Eliminating Exposure 

to Secondhand Smoke: 

Outcome Indicators for Comprehensive 

Tobacco Control Programs–2017

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. This guide was developed as the third 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 prevention and control programs. 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

Internet 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 CDC or the federal government, and 

none should be inferred. CDC is not responsible for web content posted by other organizations.

Suggested Citation

Centers for Disease Control and Prevention. Eliminating Exposure to Secondhand Smoke: Outcome Indicators 

for Comprehensive Tobacco Control Programs–2017. Atlanta, GA: Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2017.
PREFACE iii

Preface

Purpose

Exposure to secondhand smoke has been causally linked to adverse health outcomes, including 

heart disease, stroke, and lung cancer in adults, and acute respiratory infections, ear problems, 

more frequent and severe asthma, and sudden infant death syndrome in children.1-3 Among adult 

nonsmokers, secondhand smoke exposure causes an estimated 7,300 lung cancer deaths and 

34,000 heart disease deaths each year.3 The U.S. Surgeon General has concluded that there is no 

risk-free level of secondhand smoke exposure.1 

Studies have shown that comprehensive laws prohibiting smoking in all indoor areas of public 

places, including worksites, restaurants, and bars; voluntary smokefree rules prohibiting smoking 

in homes and vehicles at all times; and smokefree policies in multiunit housing protect 

nonsmokers from the health hazards of secondhand smoke exposure in these environments.1,3-7

There is a comprehensive body of scientific evidence demonstrating the positive population 

health benefits of smokefree policies. Meta-analyses have shown a variety of population-level 

health improvements immediately following smokefree policy implementation, including fewer 

cardiovascular events, preterm births, and childhood asthma exacerbations.8-9 Furthermore, these 

policies have the additional benefit of reducing smoking rates among youth and adults by 

lowering the visibility of role models who smoke, reducing opportunities to smoke, and 

diminishing the social acceptability of smoking.1,2,6,7 Studies have also shown that smokefree 

polices increase the number of tobacco users who quit and reduce initiation among young 

people.3

To sustain comprehensive tobacco prevention and 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 for state tobacco prevention and control programs continue to 

evaluate their programs. Selecting appropriate outcome indicators is a key step in designing a 

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

This publication is the third in a series of updates to the guide previously released 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,

10 hereafter 

referred to as KOI 2005. As a companion to the 2001 publication, Introduction to Program 

Evaluation for Comprehensive Tobacco Control Programs,

11 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 2 of the National Tobacco 

Control Program (NTCP), which addresses eliminating exposure to secondhand smoke. 

Additionally, the Addendum includes proposed non-rated outcome indicators to assess exposure 

to secondhand aerosol from electronic cigarettes (e-cigarettes). Although this update focuses on 

the elimination of secondhand smoke exposure, comprehensive tobacco prevention and control 

programs that simultaneously address initiation of smoking, the elimination of secondhand 
iv ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

smoke, and smoking cessation are more effective than programs that address these issues 

separately.4

This resource can be used in combination with outcome indicators from Preventing Initiation of 

Tobacco Use: Outcome Indicators for Comprehensive Tobacco Control Programs—201412 and 

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

13 Tobacco Control Programs—2015. Additionally, 

as with KOI 2005, this update supports application 

of CDC’s Framework for Program Evaluation in 

Public Health Practice,14 which consists of the 

following six steps of good evaluation: 

1. Engage stakeholders. 

2. Describe the program. 

3. Focus the evaluation. 

4. Gather credible evidence. 

5. Justify your conclusions. 

6. Ensure evaluation findings are used 

and share lessons learned. 

This publication provides updated, new, and developmental indicators and supporting 

information relevant to recent changes in the tobacco control landscape regarding elimination of 

secondhand smoke exposure. In recent years, considerable progress has been made in increasing 

the proportion of the population covered by state or local comprehensive smoke-free laws that 

prohibit smoking in indoor public places, including worksites, restaurants, and bars.15 However, 

these laws do not extend to private settings, such as homes. The home is the primary source of 

secondhand smoke exposure for children, and a major source for adults.1 Moreover, individuals 

who reside in multiunit housing are particularly susceptible to secondhand smoke drifting 

between living units. In 2016, the U.S. Department of Housing and Urban Development issued a 

rule requiring all public housing authorities to adopt smokefree polices by prohibiting the use of 

“prohibited tobacco products,” including cigarettes, cigars, pipes, and waterpipes.14

Furthermore, there has been a substantial increase in the use of emerging tobacco products over 

the past several years. For example, e-cigarettes are now the most commonly used tobacco 

product among U.S. youth, and in 2016, the U.S. Surgeon General concluded that e-cigarette 

aerosol is not harmless; it can contain harmful and potentially harmful constituents.17-20

E-cigarettes include a diverse group of devices designed to deliver aerosolized nicotine and 

additives to users. These devices are referred to by companies, the media and consumers by 

various terms, themselves, and by consumers as “e-cigarettes,” “e-cigs,” “cigalikes,” 

“e-hookahs,” “mods,” “vape pens,” “vapes,” and “tank systems.” In this guide, the term 

“e-cigarette” is used to represent all the various products in this evolving product category.20

State surveillance and evaluation efforts are critical to assess the impact of e-cigarette initiation 

and use within the broader tobacco prevention and control landscape, particularly in the context 

of youth.
PREFACE v

Given these changes, OSH recognized the importance of revisiting and updating the outcome 

indicators for Goal Area 2, Eliminating Exposure to Secondhand Smoke. This update also 

incorporates developmental indicators for e-cigarettes to underscore the importance of assessing 

their public health impact within the context of tobacco prevention and control efforts relevant to 

secondhand smoke and secondhand e-cigarette aerosol exposure. 

Tobacco prevention and control program managers and evaluators can use the information in this 

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

guide informs the selection of indicators, linking indicators to related outcomes. To help users 

make informed choices about which indicators are most suitable for each program and context, 

an external panel rated each indicator on the following relevant criteria: overall quality, resources 

needed, strength of evaluation evidence, utility, and accepted practice.

The guide can also assist 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 prevention and control program efforts by providing a summary of scientific evidence, 

example questions, and data sources for each indicator. A primary purpose of this publication is 

to assist state-specific and national evaluation and surveillance efforts and to measure and report 

these using protocols and operational definitions drawn from widely available state or national 

data collection systems. Special care was taken in choosing example data sources and survey 

questions; most are drawn from common state and national surveys and surveillance systems, 

and using them may help managers and evaluators compare their findings to data collected 

across states and nationally.

Technical Assistance

CDC/OSH helps state and territorial health departments plan, implement, and evaluate tobacco 

prevention and control programs. To contact them, please call (800) 232-4636 or e-mail 

tobaccoinfo@cdc.gov. 

References

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

exposure to secondhand 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. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

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—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. 
vi ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/#fullreport. 

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

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

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

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

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm. 

5. International Agency for Research on Cancer. Evaluating the effectiveness of smoke-free 

policies. Lyon, France: International Agency for Research on Cancer; 2009. 

6. Wakefield M, Forester J. Growing evidence for new benefit of clean indoor air laws: 

reduced adolescent smoking. Tobacco Control. 2005;14(5):292–3. 

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

exposure: smokefree policies. Available at: 

www.thecommunityguide.org/tobacco/smokefreepolicies.html. Last updated: September 22, 

2014. 

8. Tan CE, Glantz SA. Association between smoke-free legislation and hospitalizations for 

cardiac, cerebrovascular, and respiratory diseases: a meta-analysis. Circulation. 

2012;126(18):2177–83. doi: 10.1161/CIRCULATIONAHA.112.121301. 

9. Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smokefree legislation on perinatal and child health: a systematic review and meta-analysis. Lancet. 

2014;383(9928):1549–60. doi: http://dx.doi.org/10.1016/S0140-6736(14)60082-9

10. 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. 

11. 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. 

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

indicators for comprehensive tobacco control programs—2014. 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/preventing_i

nitiation/pdfs/preventing_initiation.pdf. 

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

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. 

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. 
PREFACE vii

15. Centers for Disease Control and Prevention. State Activities Tracking and Evaluation 

(STATE) System. Available at https://www.cdc.gov/statesystem/index.html. Accessed 

August 2017. 

16. U.S. Department of Housing and Urban Development, 2016. Instituting Smoke-Free 

Multiunit Housing. Available at 

https://www.federalregister.gov/documents/2016/12/05/2016-28986/instituting-smoke-freepublic-housing. Accessed August 10, 2017. 

17. King BA, Patel R, Nguyen KH, Dube SR. Trends in awareness and use of electronic 

cigarettes among U.S. adults, 2010–2013. Nicotine & Tobacco Research. 2015;17(2):219–

27.16. 

18. Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. 

NCHS Data Brief. October 2015;217. Available at: 

http://www.cdc.gov/nchs/data/databriefs/db217.pdf.

19. Arrazola RA, Singh T, Corey CG, et al. Tobacco use among middle and high school 

students—United States, 2011–2014. Morbidity and Mortality Weekly Report. 

2015;64(14):381–5. 

20. U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young 

Adults. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. 

TABLE OF CONTENTS ix

Table of Contents

Preface iii

Chapter 1 ►Introduction 1

Chapter 2 ►Goal Area 2: Eliminating Exposure to Secondhand Smoke 17

Outcome 1: Increased Knowledge of the Dangers of Secondhand Smoke 

and Support for Policies to Reduce Secondhand Smoke 24

Outcome 2: Implementation and Enforcement of Smokefree Policies 45

Outcome 3: Compliance with Smokefree Policies 78

Outcome 4: Reduced Exposure to Secondhand Smoke 92

Outcome 5: Reduced Tobacco Consumption 118

Addendum ►Electronic Cigarettes (E-Cigarettes) 139

Addendum: Electronic Cigarettes 141

Appendices and Glossary ► 153

Appendix A ► National Tobacco Control Program 155

Appendix B ► Expert Panel Members 159

Appendix C ► Selecting and Rating the Indicators 163

Appendix D ► Data Source Indicator Table 173

Glossary and Acronyms ► 179

CHAPTER 1

Introduction

CHAPTER 1 ► Introduction 1

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 prevention and control programs. This publication provides an updated 

logic model linking activities to outcomes for Goal Area 2—Eliminating Exposure to 

Secondhand Smoke—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 indicators can be used 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 and other OSH 

surveillance and evaluation resources, which can be accessed at 

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/index.htm. 

Audience

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

and territorial tobacco prevention and 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 areas:

► Preventing initiation of tobacco use. 

► Eliminating exposure to secondhand smoke. 

► Promoting quitting among adults and young people. 

► Identifying and eliminating tobacco-related disparities.

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 connect program inputs, 

activities, and outputs with short-term, intermediate, and long-term outcomes.2 Figure 1 presents 

an example of a basic logic model.
2 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

To help tobacco prevention and control programs with planning and evaluation, we numbered 

the outputs (i.e., direct results of program activities) and outcomes in each NTCP 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 longterm 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 short-term, 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 3 as a 

primary intermediate outcome. Program activities designed to achieve changes in short-term 

Outcomes 1 and 2 (linked vertically on the logic model) would be expected to lead to changes in 

Outcome 3 and to affect long-term Outcomes 4 through 7. 

The revised Goal Area 2 logic model includes the following changes to outcomes from the 

original 2005 Key Outcome Indicators for Evaluating Comprehensive Tobacco Control 

Programs (KOI 2005 hereafter): 

Figure 1: Example of Logic Model

Generic Logic Model
CHAPTER 1 ► Introduction 3

► Changed the outcome “Increased knowledge of, 

improved attitudes toward, and increased support for 

the creation and active enforcement of tobacco-free 

policies” to “Increased knowledge of the dangers of 

secondhand smoke and support for policies to reduce 

secondhand smoke” (Outcome 1). This change was 

intended to better reflect the link between increased 

knowledge of the dangers of secondhand smoke and 

support for policies to reduce secondhand smoke. 

► Combined the outcome “Creation of tobacco-free 

policies” and “Enforcement of smokefree policies” into 

one outcome: “Implementation and enforcement of 

smokefree policies” (Outcome 2). This change was 

intended to clarify the implied logic and order of 

effects. 

► Changed the outcome “Compliance with tobacco-free 

policies” to “Compliance with smokefree policies” 

(Outcome 3). This change was intended to better reflect 

the science in this area and account for the fact that 

secondhand smoke is smoke from combustible tobacco 

products, such as cigarettes, cigars, or pipes. 

Indicators

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

represent achievement of an outcome.6 For example, if your program is trying to increase 

“Adoption and enforcement of smokefree policies” (Outcome 2) and you measured the 

“Proportion of jurisdictions with comprehensive smokefree policies for indoor public places” 

(Indicator 2.2.a), the result would indicate the extent of your progress toward creating smokefree 

policies in indoor public places, including workplaces, restaurants, and bars in all jurisdictions.

Monitoring a single indicator can serve as a helpful guidepost, but it is important to include 

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

to help ensure a robust evaluation. By mapping a causal pathway across the logic model and 

measuring key indicators along this pathway, tobacco prevention and control programs can begin 

to see where efforts are making gains and where they are not. When a key indicator within the 

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

program itself is failing to achieve the intended effects 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/stateandcommunity/tobacco_control_programs/surveillance_evaluat

ion/evaluation_plan/pdfs/developing_eval_plan.pdf. 
4 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Tobacco Products Other than Cigarettes

We updated the indicators to incorporate a wide breadth of tobacco products other than cigarettes 

to acknowledge the use of new and emerging tobacco products among adults and youth. In 

particular, this publication proposes non-rated developmental indicators relevant to secondhand 

aerosol from e-cigarettes in recognition of their prominent use and public health impact within 

the context of comprehensive tobacco prevention and control efforts. Indicators in this guide are 

particularly useful for measuring progress toward reducing cigarette use and exposure to smoke 

from combustible tobacco products (e.g., cigarettes, cigars, conventional pipes, 

waterpipes/hookah). However, programs are advised to consider all tobacco product use patterns 

in their community, including e-cigarettes, when making decisions regarding surveillance and 

evaluation activities. This can help to assess their impact on tobacco control efforts, including 

their effects on tobacco use and compliance with smokefree polices.

Identifying and Eliminating Disparities

To achieve health equity in tobacco prevention and control, it is critical for tobacco prevention 

and control programs to maintain a 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 all populations, including those 

experiencing tobacco-related disparities. This includes ensuring culturally meaningful outputs, 

and collecting and analyzing data to identify populations experiencing tobacco-related disparities 

and to monitor outcomes in these populations. In considering what outcomes to monitor, it is 

important to remember that disparities in secondhand smoke exposure are not caused by a single 

factor and the impact outcomes have on reducing secondhand smoke among disparate 

populations involves a complex interaction of multiple factors.6

It is important for programs to consider their local context when making decisions regarding 

capturing information by population characteristics, such as race/ethnicity, geography, age 

group, educational attainment, employment status, and poverty status. Throughout this guide, we 

have highlighted population characteristics associated with particular indicators when the 

evidence is particularly strong in demonstrating an association between the indicator and its 

effect on reducing secondhand smoke exposure in those populations. Programs can consistently 

measure all indicators by population characteristics to better understand the reach and impacts of 

their activities on all populations and to build the evidence base needed for improved tobacco 

control. 

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 distal outcomes is well established. Therefore, tobacco prevention and control 

programs could consider demonstrating an effect on behavioral outcomes, which in turn would 

be expected to lead to favorable health effects. Second, we determined that the greatest expressed 

needs by states for evaluation assistance would be addressed by identifying short-term and 

intermediate outcome indicators.
CHAPTER 1 ► Introduction 5

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 some states have not had comprehensive 

programs in place long enough to show such effects.9-11 We also do not intend to imply that 

measuring outcomes is sufficient for evaluating a tobacco prevention and control program. 

Equally important is process evaluation, which focuses on measuring the process of program 

implementation. (See Introduction to Process Evaluation in Tobacco Use Prevention and 

Control12 for information on process evaluation.) 

Indicator Selection and Rating

To develop this guide, CDC proposed a set of outcome indicators (including new, 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 decision makers, conformity with accepted practice, uniqueness, and how essential the 

indicator is for evaluating state tobacco prevention and 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 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 that lists 

the 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. 

Figure 2 presents an example of an indicator rating and an explanation of how to read it. The 

ratings are based on the following criteria:

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

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

► Resources needed. Intensity of resources warranted to collect reliable and precise measures 

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

include availability of existing data (e.g., archival records or other secondary data) versus 

need for primary data collection, and methodological and sampling issues. Dollar signs 

show the amount of resources (funds, time, and effort) needed to collect and analyze data on 

the indicator using the most commonly available data source: the more dollar signs 

(maximum four), the more resources needed. The dollar signs do not represent specific 
6 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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 prevention and control programs, and considers 

conflicting evidence and concerns regarding the methodology of supporting studies. 

Indicators with the highest ratings have a strong demonstrated relationship between the 

indicator and a downstream logic model outcome. 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 strong. Indicators with low ratings may have substantial conflicting literature and/or 

weak methodological designs.

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

tobacco prevention and control program evaluation questions. 

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

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

control program evaluation results. 

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

accepted, real-world tobacco control practice. 

Figure 2: Example of Rating Table

Outcome 1

Increased Knowledge of the Dangers of Secondhand Smoke and Support for Policies to Reduce Secondhand Smoke
CHAPTER 1 ► Introduction 7

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). A low response 

suggests a high degree of uncertainty among raters. An example of a rating for which there 

was low reviewer response is the strength of literature support score for Indicator 2.3.a: 

Compliance with smokefree policies in public places and workplaces. 

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

warranted, 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 Indicator 

2.2.k: Number and type of enforcement actions issued regarding smokefree policies. 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 longterm outcome component of the NTCP Eliminating Exposure to Secondhand Smoke (Goal 2) 

logic model. The number of indicators for each logic model component varies considerably (e.g., 

Outcome 3 has five indicators, whereas Outcome 2 has 12 indicators). 

We provide a profile for each indicator that presents the following detailed information:

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

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

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

For example, Indicator 2.1.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 2. 

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

logic model.

► 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 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.13 We also list nonstandardized, topic-specific 

data sources (e.g., media tracking, policy tracking, worksite surveys, environmental scans, 
8 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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 

prevention and 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, 

at times, created an example question.

► 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, potential elements of a model policy that may be used to 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 recommend capturing 

information about broader groups or different types of tobacco products. Please note that 

changes to existing survey items should be made with caution. It is important to conduct 

sufficient cognitive testing 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 is one of the five essential core components of infrastructure according to the 

evidence-based Component Model of Infrastructure.15 It is critical for states to have accurate and 

timely evaluation data to demonstrate the effects of the program, account for funding, and 

enhance programs. Effective tobacco prevention and control programs require careful planning, 

implementation, and 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. It is important that programs avoid two common pitfalls: (1) implementing 

interventions without sufficient plans or funds for evaluation, and (2) selecting indicators 

primarily for research purposes rather than for program evaluation.2

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

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

Practice13 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 
CHAPTER 1 ► Introduction 9

written evaluation plan as well as implementing additional steps of CDC’s Framework for 

Program Evaluation in Public Health Practice.

13

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 preventing tobacco use initiation 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 prevention and control program’s 

efforts and expected outcomes related to the goal of preventing tobacco use initiation. An 

updated logic model is included that shows how activities lead to outcomes based on evidence 

from research and practice.

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 exercise, done in coordination with 

the ESW, can help to clarify the scope of the evaluation and provide basic information needed to 

complete step 2, describe the program. 

It is critical for program staff and stakeholders to agree on 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 
10 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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, as well as the key evaluation questions, have been 

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

objectives 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.

Step 5. Planning for conclusions

Justifying evaluation findings includes working in coordination 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, as well as through the graphic display of 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 best be 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., specific, measurable, achievable, relevant, and timebound).2

 An example of a SMART objective is increasing the proportion of the population that 
CHAPTER 1 ► Introduction 11

thinks secondhand smoke is harmful to their health (Indicator 2.1.c) from 60% in January 2016 

to 75% in January 2018. 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 Prevention and Control Program: A Hypothetical 

Example

It is important to evaluate the entire comprehensive tobacco prevention and control program 

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

example focuses on eliminating exposure to secondhand smoke. In practice, concurrent 

evaluation efforts of work related to the other goal areas would be occurring, providing 

numerous synergies in terms of program and evaluation planning. 

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

exposure of adult nonsmokers to secondhand smoke and that state legislators are concerned 

about this increase. The State Health Officer announced that new funds may become available if 

the state tobacco prevention and control program can show that it is effective in reducing 

nonsmokers’ exposure to secondhand smoke. 

