding errors. If, for example, a rater circled more than one adjacent response for a 

criterion, we averaged the responses unless the rater had noted a preference for one response 

over another. Skipped items and “don’t know” responses were combined into a missing data 

category. All data were analyzed using IBM SPSS—Version 19.0. 

For each type of rating, numerical data were analyzed in various ways. Frequency distributions 

of numerical data were analyzed to help us understand the raters’ perceptions of the indicators. 

To limit the effect of outliers, we used the median scores for each indicator. “Uniqueness” 

ratings, which were dichotomous, were only used to determine redundant indicators. Narrative 

comments included on the raters’ rating sheets were also reviewed to help us understand why 

raters gave an indicator a particularly high or low rating. 

APPENDIX C 

183 
 

 

 

 

 

 

 

 

Throughout this document, indicators that had low reviewer response or low agreement among 

reviewers are flagged with footnotes as follows: 

►	 An asterisk (*) indicates low reviewer response. If fewer than 75% of reviewers provided a 

valid rating on a criterion for an indicator, the criterion is flagged as having low reviewer 

response. For the purposes of this assessment, invalid responses included “don’t know,” 

missing data, and rating errors (e.g., selection of two non-adjacent ratings). A low response 

suggests a high degree of uncertainty among raters. An example of a rating for which there 

was low response is the resource score for indicator 1.7.h: Amount of tobacco industry 

contributions to institutions and groups. 

►	 A dagger (†) indicates a low level of agreement among reviewers. For the resources needed, 

strength of evaluation evidence, utility, face validity, and accepted practice criteria, a rating 

was considered to have a low level of agreement if fewer than 75% of valid reviewer 

responses were within ±1 point of the median. For the overall quality criterion, a rating was 

considered to have a low level of agreement if fewer than 75% of valid reviewer responses 

were within ±2 points of the median (denoted by a double dagger ††). An example of a 

rating with a low level of agreement is the overall quality score for 1.9.a: Average age at 

which young people first smoked a whole cigarette. This low level of agreement represents 

a relatively high degree of variability in the raters’ responses for the criterion. 

Expert panel members rated and offered comments on 55 candidate indicators. After reviewing 

the expert panel ratings and comments carefully, five indicators were added to address gaps 

identified by the expert reviewers and OSH staff. These new indicators were not rated by the 

expert panel, noted by an “NR” suffix to the indicator number in this publication. However, 

some information about these “NR” indicators is provided in the indicator profiles. Expert panel 

ratings and comments noted that some indicators were considered to be “not essential,” so we 

deleted four indicators and merged two indicators with two other similar indicators. Thus, this 

publication contains information on 46 Goal Area 3 indicators. 

CDC reviewed the expert panelists’ “resources needed” scores (their estimate of the intensity of 

resources required to collect and analyze data on each indicator). CDC modified scores for 37 

indicators that were rated by the experts. Some indicators included multiple types of data sources 

which added complexity to the rating process. Additionally, when data for a given indicator were 

found to be available from existing surveillance systems and/or archival sources, the resource 

rating was modified to a score of 1. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

184 Tobacco Control Programs—2015 
 CDC/OSH Key Outcome Indicator 2014 Update

Instructions for Expert Reviewers 

Background and Purpose 

In 2005, the Centers for Disease Control and Prevention’s (CDC’s) Office on Smoking and Health 

(OSH) released the Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 

(KOI Guide) to assist state and territorial tobacco control program evaluation efforts under the National 

Tobacco Control Program (NTCP). The primary audiences for the publication included planners, 

managers, and evaluators of state programs to prevent or control tobacco use and CDC’s national 

partners. 

Substantial changes and advances in tobacco control have occurred since the release of the KOI Guide. 

The passage of the Family Smoking Prevention and Tobacco Control Act in 2009 provides an 

opportunity for expanding tobacco prevention and control policy efforts, especially those focused on 

reducing tobacco industry influences through marketing, pricing, and promotion. Additionally, the 

Affordable Care Act, signed into law in March 2010, includes provisions requiring insurers to cover 

evidence-based tobacco cessation treatments; expands smoking cessation coverage for priority 

populations, including pregnant women who receive Medicaid; and invests in promotion of effective 

public health and preventive measures through the establishment of the Prevention and Public Health 

Fund. Given these changes in the national policy environment, OSH recognized the need to revisit the 

key outcome indicators related to tobacco cessation. 