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

evaluation planning steps previously described as follows: 

Step 1: Engage stakeholders 

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

plan as facilitating improvement to aid program development and reaches out to individuals who 

have a vested interest in the evaluation findings, such as clients, community groups, and staff 

involved in running the tobacco prevention program. In this example, 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 State Health Officer is providing funds 

specifically to eliminate secondhand smoke exposure. Therefore, the ESW chooses NTCP Goal 

Area 2: Eliminating Exposure to Secondhand Smoke and reviews the logic model. The group 

decides to focus on the following long-term outcome: Outcome 4. “Reduced exposure to 

secondhand smoke.” To learn more about Outcome 4, program staff review the outcome 

component overview (page 92), 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 members read the logic model for NTCP Goal Area 2 

backward (starting at the long-term outcome) to select intermediate and short-term outcomes that 

are linked to the long-term outcome. They select the intermediate outcome: Outcome 3. 

Compliance with smokefree policies.

This intermediate outcome (Outcome 3) serves as a funnel between the long-term outcome and 

two short-term outcomes in the logic model of NTCP Goal Area 2: 
12 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• Outcome 1: Increased knowledge of the dangers of secondhand smoke and support for 

policies to reduce secondhand smoke 

• Outcome 2: Implementation and enforcement of smokefree policies 

The ESW understands that, based on the evidence, achieving these short-term and intermediate 

outcomes should lead to achieving the selected long-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 long-term 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 Health Officer expressed an interest in this effort, the ESW wants to select 

indicators that have a high rating for face validity to policy makers. Also, given budget 

constraints, they want 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, 2, and 3), beginning with Outcome 1. The staff examine 

the indicator rating table for Outcome 1 (page 27). 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 28–44).

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 also considers the feasibility of the 

evaluation plan.

The ESW realizes that data collection for all of the indicators would be equally expensive if they 

were to design and implement a new survey. However, they realize that two indicators associated 

with outcome component 1 can be measured using the state Adult Tobacco Survey that they 

conduct regularly: 

2.1.c Proportion of the population that thinks secondhand smoke is harmful; 

2.1.d Level of support for adopting smokefree policies in public places and workplaces. 
CHAPTER 1 ► Introduction 13

The planners and evaluators use the same process to select indicators for outcome components 2 

and 3: 

2.2.a Proportion of jurisdictions with comprehensive smokefree policies for indoor public 

places; 

2.2.c Proportion of the employed population covered by a workplace smokefree policy; 

2.3.a Compliance with smokefree policies in public places and workplaces. 

Step 5. Planning for conclusions

As part of their comprehensive tobacco prevention and 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 that 

decrease availability of tobacco to young people. 

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

continuously (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, the program staff and ESW translate 

indicators into SMART program objectives. For example, for Indicator 2.2.a (Proportion of 

jurisdictions with comprehensive smokefree policies for indoor public places), they create the 

following objective: Increase the proportion of jurisdictions with comprehensive smokefree 

policies for indoor public places from 40% in July 2016 to at least 60% in June 2017. 

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, the 

program staff and 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 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 ESW carefully consider how, 

when, and to 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 document to engage the State Health Officer and other health 

department 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 2 logic 

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

information is included tracking change over time and comparing data with those from similar 

states.
14 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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/surveillance_eva

luation/evaluation_plan/pdfs/developing_eval_plan.pdf. 

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. 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. Lantz PM. Smoking on the rise among young adults: implications for research and policy. 

Tobacco Control. 2003;12(Suppl. 1):i60–i70. doi: 10.1136/tc.12.suppl_1.i60 

5. Gilpin EA, White VM, Pierce JP. What fraction of young adults are at risk for future 

smoking, and who are they? Nicotine & Tobacco Research. 2005;7(5):747–59. 

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

VA: United Way of America; 1996. 

7. Centers for Disease Control and Prevention. CDC health disparities and inequalities report—

United States. Morbidity and Mortality Weekly Report. 2011;60:1–109. 

8. Roeseler A, Burns D. The quarter that changed the world. Tobacco Control. 2010;19(Suppl 

1):i3–15. doi: 10.1136/tc.2009.030809 

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. 

10. Fiore M, Bailey W, Cohen S, Dorfman S, Goldstein M, Gritz E, et al. Treating tobacco use 

and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human 

Services, Public Health Service; 2008. 

11. 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. 

12. 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: 
CHAPTER 1 ► Introduction 15

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

aluation/process_evaluation/pdfs/tobaccousemanual_updated04182008.pdf. 

13. Yee SL, Schooley M. Surveillance and evaluation data resources for comprehensive tobacco 

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

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

Promotion, Office on Smoking and Health; 2001. 

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. 

15. 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, August 15–17, 2012, Kansas City, 

Missouri.

For Further Reading

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. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm. 

Patton M. Utilization-focused evaluation. 3rd edition. Thousand Oaks, CA: Sage; 1997. 

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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2000/complete_report/pdfs/fullreport.pdf. 

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. 

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. 

Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/1998/complete_report/pdfs/complete_report.pdf. 

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. 

CHAPTER 2

Goal Area 2: Eliminating Exposure to 

Secondhand Smoke

GOAL AREA 2

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke

19

Goal Area 2 

Eliminating Exposure to Secondhand Smoke
GOAL AREA 2

20 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Goal Area 2

Eliminating Exposure to Secondhand Smoke

Short-term Proposed Indicators

 Outcome 1: Increased knowledge of the dangers of secondhand smoke and support for 

policies to reduce secondhand smoke

► 2.1.a Level of awareness of media messages on the dangers of secondhand smoke

► 2.1.b Level of receptivity to media messages about secondhand smoke 

► 2.1.c Proportion of the population that thinks secondhand smoke is harmful 

► 2.1.d Level of support for adopting smokefree policies in public places and 

workplaces

► 2.1.eNR Level of support for adopting tobacco-free policies in childcare settings, 

schools, or school districts 

► 2.1.fNR Level of support for adopting tobacco-free policies on college campuses

► 2.1.g Level of support for adopting smokefree rules for homes or vehicles

 Outcome 2: Implementation and enforcement of smokefree policies

► 2.2.a Proportion of jurisdictions with comprehensive smokefree policies for indoor 

public places

► 2.2.b Proportion of jurisdictions with smokefree policies for outdoor public places 

► 2.2.cNR Proportion of the employed population covered by a workplace smokefree 

policy 

► 2.2.d Proportion of the population that lives in a jurisdiction with comprehensive 

smokefree policies

► 2.2.e Proportion of childcare settings, schools, school districts, or college campuses 

with 100% tobacco-free policies

► 2.2.f Proportion of the population reporting 100% smokefree rules for homes or 

vehicles

► 2.2.g Proportion of jurisdictions that have enacted laws prohibiting smoking in 

multiunit housing 

► 2.2.h Proportion of public housing authorities that have adopted smokefree policies 

in all of their buildings

► 2.2.i Proportion of multiunit housing operators that have adopted a smokefree 

policy in their buildings 

► 2.2.j Proportion of multiunit housing residents living in smokefree buildings 

► 2.2.k Number and type of enforcement actions issued regarding smokefree policies 

► 2.2.l Proportion of states with tobacco control laws that preempt local smokefree 

policies
GOAL AREA 2

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 21

Intermediate Proposed Indicators

 Outcome 3: Compliance with smokefree policies

► 2.3.a Compliance with smokefree policies in public places and workplaces

► 2.3.b Compliance with tobacco-free policies in childcare settings, schools or school 

districts, and college campuses 

► 2.3.cNR Compliance with smokefree policies in multiunit housing

► 2.3.d Compliance with 100% smokefree rules for homes 

► 2.3.e Compliance with smokefree rules for vehicles

Long-term Proposed Indicators

 Outcome 4: Reduced exposure to secondhand smoke

► 2.4.a Proportion of nonsmokers exposed to secondhand smoke

► 2.4.b Proportion of the employed population exposed to secondhand smoke in the 

workplace 

► 2.4.c Proportion of the population exposed to secondhand smoke in indoor public 

places

► 2.4.d Proportion of the population exposed to secondhand smoke in outdoor public 

places

► 2.4.eNR Proportion of children, youth, and young adults exposed to secondhand smoke 

in childcare or school settings 

► 2.4.fNR Proportion of students, faculty, and staff exposed to secondhand smoke on 

college campuses

► 2.4.g Proportion of multiunit housing residents exposed to secondhand smoke in 

their homes from nearby units or shared areas 

► 2.4.h Proportion of the population exposed to secondhand smoke originating in their 

homes 

► 2.4.i Proportion of the population exposed to secondhand smoke in vehicles 

 Outcome 5: Reduced tobacco consumption 

► 2.5.a Per capita consumption of tobacco products

► 2.5.b Average number of each tobacco product used per day by tobacco users 

► 2.5.c Tobacco use prevalence

► 2.5.d Proportion of young people who have never tried a tobacco product 

► 2.5.e Proportion of tobacco users who have sustained abstinence from tobacco use 

NR Denotes an indicator that is not rated (see Appendix C for an explanation).
GOAL AREA 2

22 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

The table below summarizes changes made to Goal 2 indicators since KOI 2005. As shown, we 

deleted 5 KOI 2005 indicators, revised the titles of 22 KOI 2005 indicators, and added 13 new 

indicators. Indicator deletions were based on changes in the tobacco control landscape and 

scientific evidence base that made a subset of the previous indicators obsolete or unwarranted. 

Indicator additions were used to fill gaps created where new evidence demonstrated the utility of 

certain constructs to measure outcomes that had no existing indicators. Title revisions were made 

to enhance the utility of indicators for state comprehensive tobacco prevention and control 

programs. 

2017 Revised and 2005 KOI Goal 2 Indicators Crosswalk

Revised Indicator Number Original KOI Number Revised Title

Outcome 1 

2.1.a 2.3.1 

2.1.b 2.3.2 

2.1.c 2.3.5 

Deleted 2.3.3 

Deleted 2.3.4 

Deleted 2.3.6 

2.1.d 2.3.7 

2.1.eNR 2.3.10NR 

2.1.fNR New

2.1.g 2.3.8 

Deleted 2.3.9 

Outcome 2

2.2.a 2.4.1 

2.2.b New 

2.2.cNR 2.4.2 

2.2.d 2.4.3 

2.2.e 2.4.5 

2.2.f 2.4.4 

2.2.g New

2.2.h New 

2.2.i New 

2.2.j New 

2.2.k 2.5.1, 2.5.2, 2.5.3 

2.2.l 2.4.6 
GOAL AREA 2

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 23

2017 Revised and 2005 KOI Goal 2 Indicators Crosswalk (continued)

Revised Indicator Number Original KOI Number Revised Title

Outcome 3

2.3.a 2.6.1, 2.6.2 

Deleted 2.6.3 

2.3.b 2.6.5 

2.3.cNR New

2.3.d 2.6.4 

2.3.e 2.6.4 

Outcome 4

2.4.a 2.7.5 

2.4.b 2.7.1 

2.4.c 2.7.2 

2.4.d New 

2.4.eNR 2.7.4 

2.4.fNR New

2.4.g New

2.4.h 2.7.3 

2.4.i New 

Outcome 5

2.5.a 2.8.1 

2.5.b 2.8.2 

2.5.c 2.8.3 

2.5.d New 

2.5.e New 

NR Denotes an indicator that is not rated (see Appendix C for more information). 
GOAL AREA 2

► Outcome 1 

24 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 1 

Increased Knowledge of the Dangers of Secondhand Smoke and Support 

for Policies to Reduce Secondhand Smoke

In the logic model for Goal 2 (eliminating exposure to secondhand smoke), the outcomes path 

starts with increasing knowledge of the dangers of secondhand smoke and support for smokefree 

policies. Long-term monitoring of indicators in this outcome box provides evidence for changes 

in social norms about the acceptability of exposing others to secondhand smoke and support for 

smokefree policies. Evaluation of public knowledge of the dangers of secondhand smoke and 

support for smokefree policies continues to be important after policies are adopted to facilitate

implementation and compliance. Education efforts about the harmful effects of secondhand 

smoke can promote norms about the acceptability of smoking, increase support for smokefree 

policies, ease policy enforcement efforts, and can draw attention to areas not yet covered by 

smokefree policies.1-2

Practice-based evidence suggests that interventions intended to increase knowledge of and 

support for smokefree policies can inform the policy implementation process.3-5 As the number 

of smokefree laws and voluntary policies has grown, support for those policies has increased 

significantly, even among cigarette smokers.6

 Furthermore, many jurisdictions have made steady 

progress in achieving smokefree policies in indoor public spaces, including worksites, 

restaurants, and bars. However, many states and localities do not have such policies; moreover, 

the public is not fully protected yet in spaces such as college campuses, multiunit housing, and 

outdoor public areas. For initiatives intended to expand smokefree protections to these spaces, 

measuring knowledge of the dangers of secondhand smoke and support for smokefree policies 

can gauge the level of desire for smokefree policies and the initiative’s effectiveness.7-9

The following indicators are associated with this outcome:

► 2.1.a Level of awareness of media messages on the dangers of secondhand smoke 

► 2.1.b Level of receptivity to media messages about secondhand smoke 

► 2.1.c Proportion of the population that thinks secondhand smoke is harmful 

► 2.1.d Level of support for adopting smokefree policies in public places and workplaces 

► 2.1.e Level of support for adopting tobacco-free policies in childcare settings, schools, or 

school districts

► 2.1.f Level of support for adopting tobacco-free policies on college campuses

► 2.1.g Level of support for adopting smokefree rules for homes or vehicles
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 25

References

1. Hyland A, Cummings KM, Wilson MP. Compliance with the New York City Smoke-Free 

Air Act. Journal of Public Health Management and Practice. 1999;5(1):43–52.

2. Rohrbach LA, Howard-Pitney B, Unger JB, et al. Independent evaluation of the California 

Tobacco Control Program: relationships between program exposure and outcomes, 1996–

1998. American Journal of Public Health. 2002;92(6):975–84.

3. Clarke H, Wilson MP, Cummings KM, Hyland A. The campaign to enact New York City’s 

Smoke-Free Air Act. Journal of Public Health Management and Practice. 1999;5(1):1–13. 

4. Magzamen S, Glantz SA. The new battleground: California’s experience with smoke-free 

bars. American Journal of Public Health. 2001;91(2):245–52. 

5. National Cancer Institute. ASSIST: Shaping the Future of Tobacco Prevention and Control. 

Tobacco Control Monograph No. 16. Bethesda, MD: U.S. Department of Health and Human 

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

6. Hyland A, Higbee C, Borland R, et al. Attitudes and beliefs about secondhand smoke and 

smoke-free policies in four countries: findings from the International Tobacco Control Four 

Country Survey. Nicotine & Tobacco Research. 2009;11(6):642–9. doi: 10.1093/ntr/ntp063 

7. Niemeier BS, Chapp CB, Henley WB. Improving tobacco-free advocacy on college 

campuses: a novel strategy to aid in the understanding of student perceptions about policy 

proposals. Journal of American College Health. 2014;62(7):498–505. doi: 

10.1080/07448481.2014.925456 

8. Rendon AD, Unger JB, Cruz T, Soto DW, Baezconde-Garbanati L. Perceptions of 

secondhand and thirdhand smoke among Hispanic residents of multiunit housing. Journal of 

Immigrant and Minority Health. 2015 Nov 6. 

9. Baezconde-Garbanati LA, Weich-Reushe K, Espinoza L, et al. Secondhand smoke exposure 

among Hispanics/Latinos living in multiunit housing: exploring barriers to new policies. 

American Journal of Health Promotion. 2011;25(5 Suppl):S82–90. doi: 

10.4278/ajhp.100628-QUAL-219 

For Further Reading

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. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm. 

Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 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; 2008. Available at: 

http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evaluation_toolkit/pdfs/evalu

ation_toolkit.pdf. 
GOAL AREA 2

► Outcome 1 

26 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Germain D, Wakefield M, Durkin S. Non-smokers’ responses when smokers light up: a 

population-based study. Preventive Medicine. 2007;45(1):21–5. 

Kostygina G, Hahn EJ, Rayens MK. ‘It’s about the smoke, not the smoker’: messages that 

motivate rural communities to support smoke-free policies. Health Education Research, 

2014;29(1):58–71. doi: 10.1093/her/cyt087 

Rayens MK, Butler KM, Wiggins AT, Kostygina G, Langley RE, Hahn EJ. Recall and 

effectiveness of messages promoting smoke-free policies in rural communities. Nicotine & 

Tobacco Research. 2016 May;18(5):1340–7. doi: 10.1093/ntr/ntv197. 

Reindl D, Glassman T, Price J, Dake J, Yingling F. Perceptions of college and university 

presidents regarding tobacco-free campus policies. Journal of American College Health. 

2014;62(3):193–202. doi: 10.1080/07448481.2013.877019 

Tyc VL, Puleo E, Emmons K, de Moor JS, Ford JS. Smoking restrictions among households of 

childhood and young adult cancer survivors: implications for tobacco control efforts. Journal of 

Adolescent and Young Adult Oncology. 2013;2(1):17–24. 

Vardavas CI, Dimitrakaki C, Schoretsaniti S, et al. The role of the non-smoker in enforcing 

smoke-free laws. Journal of Public Health Policy. 2011 Feb;32(1):46–59. doi: 

10.1057/jphp.2010.45 

Wilson N, Weerasekera D, Blakely T, Edwards R, Thomson G, Gifford H. What is behind 

smoker support for new smokefree areas? National survey data. BMC Public Health. 

2010;10:498. doi: 10.1186/1471-2458-10-498 
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 27

Outcome 1

Increased Knowledge of the Dangers of Secondhand Smoke and Support 

for Policies to Reduce Secondhand Smoke

Indicator Rating

better

Number Indicator

Overall Quality

low high

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice

2.1.a Level of awareness of media 

messages on the dangers of 

secondhand smoke

$$

2.1.b Level of receptivity to media 

messages about secondhand smoke

$$

2.1.c Proportion of the population that 

thinks secondhand smoke is 

harmful

$$

2.1.d Level of support for adopting 

smokefree policies in public places 

and workplaces 

$ 

2.1.eNR Level of support for adopting 

tobacco-free policies in childcare 

settings, schools or school districts

     

2.1.fNR Level of support for adopting 

tobacco-free policies on college 

campuses

     

2.1.g Level of support for adopting 

smokefree rules for homes or

vehicles

$ 

$ 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 data.

NR Denotes an indicator that is not rated (see Appendix C for more information). 
GOAL AREA 2

► Outcome 1 

28 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.1.a

Level of Awareness of Media Messages on the Dangers of Secondhand 

Smoke

Indicator 2.1.a 

KOI 2005 2.3.1

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

What to measure Level of aided, unaided, or confirmed awareness of media messages about the dangers 

of secondhand smoke 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 Research has shown that increasing awareness through media 

messages can increase support for smokefree policies.1,2

Example data 

source(s) 

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

Smokers (Tips) Campaign, Pilot Campaign Survey

Information available at: http://www.cdc.gov/tobacco/campaign/tips/. 

Evaluation of the National Tobacco Prevention and Control Public Education 

Campaign, Wave 2 Smoker Follow-up Questionnaire, 2014 (NTP)

Information available at: 

http://www.reginfo.gov/public/do/PRAViewIC?ref_nbr=201411-0920-

011&icID=210357. 

Maine Center for Public Health “Wherever You Live and Breathe, Go Smokefree” Media Campaign Evaluation Survey, 2010

Information available at:

http://www.tobaccofreemaine.org/channels/communities/documents/Overview.pdf

Population group(s) General population

Example survey 

question(s)

Aided awareness

Television

From NTP

Now we would like to show you some screenshots from a television advertisement that 

has been shown in the U.S. Once you have viewed the images displayed below, please 

click on the forward arrow below to continue with the survey.

[Display images for ad]

Have you seen this ad on television in the past 3 months?

• Yes

• No

Marketing Collateral

Have you recently seen a business card size handout from the Healthy Maine 

Partnerships and the Maine Center for Disease Control and Prevention?

• Yes

• Maybe, not sure

• No
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 29

Unaided awareness

Modified from New York and Florida ATS items

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 

secondhand smoke]?

• 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]?

Have you recently seen any anti-tobacco or antismoking ads on television [or other 

relevant medium of interest]?

What happened in the ad(s)?3,4 

Confirmed awareness

Radio

From Maine SHS Media Survey

Have you recently heard an anti-tobacco or antismoking advertisement on the radio that 

begins with [describe portion of ad]?

• Yes

• Maybe, not sure

• No

Can you describe what happens in this advertisement?

[Code open-ended responses to determine confirmed awareness]

Comments Media messages should be pretested for credibility, resonance, and receptivity with the 

target audience before implementation.

Evaluators should select survey items appropriate to the communication medium used in 

their intervention efforts (e.g., television, radio, online, out-of-home, print). To allow 

greater variation in responses and provide for dose-response analyses, evaluators may 

wish to determine frequency of exposure by asking how often the respondent saw or 

heard messages.

Individual-level awareness and recognition of advertisements can be measured in three 

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

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

research literature. 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 is then asked whether they recognize the ad. 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. 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.

Each awareness item captures different information. For example, aided awareness

helps determine specific campaign and ad awareness,5 whereas unaided awareness

allows for tracking which campaign messages are most prominent in the minds of the 

target population. When selecting an awareness item, consider the type of information to 

be captured and data collection mode. Online administration of surveys allows 
GOAL AREA 2

► Outcome 1 

30 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

advertisements and other materials (e.g., Web site banner ads, television ads) to be 

shown directly to survey respondents, 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.

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 with aided awareness measures, and given the extra 

respondent and interviewer burden of open-ended confirmed awareness items, aided 

awareness measures may be preferable.6

Evaluators can 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.7 

This indicator may be used in conjunction with E-Cigarette 2.1, which measures 

perceived harm from secondhand aerosol.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

better

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. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: mass-reach 

health communications intervention. Available at: http://www.thecommunityguide.org/tobacco/massreach.html. 

Last updated: November 18, 2015.

3. 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.

4. 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

5. New York State Department of Health Tobacco Control Program. StatShot. 2012 Oct;5(8). New York State 

Adult Tobacco Survey, 2003–2011. Analysis conducted by RTI International. Available at: 

https://www.health.ny.gov/prevention/tobacco_control/reports/statshots/volume5/n8_smokers_who_recall_cess

ation_advertisements_more_likely_to_attempt_quitting.pdf

6. Southwell BG, Barmada CH, Hornik RC, Maklin DM. Can we measure encoded exposure? Validation evidence 

from a national campaign. Journal of Health Communication. 2002;7(5):445–53.

7. 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.
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 31

Indicator 2.1.b

Level of Receptivity to Media Messages about Secondhand Smoke

Indicator 2.1.b 

KOI 2005 2.3.2

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

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. For tobacco public education campaigns, the intended audience’s perceptions 

regarding the effectiveness of advertisements have been widely used in formative and 

outcome evaluation. See “Comments” below for more information.

Why this indicator is 

useful

Message awareness is necessary but not sufficient to change knowledge of and attitudes 

toward secondhand smoke and smokefree policies. Media messages are effective only if 

they reach and resonate with the intended audience.1,2 Message receptivity measures 

have been shown to predict changes in attitudes toward social issues.1-6 Well-received 

messages help ensure campaign effectiveness.3,7-9 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. These indicators are an 

important tool for assessing the likelihood of success of potential health messages before 

a campaign is aired, especially when large-scale efficacy pretesting for behavioral 

impacts is impractical.

10 Empirical evidence indicates that measures of media message 

receptivity predict changes in attitudes, such as increased perceived benefits of quitting 

and intentions to quit; these measures also predict changes in behaviors, such as 

increased quit attempts and decreased cigarette consumption.3,4,6,9-12 

Example data 

source(s)

Evaluation of the National Tobacco Prevention and Control Public Education 

Campaign, Smoker Follow-up Questionnaire, 2014 (NTP)

Information available at: 

http://www.reginfo.gov/public/do/PRAViewIC?ref_nbr=201411-0920-

011&icID=210357.

Population group(s) General population

Example survey

question(s)

From NTP

Perceived ad effectiveness:

Now we would like to show you some screenshots from a television advertisement that 

has been shown in the U.S. Once you have viewed the images displayed below, please 

click on the forward arrow below to continue with the survey.

[Display images for ad]

Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or 

strongly disagree with the following statements.

This ad is worth remembering.

This ad grabbed my attention.

This ad is powerful.

This ad is informative.

This ad is meaningful to me.

This ad is convincing.

This ad is ridiculous.
GOAL AREA 2

► Outcome 1 

32 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

This ad is terrible.

This ad was difficult to watch.

Negative emotional reaction:

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

much this ad made you feel...

• Sad

• Afraid

• Irritated

• Ashamed

• Discouraged

• Angry

Motivational reaction:

• Hopeful

• Motivated

• Understood

Would this ad make you want to encourage someone you care about to quit smoking?

• Yes

• No

Comments Perceived effectiveness is a critical element of receptivity. Perceived effectiveness has 

been standardized and shown to be predictive of outcomes.3 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, social media, radio, billboard, print).

Evaluators should work closely with counter marketing 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.6

Rating

Overall quality

low high

Resources

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

 better

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 (IOM). Ending the tobacco problem: a blueprint for the nation. Washington, DC: The 

National Academies Press; 2007.

3. 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

4. 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
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 33

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

Smoking and Health; 2003.

5. Davis KC, Nonnemaker JM, Farrelly MC, Niederdeppe J. Exploring differences in smokers’ perceptions of the 

effectiveness of cessation media messages. Tobacco Control. 2011 Jan;20(1):26–33. doi: 

10.1136/tc.2009.035568

6. 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.

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

Medicine. 1984;13(3):299–319.

8. Kotler P, Armstrong G. Principles of marketing, 9th ed. Upper Saddle River, NJ: Prentice-Hall; 2001.9. 

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. Yzer M, LoRusso S, Nagler RH. On the conceptual ambiguity surrounding perceived message effectiveness. 

Health Communication. 2015;30(2):125–34. doi: 10.1080/10410236.2014.974131

11. Brennan E, Durkin SJ, Wakefield MA, Kashima Y. Assessing the effectiveness of antismoking television 

advertisements: do audience ratings of perceived effectiveness predict changes in quitting intentions and 

smoking behaviours? Tobacco Control. 2014;23(5):412–8. doi: 10.1136/tobaccocontrol-2012-050949

12. Davis K, Duke J, Shafer P, Patel D, Rodes R, Beistle D. Perceived effectiveness of antismoking ads and 

association with quit attempts among smokers: evidence from the Tips From Former Smokers campaign. Health 

Communication. 2016 Jul 19:1-8. [Epub ahead of print]
GOAL AREA 2

► Outcome 1 

34 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.1.c

Proportion of the Population that Thinks Secondhand Smoke Is Harmful

Indicator 2.1.c 

KOI 2005 2.3.5

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

What to measure Proportion of the population that believes exposure to secondhand smoke is harmful to 

health 

Why this indicator is 

useful

The perception that secondhand smoke is harmful is associated with strong support for 

smokefree policies and action to reduce exposure to secondhand smoke.1-4

Example data 

source(s)

Adult Tobacco Survey Questions (ATS), Core Survey, 2014

Information available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5903a1.htm. 

National Youth Tobacco Survey (NYTS), 2014

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/.

Population group(s) General population

Example survey 

question(s)

From ATS

Do you think that breathing smoke from other people’s cigarettes or from other tobacco 

products is...

• Very harmful to one’s health

• Somewhat harmful to one’s health

• Not at all harmful to one’s health

• Don’t know/Not sure

• Refused

From NYTS

Do you think that breathing smoke from other people’s cigarettes or other tobaccos 

products causes...

• No harm

• Little harm

• Some harm

• A lot of harm

From SCS-TC

Secondhand smoke seeping into apartment and condominium units is a health risk.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

• Don’t know/Not sure
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 35

In your opinion, how much does smoking in a car affect the health of children? Would 

you say...?

• Not at all

• A little bit

• Somewhat

• A lot

• A great deal

Comments In addition to the national example data sources included in this profile, local data 

sources may provide useful measures on perceived harms of secondhand smoke (e.g., 

Kentucky Health Issues Poll5

).

Evaluators may wish to ask about harm perceptions related to specific conditions linked 

to secondhand smoke exposure (e.g., sudden infant death syndrome, heart disease).

Evaluators might also want to ask about perceptions of secondhand aerosol from 

electronic cigarettes or emerging combustible products.

Evaluators might also ask specifically about perceptions of harmfulness of secondhand 

smoke to children and pregnant women, populations especially vulnerable to the harms 

of secondhand smoke.6

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

3. Blake KD, Viswanath K, Blendon RJ, Vallone D. The role of tobacco-specific media exposure, knowledge, and 

smoking status on selected attitudes toward tobacco control. Nicotine & Tobacco Research. 2010;12(2), 117–

26. doi: 10.1093/ntr/ntp184

4. Wilson N, Weerasekera D, Blakely T, Edwards R, Thomson G, Gifford H. What is behind smoker support for 

new smokefree areas? National survey data. BMC Public Health. 2010;10:498. doi: 10.1186/1471-2458-10-498

5. Foundation for a Healthy Kentucky. Kentucky Health Issues Poll. Available at: http://www.healthyky.org/presentations-reports/reports/kentucky-health-issues-poll.

6. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke—

United States, 1999–2012. Morbidity and Mortality Weekly Report. 2015 Feb 6;64(4):103–8.
GOAL AREA 2

► Outcome 1 

36 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.1.d 

Level of Support for Adopting Smokefree Policies in Public Places and 

Workplaces

Indicator 2.1.d Level of support for adopting smokefree policies in public places and workplaces

KOI 2005 2.3.7

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

What to measure Proportion of adults who support the creation of policies that restrict smoking in public 

places and workplaces

Why this indicator is 

useful

Strong public support for smokefree policies in public and workplaces increases the 

likelihood of adoption and compliance.1-5 

Example data 

source(s)

Adult Tobacco Survey Questions (ATS), Core Survey, 2014

Information available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5903a1.htm. 

Behavioral Risk Factor Surveillance System (BRFSS), Secondhand Smoke Module, 

2011

Information available at: http://www.cdc.gov/brfss/. 

California Adult Tobacco Survey (CATS) Questions, 2008

Information available at: 

https://www.cdph.ca.gov/data/surveys/Pages/CaliforniaTobaccoSurveys.aspx. 

Population group(s) Adults aged 18 or older

Example survey 

question(s)

From ATS

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

From BRFSS

At workplaces, do you think smoking indoors should be:

• Always allowed

• Allowed only at some times or in some places

• Never allowed

From CATS

Smoking should not be allowed at a public beach. 

• Agree

• Disagree

• Don’t know/Not sure

• Refused
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 37

Smoking should not be allowed in outdoor entertainment areas, such as amusement 

parks, zoos, and fairgrounds.

• Agree

• Disagree

• Don’t know/Not sure

• Refused

Comments These example questions could also be asked of decision makers, employers, opinion 

leaders, or young people. 

Rating

Overall quality

low high

Resources

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

3. Thomson G, Wilson N, Edwards R. At the frontier of tobacco control: a brief review of public attitudes toward 

smoke-free outdoor places. Nicotine & Tobacco Research. 2009;11(6) 584–90. doi: 10.1093/ntr/ntp046

4. Americans for Nonsmokers’ Rights. Fundamentals of smokefree workplace laws, 2009. Available at:

http://www.no-smoke.org/pdf/CIA_Fundamentals.pdf.

5. Satterlund TD, Cassady D, Treiber J, Lemp C. Barriers to adopting and implementing local-level tobacco 

control policies. Journal of Community Health. 2011;36(4):616–23. doi: 10.1007/s10900-010-9350-6 
GOAL AREA 2

► Outcome 1 

38 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.1.eNR

Level of Support for Adopting Tobacco-Free Policies in Childcare Settings, 

Schools, or School Districts

Indicator 2.1.eNR 

KOI 2005 2.3.10NR 

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

What to measure Proportion of adults who support adopting tobacco-free policies in childcare settings, 

schools, or school districts

Why this indicator is 

useful

Tobacco-free policies in youth-oriented settings, such as childcare centers and schools, 

play an important role in shaping tobacco-free norms and reducing secondhand smoke 

exposure among youth.1-3 Strong tobacco-free school policies require support from 

parents, school officials, and the general public for adoption and enforcement.1,2

Tobacco-free policies restrict the use of combustible, noncombustible, and electronic 

tobacco products.

Example data 

source(s)

Adult Tobacco Survey Questions (ATS), Core Survey, 2012

Information available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5903a1.htm. 

Social Climate of Tobacco Control Survey (SCS-TC), 2008

Information available at: http://www.socialclimate.org/. 

Population group(s) Adults aged 18 or older

Example survey 

question(s)

From ATS

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

From SCS-TC

In the following places, do you think that smoking should be allowed in all areas, some 

areas, or not allowed at all?

In daycare centers

• All areas

• Some areas

• Not at all

• Don’t know

• Refused
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 39

Comments Evaluators may want to analyze the level of support for creating tobacco-free policies in 

childcare settings and schools/school districts, based on the smoking status of the 

respondent.

This indicator corresponds to the Healthy People 2020 objective TU-15: “Increase 

tobacco-free environments in schools, including all school facilities, property, vehicles, 

and school events (i.e., for junior high, middle school, high school, Head Start).”4

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

better

References

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

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

Disease Control and Prevention, National Centers for Chronic Disease Prevention and Health Promotion, Office 

on Smoking and Health; 2012. 

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. Alesci NL, Forster JL, Blaine T. Smoking visibility, perceived acceptability, and frequency in various locations 

among youth and adults. Preventive Medicine. 2003;36(3):272–81.

4. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.
GOAL AREA 2

► Outcome 1 

40 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.1.fNR

Level of Support for Adopting Tobacco-Free Policies on College 

Campuses

Indicator 2.1.f 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

What to measure Proportion of adults who support adopting tobacco-free policies on college campuses

Why this indicator is 

useful

Institutional policies are needed to protect students, faculty, staff, and visitors from 

secondhand smoke on college campuses.1 Campus smokefree policies are associated 

with reduced student smoking rates and fewer students reporting exposure to 

secondhand smoke on campus.2-3 Student, faculty, and staff support for tobacco-free 

campus policies may increase the likelihood that policies are adopted on campus.4-5 

Example data 

source(s)

Adult Tobacco Survey Questions (ATS), 2012

Information available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5903a1.htm. 

Harvard School of Public Health College Alcohol Study (CAS)6

Information available at: http://tobaccocontrol.bmj.com/content/12/3/251.full.

Population group(s) Adults aged 18 or older

Example survey 

question(s)

From ATS

Please tell me if you think smoking should be allowed or not allowed in each of the 

following places...

• On-campus student housing at public colleges or universities

From CAS

To what extent do you support or oppose the following possible school policies about 

smoking?

Prohibit smoking in all campus buildings

• Strongly support

• Oppose

• Strongly oppose

Comments Tobacco-free policies restrict the use of combustible, noncombustible, and electronic 

tobacco products on campus grounds.

Evaluators may want to analyze the level of support for adopting tobacco-free policies 

on college campuses based on the smoking status of the respondent.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

better
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 41

References

1. American Nonsmokers’ Rights Foundation. Smokefree and Tobacco-Free U.S. and Tribal Colleges and 

Universities, April 4, 2016. Available at: http://www.no-smoke.org/pdf/smokefreecollegesuniversities.pdf.

2. Seo DC, Macy JT, Torabi MR, Middlestadt SE. The effect of a smoke-free campus policy on college students’ 

smoking behaviors and attitudes. Preventive Medicine. 2011;53(4-5):347–52. doi: 

10.1016/j.ypmed.2011.07.015

3. Fallin A, Roditis M, Glantz SA. Association of campus tobacco policies with secondhand smoke exposure, 

intention to smoke on campus, and attitudes about outdoor smoking restrictions. American Journal of Public 

Health. 2015 Jun;105(6):1098–100. doi: 10.2105/AJPH.2014.302251

4. Reindl D, Glassman T, Price J, Dake J, Yingling F. Perceptions of college and university presidents regarding 

tobacco-free campus policies. Journal of American College Health. 2014;62(3):193–202. doi: 

10.1080/07448481.2013.877019

5. Harbison PA, Whitman MV. Barriers associated with implementing a campus-wide smoke-free policy. Health 

Education. 2008;108(4):321–31. doi: http://dx.doi.org/10.1108/09654280810884197

6. Rigotti NA. Students’ opinion of tobacco control policies recommended for US colleges: a national survey. 

Tobacco Control. 2003;12(3):251–6. doi: 10.1136/tc.12.3.251
GOAL AREA 2

► Outcome 1 

42 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.1.g 

Level of Support for Adopting Smokefree Rules for Homes or Vehicles

Indicator 2.1.g 

KOI 2005 2.3.8

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 1 Increased knowledge of the dangers of secondhand smoke and support for policies to 

reduce secondhand smoke

What to measure Proportion of the population that supports smokefree rules that restrict the use of 

tobacco products in homes and vehicles 

Why this indicator is 

useful

Public support is necessary for advancing home and vehicle smokefree rules to protect 

nonsmokers from exposure to secondhand smoke. Public support data can also help 

document shifts in social norms before and after a policy is implemented.1 Studies show 

that the majority of adults support smokefree home and vehicle rules, particularly when 

children are present.2-5 

Example data 

source(s)

Golden Valley, MN, survey6

National Youth Tobacco Survey Questionnaire (NYTS), 2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/. 

New York Adult Tobacco Survey (NY ATS), 2009

Information available at:https://health.data.ny.gov/Health/Adult-Tobacco-SurveyBeginning-2003/ckfz-a669/data

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/. 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011

Information available at: http://appliedresearch.cancer.gov/tus-cps/.

Population group(s) General population

Example survey 

question(s)

Example item from Golden Valley, MN, survey6

What is your preference for a smoking policy in your apartment building?

• Strongly prefer a policy making it a smoke-free building

• Somewhat prefer a policy making it a smoke-free building

• No preference

• Somewhat prefer having no rules about smoking in the building

• Strongly prefer having no rules about smoking in the building

From NYTS

In your opinion, inside your home, smoking tobacco products should:

• Always be allowed

• Be allowed only at some times or in some places

• Never be allowed

In your opinion, in their vehicles, people should:

• Always allow smoking

• Sometimes allow smoking

• Never allow smoking
GOAL AREA 2

► Outcome 1 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 43

From NY ATS

• What is your opinion about policies that ban smoking in apartment buildings, 

condominiums, and other multiunit complexes, including indoor areas, private 

balconies and patios? Are you:

• Strongly in favor

• Somewhat in favor

• Neither in favor nor against

• Somewhat against

• Strongly against

From SCS-TC

In your opinion, should smoking be allowed in residents’ apartments/condos?

• Yes

• No

In your opinion, should smoking be allowed in indoor common hallways/stairways of 

apartment/condo buildings?

• Yes

• No

In your opinion, should smoking be allowed in outdoor common areas (benches, 

doorways, parking lots) of apartment buildings?

• Yes

• No

In your opinion, should smoking be allowed on private apartments’ balconies/patios?

• Yes

• No

In your opinion, should tenants in apartment buildings, duplexes, and attached condos be 

informed on the lease agreement whether smoking is allowed in any unit or common 

areas inside the building?

• Strongly agree

• Agree

• Disagree

• Strongly disagree

From TUS-CPS

Inside a car, when there are other people present, do you THINK that smoking 

SHOULD:

• Always be allowed

• Be allowed under some conditions, or

• Never be allowed?

Comments Evaluators may want to analyze the level of support for creating smokefree policies in 

homes and vehicles based on the smoking status of the respondent.

This indicator can be used to measure support for voluntary rules and more formal 

policies. The questions asked should match the specific area addressed by the policy. 

For example, if the policy would make residential units, balconies, and common areas 

smokefree, the items should measure support for smokefree policies in these areas.
GOAL AREA 2

► Outcome 1 

44 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 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; 2008. Available at: 

http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evaluation_toolkit/pdfs/evaluation_toolkit.p

df. 

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. Agaku IT, Odukoya OO, Olufajo O, Filippidis FT, Vardavas CI. Support for smoke-free cars when children are 

present: a secondary analysis of 164,819 U.S. adults in 2010/2011. European Journal of Pediatrics. 

2014;173(11):1459–66. doi: 10.1007/s00431-014-2344-0 

4. Drach LL, Pizacani BA, Rohde KL, Schubert S. The acceptability of comprehensive smoke-free policies to 

low-income tenants in subsidized housing. Preventing Chronic Disease. 2010;7(3):A66.

5. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific literature. Tobacco 

Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849

6. Hennrikus D, Pentel PR, Sandell SD. Preferences and practices among renters regarding smoking restrictions in 

apartment buildings. Tobacco Control. 2003 Jun;12(2):189–94.
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 45

Outcome 2

Implementation and Enforcement of Smokefree Policies

Creating smokefree policies in indoor public places, including worksites, restaurants, and bars, 

protects youth and nonsmoking adults from involuntary exposure to secondhand tobacco smoke, 

reduces the prevalence of tobacco use, increases tobacco cessation, and reduces youth initiation 

of tobacco use.1-3 These smokefree policies also have immediate benefits of reducing tobaccorelated morbidity and mortality, such as those due to acute cardiovascular events and asthma.1-3

A preponderance of studies indicate no negative economic effects from smokefree policies 

governing hospitality venues.2,4 Smokefree home and vehicle rules protect children from the 

health hazards of secondhand smoke exposure and reinforce anti-tobacco social norms that 

prevent tobacco use in the future.2,4

Smokefree policies may be implemented by governments (through legislation or regulation), 

individual employers or businesses, or private citizens (e.g., no-smoking rules in homes and 

vehicles). In addition, comprehensive smokefree laws can also occur at the local level.

Preemptive state laws, however, can restrict the authority of local governments to adopt policies 

or otherwise act on an issue, which can halt tobacco control progress in a state.5

 Although some 

states have successfully repealed smokefree indoor air preemption, preemption has stalled 

secondhand smoke protections for workers and the public.6,7 Where state law preempts stronger 

local laws, the private sector can adopt voluntary smokefree policies in workplaces, employer 

campuses, and multiunit housing. 

The number of smokefree policies covering public and private indoor venues has increased 

considerably over the past two decades.8 However, smokefree policies vary by region, 

disproportionately impact racial and ethnic minorities, and can contribute to disparities in health 

outcomes.9,10 No southern state has comprehensive, statewide smokefree laws prohibiting 

smoking in all indoor areas of worksites, restaurants, and bars.11,12 More than one in five adults 

still report secondhand smoke exposure at work, especially racial and ethnic minorities and those 

of low socioeconomic status.9 Smokefree policies in multiunit housing, which are especially 

important to protect children and the elderly, and those with chronic health conditions, have 

broad popular support and are increasing in number with encouragement from the U.S. 

Department of Housing and Urban Development.13-15 However, low-income housing may be less 

likely to have written policies that can be enforced,16 and voluntary policies may be less common 

among rural residents, veterans, low-income populations, or residents of states without 

comprehensive laws covering public places.16-22 Additional vulnerable populations include those 

with mental health or substance use disorders; smokefree policies in prisons and treatment 

facilities have positive health effects but are not yet uniformly implemented.2,23

Enforcement of smoke-free policies is critical for their benefits to be realized.4 It is important to

dedicate adequate resources to ensuring clear enforcement powers and following up on 

violations.1,25-26 Tracking violations of existing policy can help monitor compliance trends, 

determine where additional education or enforcement is warranted, and evaluate a policy’s 

success.28 In addition, tracking public complaints regarding smoking exposure in certain settings 

or for certain products not covered under existing laws may help inform future policy 

implementation.
GOAL AREA 2

► Outcome 2 

46 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Smokefree policies have been scientifically shown to be effective in reducing secondhand smoke 

exposure, cost-effective, feasible, and broadly supported by the public.1,2,4 The dangers of 

secondhand smoke are well-researched and well-known, and the growth and increased 

knowledge has helped to reduce the level of acceptability of smoking in public places and 

workplaces.29,30

The following indicators are associated with this outcome:

► 2.2.a Proportion of jurisdictions with comprehensive smokefree policies for indoor public 

places

► 2.2.b Proportion of jurisdictions with smokefree policies for outdoor public places 

► 2.2.c Proportion of the employed population covered by a workplace smokefree policy 

► 2.2.d Proportion of the population that lives in a jurisdiction with comprehensive 

smokefree policies

► 2.2.e Proportion of childcare settings, schools, school districts, or college campuses with 

100% tobacco-free policies

► 2.2.f Proportion of the population reporting 100% smokefree rules for homes or vehicles 

► 2.2.g Proportion of jurisdictions that have enacted laws prohibiting smoking in multiunit 

housing 

► 2.2.h Proportion of public housing authorities that have adopted smokefree policies in all of 

their buildings 

► 2.2.i Proportion of multiunit housing operators that have adopted a smokefree policy in 

their buildings 

► 2.2.j Proportion of multiunit housing residents living in smokefree buildings 

► 2.2.k Number and type of enforcement actions issued regarding smokefree policies

► 2.2.l Proportion of states with tobacco control laws that preempt local smokefree air laws

References

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

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

updated: November 10, 2014. 

2. Hahn EJ. Smokefree legislation: a review of health and economic outcomes research. 

American Journal of Preventive Medicine. 2010;39(6 Suppl 1):S66–76. doi: 

10.1016/j.amepre.2010.08.013 

3. Frazer K, Callinan JE, McHugh J, et al. Legislative smoking bans for reducing harms from 

secondhand smoke exposure, smoking prevalence and tobacco consumption. The Cochrane 

Database of Systematic Reviews. 2016;2:CD005992. 

4. 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. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 47

5. Gorovitz E, Mosher J, Pertschuk M. Preemption or prevention?: lessons from efforts to 

control firearms, alcohol, and tobacco. Journal of Public Health Policy. 1998;19(1):36–50. 

6. Centers for Disease Control and Prevention. State Tobacco Activities Tracking and 

Evaluation (STATE) System. Available at: http://www.cdc.gov/statesystem/. Last updated: 

August 25, 2016. 

7. Mowery PD, Babb S, Hobart R, Tworek C, MacNeil A. The impact of state preemption of 

local smoking restrictions on public health protections and changes in social norms. Journal 

of Environmental and Public Health. 2012;2012:632629. 

http://dx.doi.org/10.1155/2012/632629

8. American for Nonsmokers’ Rights. Smoke-free lists, maps, and data. Available at: http://nosmoke.org/goingsmokefree.php?id=519. Last updated: July 11, 2016. 

9. King BA, Homa DM, Dube SR, Babb SD. Exposure to secondhand smoke and attitudes 

toward smoke-free workplaces among employed U.S. adults: findings from the National 

Adult Tobacco Survey. Nicotine & Tobacco Research. 2014;16(10):1307–18. doi: 

10.1093/ntr/ntu069 

10. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to 

secondhand smoke—United States, 1999–2012. Morbidity and Mortality Weekly Report. 

2015 Feb 6;64(4):103–8. 

11. Centers for Disease Control and Prevention. Comprehensive smoke-free laws for worksites, 

restaurants, and bars—United States, 2015. Morbidity and Mortality Weekly Report. 

2012;61(45):914–7. 

12. Tynan MA, Holmes CB, Promoff G, Hallett C, Hopkins M, Frick B. State and local 

comprehensive smoke-free laws for worksites, restaurants, and bars—United States, 2000–

2010. Morbidity and Mortality Weekly Report. 2016;65(24):623–6. 

13. Licht AS, King BA, Travers MJ, Rivard C, Hyland AJ. Attitudes, experiences, and 

acceptance of smoke-free policies among US multiunit housing residents. American Journal 

of Public Health. 2012;102(10):1868–71. doi: 10.2105/AJPH.2012.300717 

14. U.S. Department of Housing and Urban Development. Further encouragement for O/As to 

adopt optional smoke-free housing policies. October 26, 2012. Available at: 

http://portal.hud.gov/hudportal/documents/huddoc?id=12-22hsgn.pdf. 

15. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific 

literature. Tobacco Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849 

16. Burdette LK, Rowe GC, Johansen L, et al. A statewide assessment of smoke-free policy in 

multiunit housing settings. Nicotine & Tobacco Research. 2014;16(12):1593–8. doi: 

10.1093/ntr/ntu114 

17. Bleakley A, Hennessy M, Mallya G, Romer D. Home smoking policies in urban households 

with children and smokers. Preventive Medicine. 2014;62:30–4. doi: 

10.1016/j.ypmed.2013.12.015 

18. Butler KM, Rayens MK, Ashford K, et al. Smoke-free homes, strength of smoke-free law, 

and children in the home. Nicotine & Tobacco Research. 2014;16(4):485–90. doi: 

10.1093/ntr/ntt191 
GOAL AREA 2

► Outcome 2 

48 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

19. Drach LL, Pizacani BA, Rohde KL, Schubert S. The acceptability of comprehensive smokefree policies to low-income tenants in subsidized housing. Preventing Chronic Disease. 

2010;7(3):A66. 

20. Cheng KW, Glantz SA, Lightwood JM. Association between smokefree laws and voluntary 

smokefree-home rules. American Journal of Preventive Medicine. 2011;41(6):566–72. doi: 

10.1016/j.amepre.2011.08.014 

21. King BA, Hyland AJ, Borland R, McNeill A, Cummings KM. Socioeconomic variation in 

the prevalence, introduction, retention, and removal of smoke-free policies among smokers: 

findings from the International Tobacco Control (ITC) Four Country Survey. International 

Journal of Environmental Research and Public Health. 2011;8(2):411–34. doi: 

10.3390/ijerph8020411 

22. Zhang X, Martinez-Donate AP, Cook J, Piper ME, Berg K, Jones NR. Battling tobacco use at 

home: an analysis of smoke-free home rules among U.S. veterans from 2001 to 2011. 

American Journal of Public Health. 2014;104 Suppl 4:S572–9. doi: 

10.2105/AJPH.2014.301975 

23. Stockings EA, Bowman JA, Prochaska JJ, et al. The impact of a smoke-free psychiatric 

hospitalization on patient smoking outcomes: a systematic review. The Australian and New 

Zealand Journal of Psychiatry. 2014;48(7):617–33. doi: 10.1177/0004867414533835 

24. Binswanger IA, Carson EA, Krueger PM, Mueller SR, Steiner JF, Sabol WJ. Prison tobacco 

control policies and deaths from smoking in United States prisons: population based 

retrospective analysis. BMJ. 2014;349:g4542. doi: http://dx.doi.org/10.1136/bmj.g4542

25. Bruckman D, Allan T, Stefanak M, et al. Enforcement of Ohio’s Smoke Free Workplace Law 

through the lens of public health practice. Public Health Reports. 2013;128(1):54–63. 

26. Weber MD, Bagwell DA, Fielding JE, Glantz SA. Long term compliance with California’s 

Smoke-Free Workplace Law among bars and restaurants in Los Angeles County. Tobacco

Control. 2003;12(3):269–73. doi: 10.1136/tc.12.3.269 

27. Centers for Disease Control and Prevention. Best practices user guide: health equity. Atlanta, 

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

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

Smoking and Health; 2014. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-healthequity.pdf. 

28. Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 

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; 2008. Available 

at: 

http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evaluation_toolkit/pdfs/e

valuation_toolkit.pdf. 

29. Hyland A, Higbee C, Borland R, et al. Attitudes and beliefs about secondhand smoke and 

smoke-free policies in four countries: findings from the International Tobacco Control Four 

Country Survey. Nicotine & Tobacco Research. 2009;11(6):642–9. doi: 10.1093/ntr/ntp063 
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 49

30. 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. 

Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fullreport.pdf

For Further Reading

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. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm. 

Gonzalez M, Sanders-Jackson A, Song AV, Cheng KW, Glantz SA. Strong smoke-free law 

coverage in the United States by race/ethnicity: 2000–2009. American Journal of Public Health. 

2013;103(5):e62–6. 

Hewett MJ, Ortland WH, Brock BE, Heim CJ. Secondhand smoke and smokefree policies in 

owner-occupied multi-unit housing. American Journal of Preventive Medicine. 2012;43(5 Suppl 

3):S187–96. 

Hyland A, Barnoya J, Corral JE. Smoke-free air policies: past, present and future. Tobacco 

Control. 2012;21(2):154–61. 

King BA, Patel R, Babb SD. Prevalence of smokefree home rules—United States, 1992–1993 

and 2010–2011. MMWR. Morbidity and Mortality Weekly Report. 2014;63(35):765–9. 

National Cancer Institute. Evaluating ASSIST: A Blueprint for Understanding State-level 

Tobacco Control. Tobacco Control Monograph No. 17. Bethesda, MD: U.S. Department of 

Health and Human Services, National Institutes of Health, National Cancer Institute; October 

2006. 
GOAL AREA 2

► Outcome 2 

50 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 2

Implementation and Enforcement of Smokefree Policies

Indicator Rating

better

Number Indicator

Overall Quality

low high

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice

2.2.a Proportion of jurisdictions with 

comprehensive smokefree policies 

for indoor public places

$$

2.2.b 

(New)

Proportion of jurisdictions with 

smokefree policies for outdoor 

public places

$$

2.2.cNR Proportion of the employed 

population covered by a workplace 

smokefree policy

     

2.2.d Proportion of the population that 

lives in a jurisdiction with 

comprehensive smokefree policies

$$

2.2.e Proportion of childcare settings, 

schools, school districts, or college 

campuses with 100% tobacco-free 

policies

$$$

2.2.f Proportion of the population 

reporting 100% smokefree rules for 

homes or vehicles 

$ 

2.2.g 

(New)

Proportion of jurisdictions that 

have enacted laws prohibiting 

smoking in multiunit housing

$$

2.2.h 

(New)

Proportion of public housing 

authorities that have adopted 

smokefree policies in all of their 

buildings

$ 

2.2.i 

(New)

Proportion of multiunit housing 

operators that have adopted a 

smokefree policy in their buildings 

$$$

2.2.j 

(New)

Proportion of multiunit housing 

residents living in smokefree 

buildings 

$$$
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 51

Indicator Rating

better

Number Indicator

Overall Quality

low high

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice

2.2.k Number and type of enforcement 

actions issued regarding smokefree 

policies ††

$$

2.2.l Proportion of states with tobacco 

control laws that preempt local 

smokefree air 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 ±2 point of the median 

for this indicator-specific criterion.

 Denotes no data.

NR Denotes an indicator that is not rated (see Appendix C for an explanation).
GOAL AREA 2

► Outcome 2 

52 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.a

Proportion of Jurisdictions with Comprehensive Smokefree Policies for 

Indoor Public Places

Indicator 2.2.a 

KOI 2005 2.4.1

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of local jurisdictions that have policies requiring smokefree workplaces, 

including restaurants and bars 

Why this indicator is 

useful

Evidence shows that comprehensive policies and laws making indoor workplaces and 

public areas smokefree are highly effective in reducing exposure to secondhand 

smoke.1-4 Eliminating smoking in indoor spaces is the only way to fully protect 

nonsmokers from exposure to secondhand smoke.2 However, smokefree policy coverage 

varies across states and localities, leaving some U.S. populations less protected.5

Example data 

source(s)

American Nonsmokers’ Rights Foundation. Municipalities with local 100% 

smokefree laws currently in effect (updated quarterly)

Information available at: http://www.no-smoke.org/pdf/100ordlisttabs.pdf. 

State Tobacco Activities Tracking and Evaluation (STATE) System

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, and regulations. 

Example survey 

question(s)

Not applicable.

Comments A comprehensive smokefree policy is defined by the Office on Smoking and Health 

(OSH) as a policy that does not allow smoking in any indoor areas of workplaces, 

restaurants, and bars, with no exceptions.6 Evaluators may wish to expand the OSH 

definition of “comprehensive” to include, for example, casinos and other settings as 

appropriate. 

The term “jurisdiction” refers to sub-state geographic regions with defined legal 

authority, including municipalities, counties, and other incorporated areas.

For states or jurisdictions that have already adopted comprehensive smokefree policies 

or for states or jurisdictions attempting to adopt comprehensive policies to include 

e-cigarettes, E-Cigarette 2.2 may serve as a “replacement” for Indicator 2.2.a.

This indicator can be used to measure progress toward achieving Objective TU-13 of

Healthy People 2020: “Establish laws in States, District of Columbia, Territories, and 

Tribes on smokefree indoor air that prohibit smoking in public places and worksites.”7

Rating 

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

better
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 53

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smoke-free 

policies. Available at: http://www.thecommunityguide.org/tobacco/smokefreepolicies.html. Last updated: 

September 22, 2014.

4. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

5. Gonzalez M, Sanders-Jackson A, Song AV, Cheng KW, Glantz SA. Strong smoke-free law coverage in the 

United States by race/ethnicity: 2000–2009. American Journal of Public Health. 2013;103(5):e62–6. doi: 

10.2105/ajph.2012.301045

6. Centers for Disease Control and Prevention. Comprehensive smoke-free laws—50 largest U.S. cities, 2000 and 

2012. Morbidity and Mortality Weekly Report. 2012 Nov 16;61(45):914–7.

7. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.
GOAL AREA 2

► Outcome 2 

54 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.b

Proportion of Jurisdictions with Smokefree Policies for Outdoor Public 

Places

Indicator 2.2.b 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of jurisdictions with policies prohibiting smoking in outdoor public places, 

such as beaches, parks, dining and bar patios, and in front of buildings

Why this indicator is 

useful

Although eliminating indoor secondhand smoke exposure is of paramount importance, 

outdoor exposure can also exceed safe limits, especially in hospitality settings, such as 

restaurant and bar outdoor eating areas, where smokers may be in close proximity to 

others.1 Additionally, smokefree policies in outdoor places reinforce tobacco-free social 

norms.

Example data 

source(s)

Americans for Nonsmokers’ Rights (ANR), Smokefree Lists, Maps, and Data, 

Outdoor Areas

Information available at: http://www.no-smoke.org/goingsmokefree.php?id=519%20-

%20outdoor#outdoor. 

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, and regulations. 

Example survey 

question(s)

Not applicable.

Comments Outdoor smokefree policies help protect people from exposure to secondhand smoke in 

these environments and could help to denormalize smoking. This indicator focuses on 

more general outdoor spaces that would be affected by jurisdictional policy, such as at 

public parks, zoos, public transit waiting areas, playgrounds, beaches, within specific 

distances from public building entrances, and outdoor dining or patio areas of 

restaurants and bars.

It is important to calculate the proportion of the population covered by such policies, so 

as not to underestimate the public health value of a small number of policies adopted in 

densely populated jurisdictions.2

Note: Indicator 2.2.b measures jurisdictions with smokefree policies, whereas Indicator 

2.2.e measures smokefree policies in school environments. 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

 better
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 55

References

1. Licht AS, Hyland A, Travers MJ, Chapman S. Secondhand smoke exposure levels in outdoor hospitality 

venues: a qualitative and quantitative review of the research literature. Tobacco Control. 2013;22(3):172–9. doi: 

10.1136/tobaccocontrol-2012-050493

2. Hood NE, Bernat DH, Ferketich AK, Danesh D, Klein EG. Community characteristics associated with 

smokefree park policies in the United States. Nicotine & Tobacco Research. 2014;16(6): 828–35. doi: 

10.1093/ntr/ntu007
GOAL AREA 2

► Outcome 2 

56 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.cNR

Proportion of the Employed Population Covered by a Workplace 

Smokefree Policy

Indicator 2.2.cNR 

KOI 2005 2.4.2

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of the employed population protected by smokefree policies

Why this indicator is 

useful

In addition to protecting nonsmokers from secondhand smoke, there is strong evidence 

that smokefree workplaces result in increased successful cessation among workers and 

help reduce tobacco initiation among youth.1-4 This indicator is especially relevant for 

evaluation in states that exempt some workplaces from state smokefree air laws (e.g., 

casinos, hotels/motels). In some cases, individual employers may voluntarily institute 

smokefree policies on their premises. 

Example data 

source(s)

National Adult Tobacco Survey (NATS), 2013–2014

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/.

National Youth Tobacco Survey (NYTS), 2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/. 

Population group(s) General population

Example survey 

question(s)

From NATS

Are you currently working for pay or are you self-employed, either part-time or fulltime?

• Yes

• No

Now I’m going to ask you about smoke you might have breathed at work because 

someone else was smoking, either indoors or outdoors. During the past 7 days, that is, 

since last [TODAY’S DAY OF WEEK], on how many days did you breathe the smoke 

at your workplace from someone other than you who was smoking tobacco?

• _Number of Days

• None

• Don’t know/Not sure

At your workplace, is smoking....? 

• Allowed in both indoor and outdoor areas

• Allowed in outdoor areas, but never allowed in any indoor areas

• Allowed in indoor areas, but never allowed in any outdoor areas

• Never allowed in any indoor or outdoor area

• Don’t know

From NYTS

During the past 7 days, on how many days did you breathe the smoke from someone 

who was smoking tobacco products in the place where you work?