As a first step, indicators in OSH Goal Area 3 (Promoting Quitting Among Adults and Young People) 

have been reviewed and revised internally by OSH staff. During this process, some existing key 

outcome indicators have been removed, others have been substantially revised, and several new 

indicators have been added. We will implement an external expert review process similar to what was 

used during the initial indicator development effort. 

Similar to the original KOI Guide, the updated version will 

►	 serve as a companion to OSH’s Best Practices for Comprehensive Tobacco Control Programs and 

Introduction to Program Evaluation for Comprehensive Tobacco Control Programs; 

►	 describe key outcome indicators for the evaluation of statewide, comprehensive tobacco control
 

programs, and suggest appropriate data sources and measures for these indicators;
 

►	 encourage states to use consistent evaluation measures and comparable data sources; and 

►	 guide the provision of surveillance and evaluation technical assistance to states. 

Methods 

The candidate indicators included in this document have been identified through an extensive review of 

the literature and input provided by key tobacco control experts,. Each of the proposed indicators 

included in this document is linked to a component of the revised Goal Area 3 logic model (Figure 1). 

As part of the update process, each of the original KOI Guide Goal Area 3 indicators and their 

respective profiles were reviewed. Indicator profiles were revised, as necessary, to reflect current state 

of the science. Example data sources and survey items were updated to reflect those that are readily 

available to staff involved in state tobacco control programs. If necessary, measures were drawn from 

APPENDIX C 

185 
other national and state-specific surveys and evaluation protocols that are not widely used yet but are 

accessible to state tobacco control programs. 

Internal indicator selection decisions were guided by a need to highlight key indicators for planning and 

evaluating comprehensive tobacco control programs. Linkages connecting antecedent and consequent 

logic model components (boxes) and nested indicators were reviewed for evidence of association. 

Rating Process 

The principal purpose of this expert review process is to provide CDC/OSH with expert opinion about 

the quality and utility of the candidate indicators for use in planning and evaluating comprehensive state 

tobacco control programs, and the data sources and measures that would be most useful for tracking 

these indicators. As reviewers, you are asked to do the following: 

►	 Rate each indicator on a set of criteria similar to those used to produce the original KOI Guide. 

►	 Comment on the data sources and measures that have been identified for each proposed indicator. 

►	 Suggest alternative data sources and measures. 

►	 Suggest additional cessation-related indicators that may be useful for state tobacco control
 

program evaluation.
 

The final product will be similar to the original KOI Guide in that it will include tables displaying the 

indicators, ratings of the indicators along the review criteria, and detail summary information on each 

indicator. 

We would like you to rate the indicators based on your expertise and experience in this substantive area 

using the following criteria: 

1.	 Strength of evidence 

2.	 Costs (in money, time, and other resources) required to collect and analyze indicator data 

3.	 Utility 

4.	 Face validity 

5.	 Uniqueness 

6.	 Conformity with accepted practice 

7.	 Overall quality 

Below you will find additional guidance regarding these rating criteria and the rating process. 

Rating Form 

Each indicator is presented on a separate rating form. The rating forms have three sections: 

►	 Summary information on the proposed indicator, including what to measure, example data sources, 

population group, example survey question(s), other relevant information, and references 

regarding the evidence supporting use of the indicator, where available. Please note that the 

references provided are not intended to be a comprehensive bibliography. 

►	 Rating criteria scales for reviewer response 

►	 Space for open-ended reviewer comments on the proposed indicator and data sources/measures 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

186 Tobacco Control Programs—2015 
 

 

 

In the summary information section on the rating forms, the example data sources/measures suggested 

are intended only to help operationalize the indicators and do not represent a comprehensive list of all 

possible measures for the indicators. Additionally, information included in the “Comments” section has 

been limited to what will help to provide clarity or address nuances for the specific indicator. The final, 

updated KOI Guide will include suggestions for other uses of the indicator, the limitations (if any) of 

using this indicator as a measure of a program’s progress, or sources of other information on data 

collection methods. 

IMPORTANT NOTE: Given our plan to provide information on current, relevant indicators for tobacco 

control, we ask that you not reference the original KOI Guide when rating these candidate indicators. 

Please rate these updated and new indicators based on your expertise and knowledge of the current state 

of the science. This will help to identify indicators that are no longer pertinent or that have limited 

supporting evidence. 