• I do not have a job

• I did not work during the past 7 days

• 0 days
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 57

• 1 day

• 2 days

• 3 days 

• 4 days

• 5 days

• 6 days

• 7 days 

Comments To measure this indicator, evaluators first need to establish the employment status of the 

respondent to be able to determine the denominator needed: the employed population. 

Then, evaluators should inquire about a smokefree policy at the respondent’s workplace.

Evaluators can tailor this indicator for certain settings, such as health care, behavioral 

health, and substance abuse facilities, that might choose voluntary smokefree policies 

where state-level comprehensive smokefree policies are not in place.

Although the example items are from individual-level population surveys, these items 

can also be asked of employer representatives as part of a worksite survey.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

 better

References

1. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress. A 

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

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

on Smoking and Health; 2014. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smoke-free 

policies. Available at: http://www.thecommunityguide.org/tobacco/smokefreepolicies.html. Last updated: 

September 22, 2014.

4. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.
GOAL AREA 2

► Outcome 2 

58 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.d

Proportion of the Population that Lives in a Jurisdiction with 

Comprehensive Smokefree Policies

Indicator 2.2.d 

KOI 2005 2.4.3 

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of people who live in a jurisdiction with a comprehensive smokefree policy 

(i.e., a policy that covers indoor worksites, restaurants, and bars)

Why this indicator is 

useful

Measuring this indicator helps clarify the reach of smokefree laws and policies and

highlights differing levels of protection among population subgroups. For example, 

service and hospitality workers experience some of the greatest disparities in protection

from secondhand smoke.1

Example data 

source(s)

American Nonsmokers’ Rights Foundation, Percent of U.S. State Populations 

Covered by 100% Smokefree Air Laws, updated quarterly

Information available at: http://www.no-smoke.org/pdf/percentstatepops.pdf. 

Evaluators can also estimate reach of smokefree policies by obtaining demographic data 

from the latest available U.S. census for a given jurisdiction.

Population group(s) General population

Example survey 

question(s)

Not applicable

Comments A comprehensive smokefree policy is defined by the Office on Smoking and Health 

(OSH) as a policy that does not allow smoking in any indoor areas of workplaces, 

restaurants, and bars, with no exceptions.2 Evaluators may wish to expand the OSH 

definition of “comprehensive” to include, for example, casinos and other settings as 

appropriate. 

The term “jurisdiction” refers to sub-state geographic regions with defined legal 

authority, including municipalities, counties, and other incorporated areas.

Evaluators may choose to gather data on the size and demographics of the population 

affected by the relevant laws or ordinances.

Evaluators may also want to assess the proportion of the population that lives in a 

jurisdiction with a smokefree law that also prohibits the use of e-cigarettes in all 

smokefree environments. Hundreds of communities and several states now have these 

laws in place for their whole population, with additional municipalities and states 

considering such legislation. See the addendum indicator E-Cigarette 2.2 for more 

information. 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

better
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 59

References

1. Centers for Disease Control and Prevention. Best practices user guide: health equity. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

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

http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf. 

2. Centers for Disease Control and Prevention. Comprehensive smoke-free laws—50 largest U.S. cities, 2000 and 

2012. Morbidity and Mortality Weekly Report. 2012 Nov 16;61(45):914–7.
GOAL AREA 2

► Outcome 2 

60 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.e

Proportion of Childcare Settings, Schools, School Districts, or College 

Campuses with 100% Tobacco-Free Policies

Indicator 2.2.e 

KOI 2005 2.4.5

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of childcare facilities, schools, school districts, or college campuses 

(public/private) that report having a policy that prohibits anyone from using tobacco 

products, including combustible, noncombustible, and electronic products, at all times 

on facility grounds, at all school-sponsored functions, and in school vehicles

Why this indicator is 

useful

Children exposed to secondhand smoke are at increased risk for several adverse health 

conditions, including middle ear disease, respiratory symptoms, impaired lung function, 

lower respiratory illness, and sudden infant death syndrome.1,2 Approximately half of 3- 

to 18-year-olds are exposed to secondhand smoke regularly.1

 

Example data 

source(s)

Americans for Nonsmokers’ Rights (ANR): Colleges and Universities with 100% 

Smokefree Policies, (Entire Campus, Indoors and Outdoors), 100% Tobacco-Free 

Policies, and E-cigarette-Free Policies. 

Information available at: http://no-smoke.org/goingsmokefree.php?id=447. 

Early Childhood Environment Rating Scale (ECERS), Health Practice Subscale

Information available at: http://ers.fpg.unc.edu/early-childhood-environment-ratingscale-ecers-r. 

School Health Profiles (Profiles), 2014, Principal Questionnaire

Information available at: http://www.cdc.gov/healthyyouth/profiles/. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/. 

State Tobacco Activities Tracking and Evaluation (STATE) System

Information available at: http://www.cdc.gov/statesystem/. 

Tobacco-Free College Assessment Survey for Staff, Faculty, and Students

(TFCAS), Wake Forest Baptist Health

Information available at: 

http://www.wakehealth.edu/uploadedFiles/User_Content/Research/Departments/Public_

Health_Sciences/Tobacco_Free_Colleges/TobaccoFree%20Manual_Appendix%207.pdf. 

Population group(s) School principals, superintendents, childcare facilities managers, and college/university 

health representatives

Example survey 

question(s)

From ECERS

Smoking is allowed in child care areas, either indoors or outdoors.

• Yes

• No

From Profiles

Has your school adopted a policy prohibiting tobacco use?

• Yes

• No
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 61

Does the tobacco-use prevention policy specifically prohibit tobacco use in each of the 

following locations for each of the following groups? (Mark yes or no for each location 

for each group.)

Students, Faculty/Staff, Visitors

• In school buildings

• Outside on school grounds, including parking lots and playing fields

• On school buses or other vehicles used to transport students

• At off-campus, school-sponsored events

Does the tobacco-use prevention policy specifically prohibit use of each type of tobacco 

for each of the following groups during any school-related activity? (Mark yes or no for 

each type of tobacco for each group.)

Students, Faculty/Staff, Visitors

• Cigarettes

• Smokeless tobacco (i.e., chewing tobacco, snuff, or dip)

• Cigars

• Pipes

From SCS-TC

Which of the following best describes your school’s official smoking policy for indoor 

areas...?

• Smoking is not allowed in any area.

• It is allowed in some areas.

• It is allowed in all areas.

• There is no official policy.

From TFCAS

What is the current written policy on tobacco use at this college?

• Prohibits only smoking inside buildings

• Prohibits only smoking outdoors

• Prohibits all tobacco use

• No written tobacco-use policy

• I do not know

Comments An alternative to survey data for this indicator is the collection and scoring of actual 

written policies from schools, school districts, universities, or childcare settings. 

Evaluators can maintain their own database with the written policies to assess their 

comprehensiveness. ANR tracks colleges and universities with 100% tobacco-free 

policies.

To calculate the proportion of childcare settings, schools, school districts, or college 

campuses with 100% tobacco-free policies, evaluators will have to determine the 

denominator. For example, the number of school districts may need to be obtained from 

the U.S. Department of Education. This indicator can be used to measure progress 

toward achieving Objective TU-15 of Healthy People 2020: “Increase tobacco-free 

environments in schools, including all school facilities, property, vehicles, and school 

events (i.e., for junior high, middle school, high school, Head Start).”3

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

better
GOAL AREA 2

► Outcome 2 

62 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 63

Indicator 2.2.f

Proportion of the Population Reporting 100% Smokefree Rules for Homes 

or Vehicles

Indicator 2.2.f 

KOI 2005 2.4.4

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of adults who report 100% smokefree rules in their homes or vehicles, 

whether voluntary or because of a public policy 

Why this indicator is 

useful

An estimated 15 million U.S. children were exposed to secondhand smoke during 2011–

2012.1 Smokefree home policies reduce children’s exposure to secondhand smoke, 

reduce adult smoking, and decrease youth experimentation with cigarettes.2-4

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS), 2011 Secondhand Smoke 

Module

Information available at: http://www.cdc.gov/brfss/. 

National Adult Tobacco Survey Questionnaire (NATS), 2013–2014

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/. 

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011

Information available at: http://appliedresearch.cancer.gov/tus-cps/

Population group(s) General population

Example survey 

question(s)

From BRFSS

Not counting motorcycles, in the vehicles that you or family members who live with you 

own or lease, is smoking...?

• Always allowed in all vehicles

• Sometimes allowed in at least one vehicle

• Never allowed in any vehicle

Not counting decks, porches, or garages, inside your home, is smoking...?

• Always allowed

• Allowed only at some times or in some places

• Never allowed

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
GOAL AREA 2

► Outcome 2 

64 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• Never allowed in any vehicle

• Respondent’s family does not own or lease a vehicle

• Don’t know/Not sure

• Refused

From SCS-TC

Which statement best describes the rules about smoking in your home...?

• No one is allowed to smoke anywhere

• Smoking is permitted in some places or at some times

• Smoking is permitted anywhere

From TUS-CPS

Which statement best describes the rules about smoking inside your home?

• No one is allowed to smoke anywhere inside your home

• Smoking is allowed in some places or at some times inside your home

• Smoking is permitted anywhere inside your home

Comments A 100% smokefree home rule is defined as a household rule where smoking is never 

allowed in any area of the home at any time.

This indicator can be used to measure progress toward achieving Objective TU-14 of 

Healthy People 2020: “Increase the proportion of smokefree homes.”5 

Population-level indicator data can be examined by housing type (single vs. multiunit) 

and ownership (rent v. own) to parse out multiunit housing residents who may be under 

the jurisdiction of a smokefree policy from those who have voluntary rules where no 

such policy exists. 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

 better

References

1. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke—

United States, 1999–2012. Morbidity and Mortality Weekly Report. 2015 Feb 6;64(4):103–8.

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). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

4. King BA, Hyland AJ, Borland R, McNeill A, Cummings KM. Socioeconomic variation in the prevalence, 

introduction, retention, and removal of smoke-free policies among smokers: findings from the International 

Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public 

Health. 2011;8(2), 411–34. doi: 10.3390/ijerph8020411

5. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 65

Indicator 2.2.g 

Proportion of Jurisdictions that Have Enacted Laws Prohibiting Smoking 

in Multiunit Housing

Indicator 2.2.g 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of local jurisdictions that have laws prohibiting smoking in multiunit housing

Why this indicator is 

useful

An estimated 80 million U.S. residents live in multiunit housing.1 Many of them are at 

risk for secondhand smoke exposure because smoke can travel through walls, air ducts, 

windows, and ventilation systems.2 Youth who live in multiunit housing are particularly 

susceptible to involuntary secondhand smoke exposure in the home.3 A growing number 

of municipalities have implemented smokefree building policies prohibiting smoking in 

indoor areas, including living units of multiunit housing, to reduce exposure to 

secondhand smoke in multiunit housing.4

Example data 

source(s)

Americans for Nonsmokers’ Rights Foundation. U.S. laws and policies restricting or 

prohibiting smoking in private units of multiunit housing. Updated quarterly. Available 

at: http://www.no-smoke.org/pdf/smokefreemuh.pdf.

State Tobacco Activities Tracking and Evaluation (STATE) System

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, and regulations.

Example survey 

question(s)

Not applicable.

Comments Evaluators can count municipal laws, policies covering subsidized or public housing 

authority (PHA) properties, and/or policies covering market-rate multiunit housing 

properties that prohibit smoking in 100% of private units and all indoor public areas of 

all buildings. Alternatively, evaluators may want to distinguish between publicly and 

privately owned housing. For PHA buildings, the Office on Smoking and Health (OSH) 

defines smokefree policy as a policy that “prohibits smoking in all indoor areas of all 

residential buildings under the jurisdiction of the PHA, including individual living units, 

hallways, and balconies.” A broader law covering public and market-rate multiunit 

housing would prohibit smoking in all indoor areas of all residential buildings under the 

jurisdiction’s purview (e.g., the municipality or county).

Evaluators may also want to track aspects of policy implementation, such as the 

provision of required funding and other resources, efforts to educate the target 

population about the policy, and education and training related to enforcement and 

compliance monitoring. 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

 better
GOAL AREA 2

► Outcome 2 

66 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

References

1. King BA, Peck RM, Babb SD. National and state cost savings associated with prohibiting smoking in 

subsidized and public housing in the United States. Preventing Chronic Disease. 2014 Oct;11(E171):140222. 

doi: http://dx.doi.org/10.5888/pcd11.140222

2. Bohac DL, Hewett MJ, Hammond SK, Grimsrud DT. Secondhand smoke transfer and reductions by air sealing 

and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air. 2011;21(1):36–44. doi: 

10.1111/j.1600-0668.2010.00680.x

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. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific literature. Tobacco 

Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 67

Indicator 2.2.h

Proportion of Public Housing Authorities that Have Adopted Smokefree 

Policies in All of Their Buildings

Indicator 2.2.h 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of public housing authorities (PHAs) that have smokefree policies in all of 

their buildings 

Why this indicator is 

useful

Of the approximately 7 million Americans living in government subsidized multiunit 

housing, approximately 2 million reside in public housing owned or operated by a 

PHA.

1 Because secondhand smoke can travel through walls, air ducts, windows, and 

ventilation systems,2 it poses a substantial health risk to public housing residents, the

majority of which are especially vulnerable to secondhand smoke, including children, 

the elderly, and the disabled.3 If data can be obtained on the total number of PHA units 

in the jurisdiction, this indicator will allow evaluators to determine the proportion of 

public housing units with residents who are protected from secondhand smoke 

incursions in their homes.

Example data 

source(s)

State Tobacco Activities Tracking and Evaluation (STATE) System

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, and regulations.

Example survey 

question(s)

Not applicable

Comments Subsidized housing is affordable rental housing for eligible low-income families, elderly 

persons, and persons with disabilities. Subsidized housing includes public housing, 

which is operated by PHAs. The type of housing varies (e.g., single family homes, highrise apartments).

4 The U.S. Department of Housing and Urban Development (HUD) 

oversees the public housing program and provides federal funding to local PHAs 

responsible for managing the housing.

OSH tracks government multiunit housing legislation by type of restriction: (1) lobby 

and common area and (2) living areas. Evaluators could look at this indicator within a 

state, county, or other jurisdiction.

A “smokefree building policy” prohibits smoking in all indoor areas of all residential 

buildings under the jurisdiction of the PHA, including individual living units, hallways, 

and balconies. Evaluators may wish to examine the proportion of PHAs that prohibit 

smoking in only some areas of the building. Additionally, if the number of residents in 

PHAs can be obtained, evaluators can estimate the proportion of residents who are 

susceptible to secondhand smoke because they are not covered under a smokefree 

building policy.

On December 5, 2016, HUD published a rule requiring all PHAs to adopt policies 

prohibiting combustible tobacco products in living units, indoor common areas, 

administrative offices, and within 25 feet of the housing and administrative buildings.5

Evaluators can use this indicator to establish a pre-policy baseline, and once the final 

rule is implemented (18 months after the effective date), this indicator can be used for 

local outcome evaluation efforts.
GOAL AREA 2

► Outcome 2 

68 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Note: Data from this indicator plus data on the number of residents can be used to 

estimate the proportion of residents susceptible to secondhand smoke exposure, 

Indicator 2.2.j.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Housing and Urban Development. Resident Characteristic Report System. Washington, 

DC: U.S. Department of Housing and Urban Development; 2014.

2. Bohac DL, Hewett MJ, Hammond SK, Grimsrud DT. Secondhand smoke transfer and reductions by air sealing 

and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air. 2011;21(1):36–44. doi: 

10.1111/j.1600-0668.2010.00680.x

3. King BA, Peck RM, Babb SD. National and state cost savings associated with prohibiting smoking in 

subsidized and public housing in the United States. Preventing Chronic Disease. 2014 Oct;11(E171):140222. 

doi: http://dx.doi.org/10.5888/pcd11.140222

4. U.S. Department of Housing and Urban Development. HUD’s Public Housing Program. Available at: 

http://portal.hud.gov/hudportal/HUD?src=/topics/rental_assistance/phprog. 

5. U.S. Department of Housing and Urban Development. Instituting Smoke-Free public Housing. A Rule by the 

Housing and Urban Development on 12/05/2016. Available at:

https://www.federalregister.gov/documents/2016/12/05/2016-28986/instituting-smoke-free-public-housing
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 69

Indicator 2.2.i

Proportion of Multiunit Housing Operators that Have Adopted a Smokefree 

Policy in Their Buildings

Indicator 2.2.i 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of multiunit housing operators in a jurisdiction that have adopted voluntary 

smokefree policies in their buildings

Why this indicator is 

useful

An estimated 80 million U.S. residents live in multiunit housing, which can include 

private market rates housing or government subsidized housing such as public housing.

1

Approximately one-third of U.S. multiunit housing residents with voluntary smokefree 

home rules still experience secondhand smoke infiltration into their homes from nearby 

units and shared areas.1,2 Because the proposed HUD rule will not cover private housing 

or all forms of public housing, this indicator is important to understand what proportion 

of the population is protected from secondhand smoke incursions by smokefree 

multiunit housing policies. Implementing smokefree policies in multiunit housing can 

reduce secondhand smoke exposure in this environment.

3-4

Example data 

source(s)

Los Angeles County Department of Public Health (LAC DPH), Tobacco Control & 

Prevention Program, Healthy Housing Solutions, Inc., Westat, & CDC, SmokeFree Multi-Unit Housing Policy Study: Operator Survey (ICR Reference No: 

201309-0920-011)

Information available at: 

http://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=201309-0920-011. 

UC Davis, Center for Evaluation and Research, Tobacco Control Evaluation 

Center, Multiple Housing Unit Owner/Manager Survey (MHUOS)

Information available at: http://tobaccoeval.ucdavis.edu/index.html. 

Population group(s) Multiunit housing operators

Example survey 

question(s)

From LAC DPH

Now I’d like to ask about this apartment complex’s current policies about smoking on 

the property. By “policy,” I mean any of the rules, guidelines, or procedures that tenants 

must follow about where they can or cannot smoke.

1. [Do you/Does your company] currently have any policies in place prohibiting 

smoking in any areas of this apartment complex, including individual apartments 

and indoor or outdoor shared areas?

• Yes

• No

2. The next questions are about smoke-free policies in different areas of this 

apartment complex. Please tell me whether [you/your company] have a policy 

prohibiting smoking in any of the following areas.
GOAL AREA 2

► Outcome 2 

70 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

AREA OF BUILDING

POLICY PROHIBITING 

SMOKING IF YES,

YES NO

NOT

APPLICABLE RE DK

What year 

was it 

adopted?

a) No smoking allowed anywhere on 

the property, including inside the 

apartments? ...................................... 1 2 3 -7 -8 |__|__|__|__|

If a = 2, GO TO 6

[No smoking allowed in...] 

b) Entrance ways to buildings? ............ 1 2 3 -7 -8 |__|__|__|__|

c) Indoor hallways?.............................. 1 2 3 -7 -8 |__|__|__|__|

d) Indoor stairwells?............................. 1 2 3 -7 -8 |__|__|__|__|

e) Laundry rooms? ............................... 1 2 3 -7 -8 |__|__|__|__|

f) Outdoor common areas (e.g., 

parking lots, stairwells, hallways, 

and pool area)?................................. 1 2 3 -7 -8 |__|__|__|__|

g) Balconies, patios, and backyards of 

units?................................................ 1 2 3 -7 -8 |__|__|__|__|

h) Individual apartment units?.............. 1 2 3 -7 -8 |__|__|__|__|

i) Other area?....................................... 

(SPECIFY)___________________ 

1 2 3 -7 -8 |__|__|__|__|

IF 2h = 1, CONTINUE. OTHERWISE, GO TO 4

3. In what percent of units is smoking prohibited?

PERCENT OF UNITS..................................................................|___|___|___| %

4. Under the current policy, has smoking been completely prohibited in one or more 

of the buildings in this apartment complex? This includes the apartments and the 

indoor hallways of the building.

• Yes

• No

5. Under the current policy, in how many buildings with rental units has smoking 

been completely prohibited?

NUMBER OF BUILDINGS............................................................. |___|___|___|

6. Did you implement a “grandfather clause” which would gradually phase out 

smoking in the complex by allowing current tenants to smoke in their units but 

would not allow new tenants to do so?

• Yes

• No
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 71

Comments Evaluators may wish to measure this indicator separately for market rate, subsidized, 

and public housing.