Rating Criteria 

The following criteria are to be used to rate each indicator: 

1.	 Strength of the evaluation evidence—Extent to which you believe that the literature supports use 

of the indicator for the evaluation of comprehensive, statewide tobacco control programs, as 

characterized by the logic model. Please provide a rating based on your experience and knowledge 

of the field. We have included several references for each indicator. However, the intent is not for 

you to examine each reference we have provided but rather to provide a rating based on your 

knowledge of the literature. For areas you are not as familiar with, please feel free to select “don’t 

know.” For areas where you have familiarity and feel that we may be missing a key citation, please 

add that note to the comment box as well as any issues regarding conflicting evidence and/or 

concerns with methodology. 

2.	 Costs required for collecting and analyzing indicator data—Your rating of the cost (in money, 

time, and other resources) to collect reliable and precise measures and to analyze appropriately 

primary or secondary data on the indicator. In making your judgments, please consider availability 

of existing data (e.g., archival records or other secondary data) versus the need for primary data 

collection, and methodological and sampling issues. 

3.	 Utility—Extent to which you believe that the indicator would help to answer important 

comprehensive tobacco control program evaluation questions. Although these indicators may also 

be appropriate and useful for community-level evaluation, the utility criterion refers primarily to 

statewide efforts. 

4.	 Face validity—Your estimation of how face valid the indicator would appear to be in the eyes of 

policy makers and decision makers who may be users of tobacco control program evaluation 

results. 

5.	 Uniqueness—Your opinion of whether the indicator contributes distinct information for the 

evaluation of tobacco control efforts. If you believe that the indicator is not unique, please note the 

redundant indicator in the space provided. 

6.	 Conformity with accepted practice—Your opinion of the degree to which use of the indicator is 

consistent with currently accepted, “real-world” tobacco control practice. 

7.	 Overall quality—A summary rating that reflects your opinion of the overall quality of the 

indicator. 

APPENDIX C 

187 
 

 

Reviewer Comments 

Please provide comments and suggestions regarding the proposed indicator, data sources, and measures 

in the Reviewer Comments section. 

Completing the Indicator Review 

We encourage you to use the electronic expert review packet to submit your indicator ratings and 

comments. Responses entered into the electronic expert review packet export directly to a database, 

eliminating the need for additional data entry and validation steps. If you are using the electronic 

version of the rating forms, please read the next section for more information on how to complete the 

packet and submit your ratings. Selected pages or the full expert review packet may be printed if you 

would like a hard copy to reference or record notes on, but we ask that you enter your final ratings and 

comments in the electronic expert review packet. If for some reason you are unable to submit ratings 

and comments electronically, please contact OSH to arrange for hard-copy submission. 

[RATING FORM] 

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188 Tobacco Control Programs—2015 
 

 

 

 

 

APPENDIX D
 

Data Source Indicator Table 

The following table cross-references example data sources and indicators in this publication. The 

example data sources do not represent all data sources available. When possible, Web addresses 

are provided. For additional information on tobacco-related data sources and data collection 

methods, refer to the Introduction to Program Evaluation for Comprehensive Tobacco Control 

Programs1 or Surveillance and Evaluation Data Resources for Comprehensive Tobacco Control 

Programs.

2 

Data source Indicator number For more information 

Addressing Tobacco in Managed 

Care (ATMC), Survey of Health 

Plans, 1997–2002 

3.3.a 

American Lung Association 

(ALA) State Tobacco Cessation 

Coverage Database 

3.2.b ► http://www.lungusa2.org/cessation2/ 

American Lung Association 

(ALA), Tobacco Cessation 

Coverage 2012, Survey of State 

Medicaid, Department of Health 

and Quitline staff 

3.2.a ► http://www.lung.org/assets/documents/tobacco/hel 

ping-smokers-quit-2012.pdf 

Americans for Nonsmokers’ 

Rights (ANR) 

3.3.g; 3.4.a; 3.4.c ► http://www.no-smoke.org 

See “Policy tracking system” 

Birth certificate data 3.8.b 

Behavioral Risk Factor 

Surveillance System (BRFSS), 

2011 

3.7.a; 3.7.b; 3.8.a ► http://www.cdc.gov/brfss/ 

Behavioral Risk Factor 

Surveillance System (BRFSS), 

2013 

3.8.a ► http://www.cdc.gov/brfss/ 

Campaign For Tobacco-Free Kids 

(CTFK) 

3.4.e ► http://www.tobaccofreekids.org/research/factsheets 

/pdf/0097.pdf 

CDC Pregnancy Risk Assessment 

Monitoring System (PRAMS), 

Core Questions, 2009–2012 

3.8.b ► http://www.cdc.gov/prams/Questionnaire.htm#p3 

CDC State Tobacco Activities 

Tracking and Evaluation 

(STATE) system 

3.1.f; 3.4.a; 3.4.e; 

3.6.d 

► http://www.cdc.gov/statesystem/ 

APPENDIX D 

189 
 

 

 

 

 

 

 

 

Data source Indicator number For more information 

CDC Tips From Former Smokers 

Campaign, Pilot Campaign 

Survey, 2014 

3.1.a 

CDC Tips From Former Smokers 

Campaign, Smoker Follow-up 

Questionnaire 

3.1.b 

CounterTobacco 3.5.a ► http://www.countertobacco.org 

Excise tax data from the U.S. 