Multiunit housing operators can include owners, managers, or landlords of multiunit 

housing.5

Evaluators can measure multiple elements of multiunit housing smokefree policies, such 

as

• disclosure policies, where operators have to disclose their smoking policy to 

potential tenants; 

• smoking bans in common areas, whether indoor, outdoor, or both; 

• smoking bans in common areas and individual units. 

Evaluators can also measure whether the policy is applicable to residents and visitors; 

whether it is applicable 24 hours per day, 7 days per week; and whether multiunit 

housing operators have provided cessation resources/information along with 

implementing a smokefree policy.

From MHUOS

Do you currently have a smoke-free policy for your rental property?

• Yes, the property is entirely smoke-free

• Yes, certain areas are designated as smoke-free

• No, there is no smoke-free policy

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

better

References

1. King BA, Peck RM, Babb SD. National and state cost savings associated with prohibiting smoking in 

subsidized and public housing in the United States. Preventing Chronic Disease. 2014 Oct;11(E171):140222. 

doi: http://dx.doi.org/10.5888/pcd11.140222

2. Bohac DL, Hewett MJ, Hammond SK, Grimsrud DT. Secondhand smoke transfer and reductions by air sealing 

and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air. 2011;21(1):36–44. doi: 

10.1111/j.1600-0668.2010.00680.x

3. Centers for Disease Control and Prevention. Best practices user guide: health equity. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

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

http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

5. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific literature. Tobacco 

Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849
GOAL AREA 2

► Outcome 2 

72 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.j

Proportion of Multiunit Housing Residents Living in Smokefree Buildings

Indicator 2.2.j 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Proportion of multiunit housing residents living in buildings where smoking is 

prohibited, with no exceptions

Why this indicator is 

useful

An estimated 80 million U.S. residents live in multiunit housing.1 Because smoke can

travel through walls, air ducts, windows, and ventilation systems,2 About a third of

multiunit housing residents with personal smokefree home rules still experience 

secondhand smoke infiltration into their homes.1,3Implementing smokefree policies in 

multiunit housing can reduce secondhand smoke exposure.4-5

Example data 

source(s)

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/. 

Oregon Public Health Division Tobacco Prevention and Education Program 

(TPEP) Guardian Management study6 

Smoke-Free Policies in Multiunit Housing: Smoking Behavior and Reactions to 

Messaging Strategies in Support or in Opposition7

Population group(s) Multiunit housing residents

Example survey 

question(s)

From SCS-TC

Which of the following best describes where you live? Would you say...?

• a mobile home

• a one-family house detached from any other house

• a one-family house attached to one or more houses

• an apartment or condominium building

• other

Does your property manager allow smoking in your apartment/condo units?

• Yes

• No

Does your property manager allow smoking on the property?

• Yes

• No

Adapted from the Oregon TPEP Guardian Management Study 

Tell us if you think these things are allowed or not allowed:

• Smoking inside your apartment

• Smoking in indoor shared areas, like hallways and entryways

• Smoking outdoors on porches, patios, or balconies

• Smoking in other outdoor areas of the property like the parking lot

From the Smoke-Free Policies in Multiunit Housing Study

Which statement best describes the landlord’s or property manager’s rules about 

smoking? Would you say the landlord or property manager... 

• Has no rules about smoking
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 73

• Allows smoking only in designated areas

• Doesn’t allow smoking anywhere

Comments This indicator can be measured using self-report or biochemical validation. 

Evaluators may wish to differentiate between exposures within private units, in common 

areas, and in outdoor areas, such as building entrances and balconies.

Note: Data from Indicator 2.2.h will provide information on the proportion of public 

housing authorities that have smokefree policies in all of their buildings.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

better

References

1. King BA, Peck RM, Babb SD. National and state cost savings associated with prohibiting smoking in 

subsidized and public housing in the United States. Preventing Chronic Disease. 2014 Oct;11(E171):140222. 

doi: http://dx.doi.org/10.5888/pcd11.140222

2. Bohac DL, Hewett MJ, Hammond SK, Grimsrud DT. Secondhand smoke transfer and reductions by air sealing 

and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air. 2011;21(1):36–44. doi: 

10.1111/j.1600-0668.2010.00680.x

3. Nguyen K, Gomez Y, Homa DM, King BA. Tobacco use, secondhand smoke, and smoke-free home rules in 

multiunit housing. Am J Pre Med. 2016 Nov;51(5):682-692. doi: 10.1016/j.amepre.2016.05.009.

4. Centers for Disease Control and Prevention. Best practices user guide: health equity. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

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

http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf. 

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

on Smoking and Health; 2014. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

6. Pizacani BA, Maher JE, Rohde K, Drach L, Stark MJ. Implementation of a smoke-free policy in subsidized 

multiunit housing: effects on smoking cessation and secondhand smoke exposure. Nicotine & Tobacco 

Research. 2012 Sep;14(9):1027–34. doi: 10.1093/ntr/ntr334

7. Berg CJ, Haardörfer R, Windle M, Solomon M, Kegler MC. Smoke-free policies in multiunit housing: smoking 

behavior and reactions to messaging strategies in support or in opposition. Preventing Chronic Disease. 

2015;12. http://doi.org/10.5888/pcd12.140479
GOAL AREA 2

► Outcome 2 

74 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.k 

Number and Type of Enforcement Actions Issued Regarding Smokefree 

Policies

Indicator 2.2.k 

KOI 2005 2.5.1, 2.5.2, and 2.5.3

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Number and type of enforcement-related actions (e.g., warnings, civil penalties, criminal 

penalties) taken to support smokefree policies 

Why this indicator is 

useful

Compliance with smokefree public policies improves when noncompliance has 

repercussions.1 Ensuring clear enforcement powers, defined responsibilities, and 

adequate resources is important to address noncompliance.2-4 Tracking enforcement 

actions is important to help explain compliance trends. 

Example data 

source(s)

California Tobacco Control Program (CTCP): Secondhand Smoke Law 

Enforcement Survey, 2007

Information available at:

http://www.cdph.ca.gov/programs/tobacco/Documents/Resources/Publications/Enforce

ment%20Report%202007%20-%20Final%20Submitted.pdf. 

Population group(s) Agency representatives responsible for enforcement 

Example survey 

question(s)

Adapted from the CTCP Secondhand Smoke Law Enforcement Survey

In the last year, please estimate how many citations specifically related to the smoking 

ban in bars were issued and prosecuted for the following types of establishments:

• Number of citations issued to restaurant/ bars in your jurisdiction: ___

• Number of citations issued to restaurant/ bars in your jurisdiction that were 

prosecuted: ___

• Number of citations issued to stand-alone bars in your jurisdiction: ___

• Number of citations issued to stand-alone bars in your jurisdiction that were 

prosecuted: ___

In the last year, please estimate how many citations specifically related to the smoking 

ban in worksites were issued and prosecuted. 

• Number of citations issued in your jurisdiction: ___

• Number of citations issued in your jurisdiction that were prosecuted: ___

In the last year, please estimate how many citations specifically related to the smoking 

ban in schools were issued and prosecuted. 

• Number of citations issued in your jurisdiction:___

• Number of citations issued in your jurisdiction that were prosecuted: ___

Comments Enforcement-related information must be interpreted in context. For example, a low 

number of citations may indicate either high compliance or low levels of enforcement. 

Evaluators can assess enforcement capacity to aid in interpretation of indicator data.5

Example penalties include citations, graduated fines, and suspension or revocation of 

business licenses.

There are two types of enforcement: (1) active enforcement by health inspectors, and (2) 

passive enforcement (i.e., complaints from the public to the health department or 

enforcing agency reporting violations). 
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 75

Another way to measure enforcement actions is to measure the proportion of complaints 

received that are acted upon.

Evaluators may wish to assess the number of enforcement actions by venue type or 

geographic area to identify “hot spots” of noncompliance.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$

 better

†† Denotes low agreement among reviewers, defined as less than 75% of valid ratings 

within ±2 point of the median for this indicator-specific criterion.

References

1. Centers for Disease Control and Prevention. Best practices user guide: health equity. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

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

http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf. 

2. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smoke-free 

policies. Available at: http://www.thecommunityguide.org/tobacco/RRsmokefreepolicies.html. Last updated: 

September 22, 2014.

3. Bruckman D, Allan T, Stefanak M, Chandran Pillai A, Drabousky AS, Borawski EA, Frank S. Enforcement of 

Ohio’s Smoke Free Workplace Law through the lens of public health practice. Public Health Reports. 

2013;128(1):54–63.

4. Weber MD, Bagwell DA, Fielding JE, Glantz SA. Long term compliance with California’s Smoke-Free 

Workplace Law among bars and restaurants in Los Angeles County. Tobacco Control. 2003 Sep;12(3):269–73.

doi: 10.1136/tc.12.3.269

5. Fallin A, Goodin A, Rayens MK, Adkins SA, Hahn EJ. Smoke-free policy implementation: theoretical and 

practical considerations. Policy, Politics, & Nursing Practice. 2014 Aug-Nov;15(3-4):81-92. doi: 

10.1177/1527154414562301. 
GOAL AREA 2

► Outcome 2 

76 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.2.l

Proportion of States with Tobacco Control Laws that Preempt Local 

Smokefree Air Policies

Indicator 2.2.l 

KOI 2005 2.4.6

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 2 Implementation and enforcement of smokefree policies

What to measure Any legislation that prevents local jurisdictions from enacting restrictions that are more 

stringent than the state’s restrictions on smokefree indoor air laws

Why this indicator is 

useful

Many strong and innovative tobacco control policies have originated at the local level; 

however, states with preemptive statutes or judicial opinions that prevent local 

jurisdictions from passing policies that are more stringent or vary from state-level policy 

have impeded local action to protect residents from exposure to secondhand smoke.

1-3. 

Example data 

source(s)

Americans for Nonsmokers’ Rights (ANR), Smokefree Lists, Maps, and Data, 

States with Preemption of Smokefree Air Laws

Information available at: http://www.no-smoke.org/pdf/preemptionmap.pdf. 

State Tobacco Activities Tracking and Evaluation (STATE) System

Information available at: http://apps.nccd.cdc.gov/statesystem/Default/Default.aspx

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring state tobacco 

control laws. 

Example survey 

question(s)

Not applicable.

Comments States should monitor preemption by venue to understand where preemption applies.3

This indicator can be used to measure progress toward achieving Objective TU-16.1 of 

Healthy People 2020: “Eliminate state laws that preempt stronger local tobacco control

laws on smokefree indoor air.”4

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $ 

better

†† Denotes low agreement among reviewers, defined as less than 75% of valid ratings 

within ±2 point of the median for this indicator-specific criterion.

References

1. 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, CDC; 2000.

2. National Cancer Institute. State and local legislative action to reduce tobacco use. Smoking and Tobacco 

Control Monograph No. 11. NIH Publication No. 00-4804. Bethesda, MD: U.S. Department of Health, National 

Institutes of Health, National Cancer Institute; 2000.
GOAL AREA 2

► Outcome 2 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 77

3. Centers for Disease Control and Prevention. State preemption of local smoke-free laws in government work 

sites, private work sites, and restaurants—United States, 2005–2009. Morbidity and Mortality Weekly Report.

2010;59:105-8.

4. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.
GOAL AREA 2

► Outcome 3 

78 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 3 

Compliance with Smokefree Policies

Legislated and voluntary policies covering public places and workplaces have been shown to 

become largely self-enforcing over time due to publicity of the policy’s health benefits leading 

up to its passage and increasing social support after policy implementation.1

 Even as legislated 

policies have expanded to cover bars and restaurants, where levels of support may have been 

lower among patrons, owners, and staff, research has shown increasing levels of policy 

compliance as social norms evolve.2

Compliance with smokefree policies may be attenuated when the policies are voluntary, have no 

enforcement provisions, or have attributes that make them inherently challenging to enforce. For 

example, peers’ negative opinions of smoking on campus may be enough to motivate some 

smokers to comply with smokefree campus policies; however, other smokers on campus may 

only respond to citations.3,4 One study of outdoor smokefree policies found consistently high 

levels of support for these policies among agency directors responsible for policy enforcement, 

but one in four directors still reported compliance issues.5

Concerns about dealing with noncompliance can also be a barrier to implementing smokefree 

multiunit housing policies; however, research has shown that operators implementing these 

policies rarely report enforcement issues.6,7 For smokefree policies for any setting, addressing 

noncompliance will be more straightforward if the policy is simple and applied consistently with 

no exemptions.1 Compliance tracking or studies can be helpful to identify opportunities for 

additional education, enforcement, or ways to improve the policy.8

The following indicators are associated with this outcome:

► 2.3.a Compliance with smokefree policies in public places and workplaces 

► 2.3.b Compliance with tobacco-free policies in childcare settings, schools or school 

districts, and college campuses 

► 2.3.c Compliance with smokefree policies in multiunit housing

► 2.3.d Compliance with 100% smokefree home rules 

► 2.3.e Compliance with smokefree rules for vehicles

References

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

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

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

for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. 

Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. Satterlund TD, Lee JP, Moore RS. Changes in smoking-related norms in bars resulting from 

California’s Smoke-Free Workplace Act. Journal of Drug Education. 2012;42(3):315–26. 
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 79

3. Russette HC, Harris KJ, Schuldberg D, Green L. Policy compliance of smokers on a tobaccofree university campus. Journal of American College Health. 2014;62(2):110–6. doi: 

10.1080/07448481.2013.854247 

4. Ickes MJ, Hahn EJ, McCann M, Kercsmar S. Tobacco-free Take Action!: increasing policy 

adherence on a college campus. World Medical & Health Policy. 2013;5(1):47–56. 

5. Klein EG, Forster JL, McFadden B, Outley CW. Minnesota tobacco-free park policies: 

attitudes of the general public and park officials. Nicotine & Tobacco Research. 

2007;9(Suppl 1):S49–55. 

6. Burdette LK, Rowe GC, Johansen L, et al. A statewide assessment of smoke-free policy in 

multiunit housing settings. Nicotine & Tobacco Research. 2014;16(12):1593–8. doi: 

10.1093/ntr/ntu114 

7. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific 

literature. Tobacco Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849 

8. Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 

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; 2008. Available 

at: 

http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evaluation_toolkit/pdfs/e

valuation_toolkit.pdf. 

For Further Reading

Berg CJ, Bundy L, Escoffery C, Haardorfer R, Kegler MC. Telephone-assisted placement of air 

nicotine monitors to validate self-reported smoke-free home policies. Public Health. 

2013;127(4):342–4. doi: 10.1016/j.puhe.2013.01.002 

Fallin A, Johnson AO, Riker C, Cohen E, Rayens MK, Hahn EJ. An intervention to increase 

compliance with a tobacco-free university policy. American Journal of Health Promotion. 

2013;27(3):162–9. doi: 10.4278/ajhp.110707-QUAN-275 

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

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

November 10, 2014 

Hyland A, Cummings KM, Wilson MP. Compliance with the New York City Smoke-Free Air 

Act. Journal of Public Health Management and Practice. 1999;5(1):43–52. 

King BA, Babb SD, Tynan MA, Gerzoff RB. National and state estimates of secondhand smoke 

infiltration among U.S. multiunit housing residents. Nicotine & Tobacco Research. 

2013;15(7):1316–21. 
GOAL AREA 2

► Outcome 3 

80 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 3 

Compliance with Smokefree Policies

Indicator Rating

better

Number Indicator

Overall Quality

low high

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice

2.3.a Compliance with smokefree 

policies in public places and 

workplaces

†† $$ *

2.3.b Compliance with tobacco-free 

policies in childcare settings, 

schools or school districts, and 

college campuses

$$$

2.3.c 

(New)NR

Compliance with smokefree 

policies in multiunit housing

     

2.3.d Compliance with 100% 

smokefree rules for homes

$$

2.3.e Compliance with smokefree rules 

for vehicles

$ 

$ 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 ±2 point of the median 

for this indicator-specific criterion.

 Denotes no data.

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.
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 81

Indicator 2.3.a

Compliance with Smokefree Policies in Public Places and Workplaces

Indicator 2.3.a 

KOI 2005 2.6.1 and 2.6.2

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 3 Compliance with smokefree policies

What to measure Proportion of the population that complies with smokefree policies in public places (e.g., 

bars, restaurants, sporting arenas)

Proportion of the population employed outside the home that complies with smokefree 

policies in their workplaces

Why this indicator is 

useful

If smokefree policies are not followed, they are unlikely to protect the public from the 

harmful effects of secondhand smoke or change social norms.1-3

Example data 

source(s)

Adult Tobacco Survey Questions (ATS), Supplemental Survey, 2014

Information available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5903a1.htm.

Population group(s) General population 

Example survey 

question(s)

From ATS

Not counting times while you were at work, to your knowledge, during the past 7 days, 

that is, since last [TODAY’S DAY OF WEEK], has anyone, including yourself, used

tobacco in an indoor or outdoor public place when he or she was not supposed to?

• Yes

• No

• Don’t know/Not sure

• Refused

At your workplace, is smoking ....?

• Allowed in both indoor and outdoor areas

• Allowed in outdoor areas, but never allowed in any indoor areas

• Allowed in indoor areas, but never allowed in any outdoor areas

• Never allowed in any indoor or outdoor area

• Don’t know

To your knowledge, during the past 30 days, that is, since [DATE FILL], has anyone, 

including yourself, used tobacco at your work when he or she was not supposed to?

• Yes

• No

• Don’t know/Not sure

• Refused

Comments The most cost-effective method to assess compliance is to draw on existing population 

surveys that include relevant questions on reported compliance. While this method may 

lack precision, it can still provide a useful barometer of relative compliance levels. In 

addition to gathering data on reported compliance, evaluators can measure compliance 

through observation4 and/or measure the secondhand smoke in public places and 

workplaces by monitoring indoor air quality. Evaluators also can use established 

protocols for collecting cigarette butts.5 

It is important for evaluators to take into account the use of e-cigarettes. When reporting 

compliance, the general public may not be able to distinguish between combustible 
GOAL AREA 2

► Outcome 3 

82 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

tobacco products and e-cigarettes. Inclusion or exclusion of e-cigarettes in smokefree 

policies may also pose measurement challenges. For smokefree policies that include 

e-cigarette products, E-Cigarette 2.3 may serve as a “replacement” for Indicator 2.3.a to 

assess compliance with policies that include e-cigarettes. 

Compliance data for workplaces can be analyzed by workplace size or type. Another 

way to assess compliance with smokefree policy is to ask tobacco users in specific 

settings to disclose how many days in the past month they have used tobacco on 

worksite property.

In addition to gathering data on reported compliance, evaluators can measure

compliance through observation4 and/or measure the secondhand smoke in public places 

and workplaces by monitoring indoor air quality. Evaluators also can use established 

protocols for collecting cigarette butts.

5 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$ * 

better

†† Denotes low agreement among reviewers, defined as less than 75% of valid ratings 

within ±2 point of the median for this indicator-specific criterion.

* Denotes low reviewer response, defined as fewer than 75% of valid ratings on a 

criterion for an indicator.

References

1. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

2. Weber MD, Bagwell DA, Fielding JE, Glantz SA. Long term compliance with California’s Smoke-Free 

Workplace Law among bars and restaurants in Los Angeles County. Tobacco Control. 2003 Sep;12(3):269–73.

doi: 10.1136/tc.12.3.269

3. Johns M, Farley SM, Rajulu DT, Kansagra SM, Juster HR. Smoke-free parks and beaches: an interrupted timeseries study of behavioural impact in New York City. Tobacco Control. 2015 Sep;24(5):497–500. doi: 

10.1136/tobaccocontrol-2013-051335.

4. Skeer M, Land ML, Cheng DM, Siegel MB. Smoking in Boston bars before and after a 100% smoke-free 

regulation: an assessment of early compliance. Journal of Public Health Management and Practice. 

2004;10(6):501–7.

5. Ickes MJ, Gokun Y, Rayens MK, Hahn EJ. Comparing two observational measures to evaluate compliance with 

tobacco-free campus policy. Health Promotion Practice. 2015 Mar;16(2):210-7. doi: 

10.1177/1524839914561060.
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 83

Indicator 2.3.b 

Compliance with Tobacco-Free Policies in Childcare Settings, Schools or 

School Districts, and College Campuses

Indicator 2.3.b 

KOI 2005 2.6.5

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 3 Compliance with smokefree policies

What to measure Proportion of students, teachers, or caregivers in compliance with the facility or campus’ 

tobacco-free policies 

Why this indicator is 

useful

Compliance with tobacco-free school policies reduces students’ exposure to secondhand 

smoke and reinforces anti-tobacco social norms.1 Young people’s attitudes toward the 

acceptability of tobacco use are influenced by the actions of their peers and educators at 

school.1-2 Reported and perceived compliance with tobacco-free policies is one measure 

of actual compliance with these policies.3-4 

Example data 

source(s)

School Health Policies and Practices Study (SHPPS), 2014

Information available at: http://www.cdc.gov/healthyyouth/shpps/index.htm

Population group(s) Students, teachers, caregivers

Example survey 

question(s)

From SHPPS

During the 2012–2013 school year, were there four or more times that students at your 

school were caught smoking cigarettes?