Department of Treasury’s 

Alcohol and Tobacco Tax and 

Trade Bureau 

3.8.c 

Environmental scan of social 

media Web sites for industry 

presence and pro-tobacco 

content; monitoring and content 

analysis of brand and corporate 

Web sites for age identification 

requirements and messaging 

HealthStyles Survey, 2013 

HealthStyles Survey, 2012 

3.5.e 

3.1.h 

3.5.h 

► Social media monitoring tools can be used for 

surveillance. For example, keywords can be used 

to monitor product and Web site mentions on 

Twitter, blogs, and other social media sites. 

► http://www.cdc.gov/breastfeeding/data/healthstyle 

s_survey/survey_2012.htm 

► http://www.cdc.gov/breastfeeding/data/healthstyle 

s_survey/survey_2012.htm 

International Tobacco Control 

Survey (ITC), 2012 

3.1.h ► http://www.itcproject.org/ 

International Tobacco Control 

Policy Evaluation Study (ITC), 

2011 

3.5.h ► http://www.itcproject.org/surveys 

International Tobacco Control 

Policy Evaluation Study (ITC), 

2008 

3.5.f ► http://www.itcproject.org/surveys 

Interviews with Retailers 3.5.c 

Minnesota Adult Tobacco Survey 

(MATS), 2007 

3.1.c ► http://www.mntobacco.nonprofitoffice.com/ 

National Adult Tobacco Survey 

(NATS), 2009-2010 

3.1.e; 3.1.h; 3.3

3.3.c; 3.3.d; 3.3

3.3.f; 3.6.b; 3.6

3.8.d 

.b; 

.e; 

.c; 

► http://www.cdc.gov/tobacco/data_statistics/surveys 

/nats/ 

National Adult Tobacco Survey 

(NATS), 2013–2014 

3.1.c; 3.1.d; 3.4

3.4.f; 3.5.h; 3.6

3.7.a; 3.7.b; 3.7

3.8.a; 3.8.d 

.d; 

.a; 

.c; 

► http://www.cdc.gov/tobacco/data_statistics/surveys 

/nats/ 

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Data source Indicator number For more information 

National Ambulatory Medical 

Care Survey (NAMCS), 

Electronic Health Records 

3.3.a ► http://www.cdc.gov/nchs/ahcd.htm 

Survey, 2013 

National Ambulatory Medical 

Care Survey (NAMCS), 

Lookback Module, 2013 

3.3.c; 3.3.e ► http://www.cdc.gov/nchs/ahcd/about_ahcd.htm 

National Ambulatory Medical 

Care Survey (NAMCS), Patient 

Record Form, 2011 

3.3.b ► http://www.cdc.gov/nchs/ahcd.htm 

National Health Interview 

Survey (NHIS), 2014 

3.3.b; 3.6.a; 3.7.b; 

3.7.c; 3.8.a 

► http://www.cdc.gov/nchs/nhis/quest_data_related_ 

1997_forward.htm#2013_NHIS 

National Health Interview 

Survey (NHIS), 2012 

3.7.d ► http://www.cdc.gov/nchs/nhis/tobacco/tobacco_que 

stions.htm#questions 

National Health Interview 

Survey (NHIS), Adult Cancer 

Supplement, 2010 

3.3.c ► http://www.cdc.gov/nchs/nhis/quest_data_related_ 

1997_forward.htm#2013_NHIS 

National Health Interview 

Survey (NHIS), Sample Adult 

Diet and Nutrition Supplement, 

2010 

3.8.b ► http://www.cdc.gov/nchs/nhis.htm 

National Hospital Ambulatory 

Medical Care Survey 

(NHAMCS), 2013 Lookback 

Module 

3.3.a; 3.3.c; 3.3.e ► http://www.cdc.gov/nchs/ahcd/about_ahcd.htm 

National Quitline Data 

Warehouse (NQDW) Intake 

Questionnaire, 2012 

3.1.a ► http://www.naquitline.org/?page=NatDataWarehou 

se 

National Quitline Data 

Warehouse (NQDW), Quitline 

Services Survey, 2012 

3.1.f ► http://www.naquitline.org/?page=NatDataWarehou 

se 

National Quitline Data 

Warehouse (NQDW), Quitline 

Services Survey, 2011 

3.6.d ► http://www.naquitline.org/?page=NatDataWarehou 

se 

National Survey on Drug Use 

and Health (NSDUH), 2011 

3.8.d ► http://www.samhsa.gov/data/NSDUH.aspx 

National Survey of Substance 

Abuse Treatment Services (NSSATS), 2012 Questionnaire 

3.3.a ► http://www.icpsr.umich.edu/icpsrweb/ICPSR/series 

/58 

National Survey of Substance 

Abuse Treatment Services (NSSATS), 2011 Questionnaire 

3.3.g ► http://www.icpsr.umich.edu/icpsrweb/ICPSR/series 

/58 

APPENDIX D 

191 
 

 

 

 

 

 

 

 

 

 

Data source Indicator number For more information 

National Youth Tobacco Survey 

(NYTS), 2011 

3.3.b; 3.3.c; 3.4.d; 

3.5.f; 3.6.b; 3.7.a; 

3.7.b; 3.8.a 

► http://www.cdc.gov/tobacco/data_statistics/surveys 

/nyts/ 

National Youth Tobacco Survey 

(NYTS), 2012 

3.1.d; 3.5.h; 3.6.a; 

3.8.d 

► http://www.cdc.gov/tobacco/data_statistics/surveys 

/nyts/index.htm 

New York Adult Tobacco Survey 3.1.a 

New York State’s Retail 

Advertising Tracking Study 

(RATS) 

3.5.a; 3.5.b ► http://www.health.ny.gov/prevention/tobacco_cont 

rol/docs/tobacco_marketing_exposure_rpt.pdf 

Observation of tobacco 

advertising in retail outlets: 

Standardized Tobacco 

Assessment for Retail Settings 

(STARS) 

3.5.a; 3.5.b ► http://www.sctcresearch.org 

Policy tracking system 3.3.g; 3.4.a; 3.4.b; 

3.4.c 

► Americans for Nonsmokers’ Rights 

(http://www.no-smoke.org) 

► State Legislated Actions on Tobacco Issues (SLATI) 

online database 

(http://lungusa2.org/slati/about.php ) 

Population Assessment of 

Tobacco and Health (PATH) 

Study, Adult Extended Interview, 

2012 

3.1.c; 3.5.g; 3.6.f; 

3.7.c; 3.7.d 

► https://pathstudyinfo.nih.gov/UI/FAQsResMob 

ile.aspx 

Pregnancy Risk Assessment 

Monitoring System (PRAMS), 

2009 

3.3.b; 3.3.c; 3.3.e; 

3.6.c 

► http://www.cdc.gov/prams/AboutPRAMS.htm 

Retail observation 3.4.f; 3.5.c ► Operation Storefront: Youth Against Tobacco 

Advertising and Promotion Initiative 

http://www.dhs.ca.gov/tobacco/html/Evaluation_ 

Resources.htm 

Scanner data 3.4.f; 3.5.b 

Scene Smoking, “Thumbs Up! 

Thumbs Down!” 

3.5.d ► http://www.scenesmoking.org/frame.htm 

State departments of revenue 3.4.e; 3.8.c ► State tax sales data, tobacco product excise taxes 

Survey of Dental Practice, 2010 3.3.e ► http://www.healthindicators.gov/Resources/DataSo 

urces/SDP_229/Profile 

The Tax Burden on Tobacco 3.8.c ► https://chronicdata.cdc.gov/Policy/The-Tax-Burdenon-Tobacco-Volume-49-1970-2014/7nwe-3aj9 

Tobacco Industry document 

reviews 

3.5.c ► Legacy Tobacco Documents Library 

http://legacy.library.ucsf.edu/ 

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192 Tobacco Control Programs—2015 
 

 

 

Data source Indicator number For more information 

Tobacco Use Supplement to the 

Current Population Survey (TUSCPS), 2006–2007 

3.1.d; 3.4.d ► http://riskfactor.cancer.gov/studies/tus-cps/ 

Tobacco Use Supplement to the 

Current Population Survey (TUSCPS), 2010–2011 

3.6.b; 3.6.c; 3.6.e; 

3.6.f; 3.7.d 

► http://appliedresearch.cancer.gov/tus-cps/info.html 

Youth Risk Behavior 

Surveillance System (YRBSS), 

2015 

3.8.a ► http://www.cdc.gov/HealthyYouth/yrbs/index.htm 

References 

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

program evaluation for comprehensive tobacco control programs. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, 

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

and Health; 2001. 