• Yes

• No

During the 2012–2013 school year, were there four or more times that students at your 

school were caught using smokeless tobacco?

• Yes

• No

Comments Compliance data can be analyzed by grade level and type of school (e.g., elementary, 

middle, high school, private, parochial, public).

Passive air monitoring may be the best form of measurement for childcare settings.5

Questions about tobacco use on university or college campuses could be asked of 

faculty, staff, students, and visitors. Direct observation (e.g., of violators or cigarette 

butts) is another way to measure adherence to tobacco-free policies at schools and 

college campuses.6

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

 better
GOAL AREA 2

► Outcome 3 

84 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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 Centers for Chronic Disease Prevention and Health Promotion, Office 

on Smoking and Health; 2012.

2. Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and 

addiction. MMWR Recommendations and Reports. 1994;43(RR-2):1–18.

3. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in smoke-free workplace policies among 

food service workers. Journal of Occupational and Environmental Medicine. 2004;46(4):347–56.

4. Weber MD, Bagwell DA, Fielding JE, Glantz SA. Long term compliance with California’s Smoke-Free 

Workplace Law among bars and restaurants in Los Angeles County. Tobacco Control. 2003 Sep;12(3):269–73.

doi: 10.1136/tc.12.3.269

5. Apelberg BJ, Hepp LM, Avila-Tang E, et al. Environmental monitoring of secondhand smoke exposure. 

Tobacco Control. 2013 May;22(3):147-55. doi: 10.1136/tobaccocontrol-2011-050301

6. Ickes MJ, Gokun Y, Rayens MK, Hahn EJ. Comparing two observational measures to evaluate compliance with 

tobacco-free campus policy. Health Promotion Practice. 2015 Mar;16(2):210-7. doi: 

10.1177/1524839914561060.
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 85

Indicator 2.3.c 

Compliance with Smokefree Policies in Multiunit Housing

Indicator 2.3.cNR 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 3 Compliance with smokefree policies

What to measure Proportion of multiunit housing residents, visitors, and employees in compliance with 

smokefree policies 

Why this indicator is 

useful

Because secondhand smoke can travel through walls, air ducts, windows, and ventilation 

systems,1 it poses a substantial health risk to multiunit housing residents.2 If smokefree 

policies are not followed, they are unlikely to protect nonsmokers from the harmful 

effects of secondhand smoke.2-3 Smokefree environments in multiunit housing can 

reduce secondhand smoke exposure and cigarette consumption and can support smoking 

cessation.4

 

Example data 

source(s)

National Adult Tobacco Survey Questionnaire (NATS), 2012–2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/. 

Population group(s) Employees and residents of multiunit housing complexes with smokefree policies 

Example survey 

question(s)

Establish whether person is covered by smokefree multiunit housing policy 

(Indicator 2.2.j)

From SCS-TC

Which of the following best describes where you live? Would you say...?

• A mobile home

• A one-family house detached from any other house

• A one-family house attached to one or more houses

• An apartment or condominium building

• Other

Does your property manager allow smoking in your apartment/condo units?

• Yes

• No

Does your property manager allow smoking on the property?

• Yes

• No

The next series of questions are about where you live. In the past 30 days, have you 

smelled cigarette smoke...?

• In outdoor areas

o Yes

o No

• On your balcony

o Yes

o No

o Not applicable
GOAL AREA 2

► Outcome 3 

86 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• In indoor staircases

o Yes

o No

o Not applicable

• In elevators

o Yes

o No

o Not applicable

• Some other place

o Yes

o No

Do you smell it in your unit?

• Yes

• No

Over the past 3 months, has anyone smoked anywhere in your home?

• Yes

• No

Comments It is important for evaluators to take into account the use of e-cigarettes. When reporting 

compliance, the general public may not be able to distinguish between combustible 

tobacco products and e-cigarettes. Inclusion or exclusion of e-cigarettes in smokefree 

policies may also pose measurement challenges. See E-Cigarette Addendum indicator 

2.2. 

This indicator differs from 2.4.f, which measures exposure to secondhand smoke in 

private homes, in that it measures policy compliance in the context of whether the 

individual is protected by a public, property, or building-level policy prohibiting 

smoking in private units. Evaluators first establish whether a person is covered by a 

smokefree policy and then assess self-reported exposure to understand compliance.

This indicator can also be measured by observation (e.g., direct observation of residents 

and employees in common areas), complaints received regarding policy violations, and 

review of documentation of written warnings issued to violators. See Fallin et al.5 for an 

example observation tool.

In addition to observing smoking-related behavior in multiunit housing buildings, 

evaluators can measure the secondhand smoke in common areas or residences by 

monitoring indoor air quality.6

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

better

References

1. Bohac DL, Hewett MJ, Hammond SK, Grimsrud DT. Secondhand smoke transfer and reductions by air sealing 

and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air. 2011;21(1):36–44. doi: 

10.1111/j.1600-0668.2010.00680.x

2. King BA, Peck RM, Babb SD. National and state cost savings associated with prohibiting smoking in 

subsidized and public housing in the United States. Preventing Chronic Disease. 2014 Oct;11(E171): 140222. 

doi: http://dx.doi.org/10.5888/pcd11.140222
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 87

3. Licht AS, King BA, Travers MJ, Rivard C, Hyland AJ. Attitudes, experiences, and acceptance of smoke-free 

policies among U.S. multiunit housing residents. American Journal of Public Health. 2012;102:1868–71. doi: 

10.2105/AJPH.2012.300717

4. Pizacani BA, Maher JE, Rohde K, Drach L, Stark MJ. Implementation of a smoke-free policy in subsidized 

multiunit housing: effects on smoking cessation and secondhand smoke exposure. Nicotine & Tobacco 

Research. 2012 Sep;14(9):1027–34. doi: 10.1093/ntr/ntr334.

5. Fallin A, Goodin A, Rayens MK, Adkins SA, Hahn EJ. Smoke-free policy implementation: theoretical and 

practical considerations. Policy, Politics, & Nursing Practice. 2014 Aug-Nov;15(3-4):81-92. doi: 

10.1177/1527154414562301. 

6. Apelberg BJ, Hepp LM, Avila-Tang E, et al. Environmental monitoring of secondhand smoke exposure. 

Tobacco Control. 2013 May;22(3):147-55. doi: 10.1136/tobaccocontrol-2011-050301
GOAL AREA 2

► Outcome 3 

88 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.3.d 

Compliance with 100% Smokefree Rules for Homes

Indicator 2.3.d 

KOI 2005 2.6.4

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 3 Compliance with smokefree policies

What to measure Proportion of the population that reports compliance with 100% smokefree home rules

Why this indicator is 

useful

Compliance with home smokefree rules is especially important for protecting the health 

of children, for supporting anti-tobacco social norms, and for decreasing tobacco 

initiation among youth.1-3

Example data 

source(s)

Adult Tobacco Survey Questions (ATS), Core and Supplemental Survey, 2014

Information available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5903a1.htm. 

Oregon Department of Human Services Survey, 19974

Population group(s) General population

Example survey 

question(s)

From ATS

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

Not counting decks, porches, or garages, to your knowledge, during the past 7 days, that 

is, since last [TODAY’S DAY OF WEEK], has anyone, including yourself, smoked 

tobacco inside your home when he or she was not supposed to?

• Yes

• No

• Don’t know/Not sure

• Refused

From Oregon Department of Human Services Survey:

Which of the following statements best describes the rules about smoking inside your 

home?

• No one is allowed to smoke anywhere inside your home. 

• Smoking is allowed in some places or at some times. 

• Smoking is permitted anywhere inside your home.

On how many of the past 30 days has someone, including yourself, smoked cigarettes, 

cigars, or pipes anywhere inside your home?” 

• No days

• 1 or more days

Comments To capture compliance, the following need to be measured: presence of a smokefree rule 

in the home and smoking behavior in the home.

This indicator differs from 2.4.g, which measures exposure to secondhand smoke in 

private homes, in that it measures policy compliance in the context of whether the 

individual has a personal home smokefree rule. Evaluators first establish whether a 

person has a home rule and then assess exposure to understand compliance.
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 89

A 100% smokefree home rule is defined as a household rule where smoking is never 

allowed in any area of the home at any time.

Evaluators may also want to measure whether people’s smokefree home rules include 

e-cigarettes and whether anyone has used these products in their homes. 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

better

References

1. Cartmell KB, Miner C, Carpenter MJ, et al. Secondhand smoke exposure in young people and parental rules 

against smoking at home and in the car. Public Health Reports. 2011 Jul-Aug;126(4):575–82.

2. Albers AB, Biener L, Siegel M, Cheng DM, Rigotti NA. Household smoking bans and adolescent antismoking 

attitudes and smoking initiation: findings from a longitudinal study of a Massachusetts youth cohort. American 

Journal of Public Health. 2008 Oct;98(10):1886–93. doi: 10.2105/AJPH.2007.129320.

3. Gonzales M, Malcoe LH, Kegler MC, Espinoza J. Prevalence and predictors of home and automobile smoking 

bans and child environmental tobacco smoke exposure: a cross-sectional study of U.S.- and Mexico-born 

Hispanic women with young children. BMC Public Health. 2006 Oct 27;6:265.

4. Pizacani BA, Martin DP, Stark MJ, Koepsell TD, Thompson B, Diehr P. Household smoking bans: which 

households have them and do they work? Preventive Medicine. 2003 Jan;36(1):99–107.
GOAL AREA 2

► Outcome 3 

90 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.3.e

Compliance with Smokefree Rules for Vehicles

Indicator 2.3.e 

KOI 2005 2.6.4

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 3 Compliance with smokefree policies

What to measure Proportion of the population that reports compliance with smokefree policies in their 

vehicles

Why this indicator is 

useful

Compliance with smokefree vehicle rules is especially important for protecting the 

health of children, for supporting anti-tobacco social norms, and for decreasing tobacco 

initiation among youth.1-2 

Example data 

source(s)

National Adult Tobacco Survey (NATS), 2013–2014

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/.

Population group(s) General population

Example survey

question(s)

From NATS

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

Created item to follow up on NATS item:

Over the past 30 days, has anyone, including yourself, smoked tobacco inside the 

vehicle that you or family members who live with you own or lease when he or she was 

not supposed to?

• Yes

• No

• Don’t know/Not sure

• I don’t have a car

From SCS-TC

Please tell me which best describes how cigarette smoking is handled in your car or the 

car you regularly travel in.

• No one is allowed to smoke in the car.

• Only special guests are allowed to smoke in the car.

• People are allowed to smoke in the car only if the windows are open.

• People are allowed to smoke in the car at any time.
GOAL AREA 2

► Outcome 3 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 91

In the past 3 months, has anyone smoked in your car?

• Yes

• No

• I don’t have a car

Comments To capture compliance, the following need to be measured: presence of a smokefree rule 

in vehicles and smoking behavior in vehicles.

A 100% smokefree vehicle rule is defined as a rule where smoking is never allowed in 

any area of the owner’s vehicle at any time.

Evaluators may also consider measuring whether people’s smokefree vehicle rules 

include e-cigarettes and whether anyone has used these products in their vehicle.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

 better

References

1. Cartmell KB, Miner C, Carpenter MJ, et al. Secondhand smoke exposure in young people and parental rules 

against smoking at home and in the car. Public Health Reports. 2011 Jul-Aug;126(4):575–82.

2. Albers AB, Biener L, Siegel M, Cheng DM, Rigotti NA. Household smoking bans and adolescent antismoking 

attitudes and smoking initiation: findings from a longitudinal study of a Massachusetts youth cohort. American 

Journal of Public Health. 2008 Oct;98(10):1886–93. doi: 10.2105/AJPH.2007.129320.
GOAL AREA 2

► Outcome 4 

92 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 4 

Reduced Exposure to Secondhand Smoke

Substantial evidence demonstrates the harm caused by exposure to secondhand tobacco smoke. 

Secondhand smoke can lead to lung cancer, heart disease, and stroke in adults and to many 

serious health problems in children, including lower respiratory infections, more frequent and 

severe asthma, sudden infant death syndrome, and ear infections.1,2 Evidence also indicates that 

tobacco smoke is especially harmful to pregnant women and to fetal development.3,4 Reducing 

nonsmokers’ exposure to secondhand smoke prevents disease and saves lives.1,5,6

The overall prevalence of secondhand smoke exposure in the United States has declined in the 

past two decades, as measured by self-reported exposure and biometric screenings for 

continine.2,7,8 Awareness of the harms of secondhand smoke has contributed to a rapid, 

nationwide expansion in the number and comprehensiveness of smokefree laws and regulations.9

Evaluations of comprehensive smokefree policies consistently show reductions in secondhand 

smoke exposure of 80% to 90% in covered venues, and immediate improvements in short-term 

population health outcomes, such as heart disease.5,6

Much progress has been made to reduce secondhand smoke exposure in indoor workplaces and 

public places; however, as of late 2017, nearly 60% of the U.S. population is currently protected 

by a comprehensive state or local smokefree air policy, and half of nonsmoking U.S. students in 

grades 6 through 12 report secondhand smoke exposure in the past week.10,11 Certain 

populations, including young children, individuals living in poverty, residents of rental housing, 

non-Hispanic blacks, and lesbian and bisexual women, are at greater risk of exposure.7,8,12

Compared with indoor venues, outdoor venues are less likely to be covered by smokefree 

policies, even though they can still pose health risks. For example, high concentrations of fine 

particulate matter have been detected in outdoor areas near where smokers congregate on a 

college campus, and students report lower rates of secondhand smoke exposure on tobacco-free 

college campuses.13,14

The home has emerged as a major source for secondhand smoke exposure, especially for 

children.2

 Those living in multiunit housing, such as apartment buildings and condominiums, are 

particularly at risk of exposure in the home, where secondhand smoke can transfer between 

neighboring living units.2,15 An estimated 27.6 to 28.9 million nonsmoking U.S. multiunit 

housing residents with smoke-free home policies are exposed to secondhand smoke infiltrating 

their home from elsewhere in the building, and multiunit dwellings are home to high percentages 

of children, racial and ethnic minorities, and individuals of low socioeconomic status.15,16

Smokefree vehicle rules are less prevalent than smokefree home rules, and in 2009, more than 

20% of U.S. youth reported secondhand smoke exposure in the car in the past week.17,18

Although secondhand smoke exposure in indoor workplaces has become less common, 

workplace exposure among adults who do not smoke persists: about one in five nonsmoking U.S. 

workers still report being exposed to secondhand smoke in the workplace.19 Nonsmoking 

workers who are racial and ethnic minorities, young adults, males, those with less income and 

education, and those who live in the western United States are more likely to be exposed to 
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 93

secondhand smoke in the workplace.19 Gaps in coverage may reflect policy exemptions, which 

are common for hospitality venues; casinos; tobacco-oriented businesses, such as smoke shops; 

and outdoor workplaces.5

 Support for smokefree outdoor worksites is also significantly lower 

than that for indoor workplaces, which may result in higher exposure in outdoor worksites that 

are not covered by state or employer policy.19

The following indicators are associated with this outcome:

► 2.4.a Proportion of nonsmokers exposed to secondhand smoke 

► 2.4.b Proportion of the employed population exposed to secondhand smoke in the 

workplace 

► 2.4.c Proportion of the population exposed to secondhand smoke in indoor public places 

► 2.4.d Proportion of the population exposed to secondhand smoke in outdoor public places 

► 2.4.e Proportion of children, youth, and young adults exposed to secondhand smoke in 

childcare settings and schools 

► 2.4.f Proportion of students, faculty, and staff exposed to secondhand smoke on college 

campuses

► 2.4.g Proportion of multiunit housing residents exposed to secondhand smoke in their 

homes from nearby units or shared areas 

► 2.4.h Proportion of the population exposed to secondhand smoke originating in their homes 

► 2.4.i Proportion of the population exposed to secondhand smoke in vehicles 

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. 

Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fullreport.pdf. 

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

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

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

for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. 

Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

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. Women and 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; 2002. 
GOAL AREA 2

► Outcome 4 

94 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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

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

updated: November 10, 2014. 

6. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer 

Prevention, Tobacco Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. 

Lyon, France: IARC; 2009.

7. Gan WQ, Mannino DM, Jemal A. Socioeconomic disparities in secondhand smoke exposure 

among US never-smoking adults: the National Health and Nutrition Examination Survey 

1988–2010. Tobacco Control. 2015;24(6):568–73. doi: 10.1136/tobaccocontrol-2014-051660 

8. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to 

secondhand smoke—United States, 1999–2012. Morbidity and Mortality Weekly Report. 

2015;64(4):103–8. 

9. American Nonsmokers' Rights Foundation. Chronological Table of U.S. Population 

Protected by 100% Smokefree State or Local Laws. Available at http://www.nosmoke.org/pdf/EffectivePopulationList.pdf 

10. Agaku IT, Singh T, Rolle I, Olalekan AY, King BA. Prevalence and determinants of 

secondhand smoke exposure among middle and high school students. Pediatrics. 

2016;137(2): e20151985. doi: 10.1542/peds.2015-1985 

11.Tynan MA, Holmes CB, Promoff G, Hallett C, Hopkins M, Frick B. State and Local 

Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars — United States, 

2015. MMWR Morb Mortal Wkly Rep 2016;65:623–626. DOI: 

http://dx.doi.org/10.15585/mmwr.mm6524a4

12. Cochran SD, Bandiera FC, Mays VM. Sexual orientation-related differences in tobacco use 

and secondhand smoke exposure among US adults aged 20 to 59 years: 2003–2010 National 

Health and Nutrition Examination Surveys. American Journal of Public Health. 

2013;103(10):1837–44. doi: 10.2105/AJPH.2013.301423 

13. Cho H, Lee K, Hwang Y, et al. Outdoor tobacco smoke exposure at the perimeter of a 

tobacco-free university. Journal of the Air & Waste Management Association (1995). 

2014;64(8):863–6. 

14. Fallin A, Roditis M, Glantz SA. Association of campus tobacco policies with secondhand 

smoke exposure, intention to smoke on campus, and attitudes about outdoor smoking 

restrictions. American Journal of Public Health. 2015 Jun;105(6):1098–100. doi: 

10.2105/AJPH.2014.302251 

15. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific 

literature. Tobacco Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849 

16. King BA, Babb SD, Tynan MA, Gerzoff RB. National and state estimates of secondhand 

smoke infiltration among U.S. multiunit housing residents. Nicotine & Tobacco Research. 

2013;15(7):1316–21. doi: 10.1093/ntr/nts254 
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 95

17. 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;10:120218. 

doi: http://dx.doi.org/10.5888/pcd10.120218. 

18. King BA, Dube SR, Tynan MA. Secondhand smoke exposure in cars among middle and high 

school students—United States, 2000–2009. Pediatrics. 2012;129(3):446–52. 

19. King BA, Homa DM, Dube SR, Babb SD. Exposure to secondhand smoke and attitudes 

toward smoke-free workplaces among employed U.S. adults: findings from the National 

Adult Tobacco Survey. Nicotine & Tobacco Research. 2014;16(10):1307–18. doi: 

10.1093/ntr/ntu069 

For Further Reading

Agaku IT, Vardavas CI. Disparities and trends in indoor exposure to secondhand smoke among 

U.S. adolescents: 2000–2009. PloS One. 2013;8(12):e83058. doi: 10.1371/journal.pone.0083058 

Avila-Tang E, Elf JL, Cummings KM, et al. Assessing secondhand smoke exposure with 

reported measures. Tobacco Control. 2013;22(3):156–63. doi: 10.1136/tobaccocontrol-2011-

050296 

Azagba S. Effect of smoke-free patio policy of restaurants and bars on exposure to second-hand 

smoke. Preventive Medicine. 2015;76:74–8. doi: 10.1016/j.ypmed.2015.04.012 

Lee K, Hahn EJ, Robertson HE, Lee S, Vogel SL, Travers MJ. Strength of smoke-free air laws 

and indoor air quality. Nicotine & Tobacco Research. 2009;11(4):381–6. doi: 10.1093/ntr/ntp026 

Mills AL, Messer K, Gilpin 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 
GOAL AREA 2

► Outcome 4 

96 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 4

Reduced Exposure to Secondhand Smoke

Indicator Rating

better

Number Indicator

Overall Quality

low high

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice

2.4.a Proportion of nonsmokers exposed 

to secondhand smoke

$ 

2.4.b 

(New)

Proportion of the employed 

population exposed to secondhand 

smoke in the workplace

$ 

2.4.c Proportion of the population

exposed to secondhand smoke in 

indoor public places

$ 

2.4.d 

(New) 

Proportion of the population 

exposed to secondhand smoke in 

outdoor public places

$ 

2.4.eNR Proportion of children, youth, and 

young adults exposed to 

secondhand smoke in childcare or 

school settings

     

2.4.fNR

(New)

Proportion of students, faculty, and 

staff exposed to secondhand smoke 

on college campuses

      

2.4.g 

(New)

Proportion of multiunit housing 

residents exposed to secondhand 

smoke in their homes from nearby 

units or shared areas

$

2.4.h Proportion of the population 

exposed to secondhand smoke 

originating in their homes

$

2.4.i 

(New)

Proportion of the population 

exposed to secondhand smoke in 

vehicles

$

$ 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 data.