2. Centers for Disease Control and Prevention. Surveillance and evaluation data resources for 

comprehensive tobacco control programs. Atlanta, GA: Centers for Disease Control and 

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

on Smoking and Health; 2014. Available at: 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/pdfs/surve 

illance_evaluation_508.pdf 

APPENDIX D 

193 

 

 

 

 

 

 

Glossary and Acronyms 

Activities 

The events or actions that are part of a tobacco control program. 

Attitudes 

Biases, inclinations, or tendencies that influence a person’s response to situations, activities, 

other people, or program goals. 

Awareness 

The extent to which people in the target population know about an event, activity, or 

campaign. 

Capacity 

The resources (e.g., staff, data collection systems, funds) needed to conduct a tobacco control 

program or to evaluate such a program. 

CDC 

Centers for Disease Control and Prevention. 

Cognitive-behavioral interventions 

Activities based on the premise that people can learn new behaviors to use in response to 

stimuli and that the thought processes that serve as intermediate steps between stimuli and 

behaviors can be altered, thereby influencing behavior. Basic applications of this theory for 

tobacco-use cessation are 

► establishing self-awareness of tobacco use, 

► providing the motivation to quit, 

► preparing to quit, and 

► providing strategies to maintain abstinence. 

Comprehensive cessation coverage 

Comprehensive cessation services are currently defined as coverage of all 10 evidence-based 

treatments recommended by the U.S. Public Health Service.1 

Consumption 

The number of tax-paid cigarettes (pack of 20) purchased by consumers in a particular 

calendar year. 

Current tobacco user 

An individual who reports using a given tobacco product everyday or some days in the past 

30 days. Note that some surveys restrict current adult tobacco users to those who have 

smoked at least 100 cigarettes (or used a given tobacco product) in their lifetime as well as 

used a given tobacco product in the past 30 days. 

GLOSSARY 

195 
 

 

Data 

Documented information or evidence. 

Data sources 

Surveys or surveillance systems used to gather data. 

Designated market area (DMA) 

A region (i.e., a number of grouped counties that in some instances cross state borders) where 

the population can receive the same (or similar) retail, television, and radio station offerings, 

and may also include other types of media, including newspapers and Internet content. 

Dual use 

Use of two different types of tobacco products either every day or some days. 

Earned media 

Refers to publicity gained through promotional efforts other than paid advertising. 

Electronic Health Record 

An electronic health record is a digital version of a patient’s paper medical chart. Electronic 

health records are real-time, patient-centered records that make information available 

instantly and securely to authorized users.3 

Emerging tobacco products 

All newer, non-cigarette tobacco or nicotine-containing products that are not nicotine 

replacement therapies (NRTs). Examples include electronic nicotine delivery systems such as 

e-cigarettes, dissolvables, nicotine gels, snus, and waterpipe tobacco. 

Evaluation 

The process of determining whether programs—or certain aspects of programs—are 

appropriate, adequate, effective, or efficient and, if not, how to make them so. 

Everday smoker 

An individual who reports having smoked at least 100 cigarettes in their lifetime and 

currently using cigarettes everyday. 

Ever-smoker 

A person who reports having tried cigarette smoking, even one or two puffs. 

Example data source 

Surveys or surveillance systems used to measure an indicator and the population on which 

the data are needed. 

Face validity 

The degree to which data on an indicator appear reliable to stakeholders and policy makers. 

Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) 

Gives the Food and Drug Administration (FDA) the authority to regulate the manufacture, 

distribution, and marketing of tobacco products to protect public health. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

196 Tobacco Control Programs—2015 
 

FDA 

U.S. Food and Drug Administration. 

Former tobacco users 

An individual who reports having used a given tobacco product in their lifetime but currently 

does not use the tobacco product. Note that some surveys qualify former smokers as those 

individuals who report having smoked at least 100 cigarettes during their lifetime but 

currently do not use cigarettes. 

Goal area 

One of the four components of the overall goal of CDC’s National Tobacco Control 

Program. 

Implementation 

Carrying out or putting into effect a plan or program. 

Indicator 

An observable and measurable characteristic or change that shows the progress a program is 

making toward achieving a specified outcome. 

Indicator profile 

The term used in this manual for a table with detailed information on one indicator listed in 

this publication (see page 32 for an example). 

Indicator rating table 

The term used in this publication for the list of indicators associated with one outcome in one 

National Tobacco Control Program logic model. The experts’ rating for each indicator is also 

included (see page 31 for an example). 

Inputs 

Resources used to plan and set up a tobacco control program. 

Intervention 

The method, device, or process used to prevent an undesirable outcome or create a desirable 

outcome. 

Logic model 

A graphic depiction of the presumed causal pathways that connect program inputs, activities, 

outputs, and outcomes. 

Media messages 

Anti-tobacco information provided to the public through various media (e.g., television, 

radio, billboards). 

Morbidity 

Disease or disease rate. 

GLOSSARY 

197 
 

 

NCI 

National Cancer Institute. 

Never-smoker 

A person who reports never having tried cigarette smoking, even one or two puffs. 

NIH 

National Institutes of Health. 

NTCP 

National Tobacco Control Program. 

Observation 

A method of collecting data that does not involve any communication with the subjects being 

studied. The investigators merely watch for particular behaviors and record what they see. 

Opinion leader survey 

Collection of information (data) from leaders in the community. 

Outcome 

The results of an activity such as a countermarketing campaign or an effort to reduce 

nonsmokers’ exposure to smoke. Outcomes can be short-term, intermediate, or long-term. 

Outcome components 

The term used in this publication for the short-term, intermediate, and long-term results 

described in the National Tobacco Control Program logic models for the first three goal 

areas. These are the results expected if tobacco control programs provide the needed inputs 

and engage in the recommended activities also described in the logic models. 

Outcome evaluation 

The systematic collection of information to assess the effect of a program or an activity 

within such a program to reduce the adverse health effects of tobacco use. Good evaluation 

allows evaluators to draw conclusions about the merit of a program and make 

recommendations about the program’s direction. 

Outcome overview 

The term used in this publication for the summary of the scientific evidence in support of the 

assumption that achieving an outcome on a National Tobacco Control Program logic model 

affects all concurrent and later activities and outcomes (see page 28 for an example). 

Outputs 

The direct products of a program (e.g., the materials needed for a media campaign). 

Point of sale 

Retail environment where tobacco products are purchased. 

Population group 

Individuals from which data about a given indicator can most commonly be collected. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

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Preemption 

Federal or state legislation that prevents states or local jurisdictions from enacting tobacco 

control laws more stringent than or otherwise different from the federal or state law. 

Prevalence 

The proportion or percent of a specificed population that has a factor of interest (e.g., tobacco 

use, awareness of a media campaign) at a specified point in time. 

Price discounts 

Tobacco manufacturers’ reductions in the prices paid by retailers and/or wholesalers for 

tobacco products, who in turn reduce the prices to consumers, such as off-invoice discounts, 

buy-downs, and voluntary price reductions. 

Process evaluation 

Systematic collection of information to determine how well a program is implemented and 

operated. 

Program evaluation 

Systematic collection of information about activities, characteristics, and outcomes of 

programs, used to make judgments about a program, improve its effectiveness, or inform 

decisions about future program activities. 

Purchaser 

Health insurance purchasers include companies, government agencies, or other consortia who 

procure health care benefits for a group of individuals. 

Quit attempt 

Stopping use of a given tobacco product for one day or more because an individual is trying 

to quit using the product. Note that surveys may differ in the time threshold for a quit 

attempt, from the prior twelve months for a recent quit attempt to ever quitting in a lifetime.2 

Rate 

A measurement of how frequently an event occurs in a certain population at one point in time 

or during a particular period of time. 

Reach 

The absolute number, proportion, and representativeness of persons who are exposed to or 

participate in a given program or intervention. Representativeness refers to whether 

participants have characteristics that reflect the target population. 

Recent successful quit attempts 

Proportion of former smokers who last smoked 6 months to 1 year ago. 

Receptivity 

The extent to which people are willing to listen to a persuasive message. 

GLOSSARY 

199 
 

Resources 

Assets available or expected to be available for program operations. Resources include 

people, equipment, facilities, and other items used to plan, implement, and evaluate public 

health programs whether or not they are paid for directly with public funds. 

Retail observation 

In-store observations of product displays, display position and prominence, placement, 

shelving, inventory, variety of product available, measurement of shelf space, price, and 

availability of discounts or special pricing. 

Slotting fees 

Payments for stocking, shelving, displaying, and merchandising tobacco brands in a certain 

manner. 

Some-day smoker 

A current smoker who has smoked at least 100 cigarettes in their lifetime and gives a 

“smoked on some days” response. 

SMART Objective 

“Objectives are statements describing the results to be achieved and the manner in which 

these results will be achieved... A well-written and clearly defined objective is SMART: 

Specific, Measurable, Achievable and Ambitious, Relevant, and Time-bound.” (page 25)4 

Smoking initiation 

The beginning of cigarette use. Survey definitions of smoking initiation vary from when a 

respondent reports smoking part of a cigarette, to smoking a whole cigarette, to smoking 

cigarettes on a fairly regular or daily basis. 

Stakeholder 

The persons or organizations that have a vested interest in what will be learned from an 

evaluation and what will be done with the information. 

Surveillance 

The ongoing, systematic collection, analysis, and interpretation of data about a hazard, risk 

factor, exposure, or health event. 

Survey 

A quantitative method of collecting information on a target population at one point in time. 

Surveys can be conducted by interview (in person or by telephone) or by questionnaire. 

Susceptibility 

The intention to smoke or the absence of a strong intention not to smoke. 

Sustained abstinence 

Complete cessation of tobacco use for 6 months or longer. 

Theory of change 

Intellectual framework for understanding the process of behavior change. 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

200 Tobacco Control Programs—2015 
 

Utility
 

The extent to which evaluation produces reports that are disseminated to relevant audiences,
 

that inform program decisions, and that have a beneficial effect.
 

GLOSSARY 

201 
 

 

 

 

 

 

References: 

1. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco 

use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; May 2008. 

2. Agaku IT, King BA, Dube SR; Centers for Disease Control and Prevention. Current cigarette 

smoking among adults—United States, 2005–2012. Morbidity and Mortality Weekly Report. 

2014 Jan 17;63(2):29–34. 

3. HealthIT.gov. What is an electronic health record (EHR)? Available at: 

http://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr. 

Accessed June 4, 2014. 

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

program evaluation for comprehensive tobacco control programs. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, 

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

and Health; 2001. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/surveillance_eva 

luation/evaluation_manual/index.htm 

Additional Resources: 

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

course for effective program evaluation. Atlanta, GA: Centers for Disease Control and Prevention, 

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

Health; Division of Nutrition, Physical Activity, and Obesity; 2011. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/surveillance_evaluation/ 

evaluation_plan/index.htm 

Centers for Disease Control and Prevention. Developing an effective evaluation report: setting the 

course for effective program evaluation . Atlanta, GA: Centers for Disease Control and Prevention, 

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

Health; Division of Nutrition, Physical Activity, and Obesity; 2013. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/surveillance_evaluation/ 

evaluation_report/index.htm 

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

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

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

Smoking and Health, 2014. Available at: 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/preventing_89i/pdfs/ 

preventing_initiation.pdf 

PROMOTING QUITTING AMONG ADULTS AND YOUNG PEOPLE: OUTCOME INDICATORS for Comprehensive 

202 Tobacco Control Programs—2015 
 

Figure 2: How to Use the Rating Table 

Outcome 1 

Increased intention to quit, perceived harm of tobacco use, and awareness of and support 

for cessation services 

Indicator Rating

 better 

Overall Quality 

Number Indicator low high 

3.1.a Level of awareness of anti-tobacco $$

media messages 

Indicator number 

Strength of Evaluation 

Evidence

Resources Needed

Accepted Practice 

Utility

Face

Validity

3.1.a 

Goal area Outcome component 

within the goal 

Indicator 

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

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

Resources needed: Dollar signs show the amount of resources (funds, time, and effort) needed to collect 

and analyze data on the indicator using the most commonly available data source: the more dollar signs 

(maximum four), the more resources needed. The dollar signs do not represent specific amounts because 

the actual cost of measuring and analyzing an indicator varies according to the existing capacity of a state 

health department or organization to evaluate its programs. 

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

implementing interventions to effect change in a given indicator will lead to a measurable downstream 

outcome. This includes the extent to which reviewers believed that the scientific literature supports use 

of the indicator for the evaluation of comprehensive, statewide tobacco control programs and considers 

conflicting evidence as well as concerns regarding the methodology of supporting studies. 

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

program evaluation questions. 

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

stakeholders, such as policy and decision makers who may be users of tobacco control program evaluation 

results. 

Accepted practice: The degree to which use of the indicator is consistent with currently accepted, realworld tobacco control practice. 
CS247639