NR Denotes an indicator that is not rated (see Appendix C for an explanation).
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 97

Indicator 2.4.a

Proportion of Nonsmokers Exposed to Secondhand Smoke

Indicator 2.4.a 

KOI 2005 2.7.5

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Nonsmokers’ exposure to secondhand smoke. Exposure can occur in workplaces, public 

places, homes, and vehicles.

Why this indicator is 

useful

Exposure to secondhand smoke is a major cause of premature death and disease in 

children and adults who do not smoke.1-3 Secondhand smoke contains more than 7,000 

chemicals; hundreds are toxic, and nearly 70 can cause cancer.3 Each year, 

approximately 34,000 heart disease deaths and 7,300 lung cancer deaths among 

nonsmoking adults in the United States are attributable to secondhand smoke exposure.

3

There is no risk-free level of exposure to secondhand smoke.1 About 1 in 4 people in the 

U.S remain exposed to secondhand smoke.4

Example data

source(s)

California Adult Tobacco Survey (CATS), 2008

Information available at: 

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPCaliforniaAdultTobaccoSu

rvey2008.pdf.

National Health and Nutrition Examination Survey (NHANES), 2013–2014

Information available at: http://www.cdc.gov/nchs/nhanes/about_nhanes.htm. 

National Youth Tobacco Survey (NYTS), 2016

Information available at:

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/.

Population group(s) General population

Example survey 

question(s)

From CATS

In the past week, about how many minutes or hours were you exposed to other people’s 

tobacco smoke in all environments?

• ____Enter response

• None at all

• Don’t know/Not sure

• Refused

From NHANES (biochemical marker)

Measured serum cotinine level greater than or equal to 0.05 ng/mL and less than or 

equal to 10 ng/ml among self-reported non-tobacco users and those not using nicotine 

replacement therapy.

From NYTS

During the past 30 days, on how many days did you breathe the vapor from someone 

who was using an e-cigarette in an indoor or outdoor public place? Examples of indoor 

public places are school buildings, stores, restaurants, and sports arenas. Examples of 

outdoor public places are school grounds, parking lots, stadiums, and parks. 

• 0 days

• 1 or 2 days
GOAL AREA 2

► Outcome 4 

98 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• 3 to 5 days

• 6 to 9 days

• 10 to 19 days

• 20 to 29 days

• All 30 days

From SCS-TC

During the past seven days, in which of the following places have you smelled 

secondhand smoke?

• In your home

• In your car

• In someone else’s car

• At work

• On a public sidewalk

• Outside the doorway of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home

Comments Exposure to secondhand smoke can be measured in many ways, including by using selfreported data, biochemical markers, or environmental measures of air quality.5-7 Selfreported smokers and those currently using nicotine replacement therapy should be 

excluded when measuring smoke exposure via biochemical markers.

It is important for evaluators to carefully consider evaluation needs, available resources, 

and population of interest when selecting a data collection approach. For instance, selfreport is not feasible for measuring exposure among very young children. For more

information on measuring secondhand smoke exposure, please refer to the Evaluation 

Toolkit for Smoke-free Policies.

10

This indicator may be used in conjunction with E-Cigarette 2.4, which measures 

exposure to secondhand e-cigarette aerosol.

This indicator can be used to measure progress toward achieving Objective TU-11 of 

Healthy People 2020: “Reduce the proportion of nonsmokers exposed to secondhand 

smoke.”8

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. U.S. Department of Health and Human Services. A report of the Surgeon General: how tobacco smoke causes 

disease: what it means to you. 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 
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 99

on Smoking and Health; 2010. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

4. Homa DM, Neff LJ, King BA, Caraballo RS, Bunnell RE, Babb SD, Garrett BE, Sosnoff CS, Wang L. Vital 

signs: disparities in nonsmokers’ exposure to secondhand smoke–United States, 1999-2012. MMWR Morb 

Mortal Wkly Rep 2015;64:103-108.

5. Avila-Tang E, Elf JL, Cummings KM, Fong GT, Hovell MF, Klein JD, Samet JM. Assessing secondhand 

smoke exposure with reported measures. Tobacco Control. 2013;22(3):156–63. doi: 10.1136/tobaccocontrol2011-050296

6. Avila-Tang E, Al-Delaimy WK, Ashley DL, Benowitz N, Bernert JT, Kim S, Hecht SS. Assessing secondhand 

smoke using biological markers. Tobacco Control. 2013;22(3):164–71. doi: 10.1136/tobaccocontrol-2011-

050298

7. Apelberg BJ, Hepp LM, Avila-Tang E, et al. Environmental monitoring of secondhand smoke exposure. 

Tobacco Control. 2013;22(3):147–55. doi: 10.1136/tobaccocontrol-2011-050301

8. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives. 

9. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

10. Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 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; 2008. Available at: 

http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evaluation_toolkit/pdfs/evaluation_toolkit.p

df. 
GOAL AREA 2

► Outcome 4 

100 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.4.b

Proportion of the Employed Population Exposed to Secondhand Smoke in 

the Workplace

Indicator 2.4.b 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of the general population employed outside the home that report exposure to 

secondhand smoke in the workplace 

Why this indicator is 

useful

The workplace is a primary source of involuntary exposure to tobacco smoke for adults.1

Secondhand smoke exposure in the workplace has been linked to an increased risk of 

adverse health outcomes.1,2 Blue collar and service employees are more likely to be 

exposed to secondhand smoke in the workplace and are less likely to be covered by 

smokefree policies.1,3,4 Studies have shown significantly higher levels of tobacco smoke 

exposure in restaurants, bars, and casinos not covered by smokefree policies compared 

with other worksites and public spaces.1,3-8 About one-fifth of employed U.S. adult 

nonsmokers report secondhand smoke exposure in the workplace.9

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS), 2011, Module 16

Information available at: http://www.cdc.gov/brfss/questionnaires.htm#archive.

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/. 

National Youth Tobacco Survey (NYTS), 2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/.

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/.

Population group(s) Employed population 

Example survey 

question(s)

From BRFSS

Now I’m going to ask you about smoke you might have breathed at work because 

someone else was smoking indoors. During the past 7 days, that is, since last 

[TODAY‟S DAY OF THE WEEK], on how many days did you breathe the smoke at 

your workplace from someone other than you who was smoking tobacco?

• Number of days [01-07]

• None

• Don’t know/Not sure

• Refused

From NATS

Now I’m going to ask you about smoke you might have breathed at work because 

someone else was smoking, either indoors or outdoors. During the past 7 days, that is, 

since last [TODAY’S DAY OF WEEK], on how many days did you breathe the smoke 

at your workplace from someone other than you who was smoking tobacco?

• Number of days

• None

• Don’t know/Not sure

• Refused
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 101

From NYTS

During the past 7 days, on how many days did you breathe the smoke from someone 

who was smoking tobacco products in the place where you work?

• I do not have a job

• I did not work during the past 7 days

• 0 days

• 1 day

• 2 days

• 3 days

• 4 days

• 5 days

• 6 days

• 7 days

From SCS-TC

During the past SEVEN DAYS, in which of the following places have you smelled 

secondhand smoke?

• In your home

• In your car

• In someone else’s car

• At work

• On a public sidewalk

• Outside the door way of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home

Comments Evaluators may want to consider capturing information regarding exposure to different 

types of tobacco products. Other tobacco products of interest may include cigarettes, 

cigars, little cigars, regular pipes, hookah (water pipe), and e-cigarettes. 

Evaluators may also choose to gather data on the size and demographics of the 

population exposed to secondhand smoke by product type. 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. Clark JD, Wilkinson JD, LeBlanc WG, et al. Inflammatory markers and secondhand tobacco smoke exposure 

among U.S. workers. American Journal of Industrial Medicine. 2008;51(8):626–32. doi: 10.1002/ajim.20591
GOAL AREA 2

► Outcome 4 

102 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

3. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in smoke-free workplaces among food 

service workers. Journal of Occupational and Environmental Medicine. 2004;46(4):347–56.

4. Lee DJ, Fleming LE, Arheart KL, et al. Smoking rate trends in U.S. occupational groups: the 1987 to 2004 

National Health Interview Survey. Journal of Occupational and Environmental Medicine. 2007;49(1):75–81.

5. Trout D, Decker J, Mueller C, et al. Exposure of casino employees to environmental tobacco smoke. Journal of 

Occupational and Environmental Medicine. 1998;40(3):270–6.

6. Centers for Disease Control and Prevention. Health hazard evaluation report: environmental and biological 

assessment of environmental tobacco smoke exposure among casino dealers, Las Vegas, Nevada. Cincinnati, 

OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Institute for Occupational Safety and Health; 2009. Available at: 

http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0201-3080.pdf. 

7. Arheart KL, Lee DJ, Dietz NA, et al. Declining trends in serum cotinine levels in U.S. worker groups: the 

power of policy. Journal of Occupational and Environmental Medicine. 2008;50(1):57–63. doi: 

10.1097/JOM.0b013e318158a486

8. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

9. King BA, Homa DM, Dube SR, Babb SD.Exposure to secondhand smoke and attitudes toward smoke-free 

workplaces among employed U.S. adults: findings from the National Adult Tobacco Survey. Nicotine & 

Tobacco Research. 2014 Oct;16(10):1307-18.
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 103

Indicator 2.4.c

Proportion of the Population Exposed to Secondhand Smoke in Indoor 

Public Places

Indicator 2.4.c 

KOI 2005 2.7.2

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of the general population that reports exposure to secondhand smoke in 

indoor public places, including bars, restaurants, casinos, indoor sporting arenas, and 

concert venues 

Why this indicator is 

useful

Indoor secondhand smoke is a major air pollutant and the main source of exposure to 

tobacco smoke among nonsmokers.1 Studies have shown that implementation of indoor 

smokefree policies reduces secondhand smoke exposure substantially, with decreases as 

high as 90% in some studies.1-4

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS), 2011, Module 16

Information available at: http://www.cdc.gov/brfss/questionnaires.htm#archive.

California Adult Tobacco Survey (CATS), 2008

Information available at: 

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPCaliforniaAdultTobaccoSu

rvey2008.pdf.

National Adult Tobacco Survey (NATS), 2010

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/. 

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/.

Population group(s) General population

Example survey 

question(s)

From BRFSS

Not counting times while you were at work, during the past 7 days, that is, since last 

[TODAY’S DAY OF WEEK], on how many days did you breathe the smoke from 

someone else who was smoking in an indoor public place?

• Number of days [01–07]

• None

• Don’t know/Not sure

• Refused

From CATS

In the past two weeks, have you been exposed to other people’s tobacco smoke on 

campus indoors?

• Yes

• No

• Don’t know

• Refused

• Don’t know/Not sure
GOAL AREA 2

► Outcome 4 

104 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Modified from NATS

[Not counting times while you were at work,] during the past 7 days, that is, since last 

[TODAY’S DAY OF WEEK], on how many days did you breathe the smoke from 

someone else who was smoking in an indoor public place?

• __Number of days

• None

• Don’t know/Not sure

• Refused

From SCS-TC

During the past SEVEN DAYS, in which of the following places have you smelled 

secondhand smoke?

• In your home

• In your car

• In someone else’s car

• At work

• On a public sidewalk

• Outside the door way of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home

Comments In addition to self-report, air quality monitoring can be used to measure secondhand 

smoke exposure. For more information, refer to the Evaluation Toolkit for Smoke-free 

Policies.

5

 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. Centers for Disease Control and Prevention. Reduced secondhand smoke exposure after implementation of a 

comprehensive statewide smoking ban—New York, June 26, 2003–June 30, 2004. Morbidity and Mortality 

Weekly Report. 2007 Jul 20;56(28):705–8.

3. Repace JL, Hyde JN, Brugge D. Air pollution in Boston bars before and after a smoking ban. BMC Public 

Health. 2006;6:266.

4. Lee K, Hahn EJ, Robertson HE, Lee S, Vogel SL, Travers MJ. Strength of smoke-free air laws and indoor air 

quality. Nicotine & Tobacco Research. 2009;11(4):381–6. doi: 10.1093/ntr/ntp026

5. Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 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; 2008. Available at: http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/ 

evaluation_toolkit/pdfs/evaluation_toolkit.pdf.
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 105

Indicator 2.4.d

Proportion of the Population Exposed to Secondhand Smoke in Outdoor 

Public Places

Indicator 2.4.d 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of the general population that reports exposure to secondhand smoke in 

outdoor public places, including bar and restaurant patios, parks, beaches, outdoor 

sporting arenas, and concert venues. 

Why this indicator is 

useful

Eliminating secondhand smoke exposure in outdoor public spaces can protect children, 

youth, and nonsmoking adults from the health effects of secondhand smoke in these 

environments, and can help reinforce tobacco-free social norms.1

 

Example data 

source(s)

California Adult Tobacco Survey (CATS), 2008

Information available at: 

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPCaliforniaAdultTobaccoSu

rvey2008.pdf

National Adult Tobacco Survey (NATS), 2010

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/

Population group(s) General Population

Example survey 

question(s)

From CATS

In the past two weeks, have you been exposed to other people’s tobacco smoke on 

campus outdoors?

• Yes

• No

• Don’t know

• Refused

• Don’t know/Not sure

Modified from NATS

[Not counting times while you were at work,] during the past 7 days, that is, since last 

[TODAY’S DAY OF WEEK], on how many days did you breathe the smoke from 

someone else who was smoking in an outdoor public place?

• __Number of days

• None

• Don’t know/Not sure

• Refused

From SCS-TC

During the past SEVEN DAYS, in which of the following places have you smelled 

secondhand smoke?

• In your home

• In your car
GOAL AREA 2

► Outcome 4 

106 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• In someone else’s car

• At work

• On a public sidewalk

• Outside the door way of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home

Comments It is particularly useful for programs in areas with limited smokefree polices to ask about 

location of exposure (as the SCS-TC does).

In addition to self-report, air quality monitoring can be used to monitor secondhand 

smoke exposure. For more information, refer to the Evaluation Toolkit for Smoke-free 

Policies.

2

 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. Centers for Disease Control and Prevention. Evaluation toolkit for smoke-free policies. 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; 2008. Available at: 

http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evaluation_toolkit/pdfs/evaluation_toolkit.p

df. 
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 107

Indicator 2.4.eNR

Proportion of Children, Youth, and Young Adults Exposed to Secondhand 

Smoke in Childcare or School Settings

Indicator 2.4.eNR 

KOI 2005 2.7.4

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of children and youth exposed to secondhand tobacco smoke while in 

childcare settings, on school grounds, at school-sponsored functions, or in school 

vehicles

Why this indicator is 

useful

Exposure to secondhand smoke is a major cause of premature death and disease among 

children and adults who do not smoke.1-3 Young people spend many of their waking 

hours in childcare or school settings, where they might be exposed to secondhand smoke 

or other tobacco products.4-5

Example data 

source(s)

Early Childhood Environment Rating Scale (ECERS), Health Practice Subscale

Information available at: http://ers.fpg.unc.edu/early-childhood-environment-ratingscale-ecers-r

National Youth Tobacco Survey (NYTS), 2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

Population group(s) Students, parents, staff

Example survey 

question(s)

From ECERS

Smoking does not take place in child care areas. 

• Yes

• No

From NYTS

During the past 7 days, on how many days did you breathe the smoke from someone 

who was smoking a tobacco product at your school, including school buildings, school 

grounds, and school parking lots?

• 0 days

• 1 day

• 2 days

• 3 days

• 4 days

• 5 days

• 6 days

• 7 days

Comments As with other indicators in Outcome 4, exposure to secondhand smoke can be measured 

in a variety of ways. Using mixed methods to evaluate exposure to secondhand smoke is 

important to consider for very young children to improve validity and reliability of selfreported data. In these cases, the use of biomarkers, air quality monitoring, and 

observation methods may be warranted. 
GOAL AREA 2

► Outcome 4 

108 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. U.S. Department of Health and Human Services. A report of the Surgeon General: how tobacco smoke causes 

disease: what it means to you. 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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

4. Olufajo OA, Agaku IT. Assessment of secondhand smoke exposure at school among U.S. middle and high 

school students. Journal of School Nursing. 2015 Jun;31(3):212–8. doi: 10.1177/1059840514537075.

5. Jacobs M, Alonso AM, Sherin KM, Koh Y, Dhamija A, Lowe AL; ACPM Prevention Practice Committee. 

Policies to restrict secondhand smoke exposure: American College of Preventive Medicine Position Statement. 

American Journal of Preventive Medicine. 2013 Sep;45(3):360–7. doi: 10.1016/j.amepre.2013.05.007.
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 109

Indicator 2.4.f

Proportion of Students, Faculty, and Staff Exposed to Secondhand Smoke 

on College Campuses

Indicator 2.4.fNR 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of students, faculty, and staff exposed to secondhand tobacco smoke while 

on college campuses.

Why this indicator is 

useful

Exposure to secondhand smoke is a major cause of premature death and disease in 

children and adults who do not smoke.1-3 Comprehensive tobacco-free policies at college 

campuses are effective in reducing exposure to secondhand smoke among students and 

has been linked to lower smoking rates.4,5 

Example data 

source(s)

Tobacco Free College Assessment Survey for Staff, Faculty, and Students 

(TFCAS), Wake Forest Baptist Health6 

Information available at: 

http://www.wakehealth.edu/uploadedFiles/User_Content/Research/Departments/Public_

Health_Sciences/Tobacco_Free_Colleges/TobaccoFree%20Manual_Appendix%207.pdf

University of California San Francisco (UCSF) California campus survey, 20144 

Information available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431121/

Population group(s) Students, faculty, and staff at a given university 

Example survey 

question(s) 

From TFCAS

When I walk through campus, I am [exposed] to secondhand smoke:

• Never

• Rarely

• Sometimes

• Often

• Always

From UCSF California campus survey: 

“In the past 7 days, I have been exposed to other people’s tobacco smoke on campus 

(yes/no).”

Comments In addition to self-report, exposure to secondhand smoke on a tobacco-free campus 

could be measured through observation of smokers, discarded cigarette butt data, and air 

quality monitoring, if resources are available.7-8

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

better
GOAL AREA 2

► Outcome 4 

110 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. U.S. Department of Health and Human Services. A report of the Surgeon General: how tobacco smoke causes 

disease: what it means to you. 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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

4. Fallin A, Roditis M, Glantz SA. Association of campus tobacco policies with secondhand smoke exposure, 

intention to smoke on campus, and attitudes about outdoor smoking restrictions. American Journal of Public 

Health. 2015 Jun;105(6):1098–100. doi: 10.2105/AJPH.2014.302251

5. Seo DC, Macy JT, Torabi MR, Middlestadt SE. The effect of a smoke-free campus policy on college students’ 

smoking behaviors and attitudes. Preventive Medicine, 2011; 53(4-5): 347–52. doi: 

10.1016/j.ypmed.2011.07.015

6. Wolfson M, McCoy TP, Sutfin EL. College students’ exposure to secondhand smoke. Nicotine & Tobacco 

Research. 2009;11(8):977–84. doi: 10.1093/ntr/ntp100

7. Fallin A, Murrey M, Johnson AO, Riker CA, Rayens MK, Hahn EJ. Measuring compliance with tobacco-free 

campus policy. Journal of American College Health. 2012;60(7):496–504.

8. Ickes MJ, Gokun Y, Rayens MK, Hahn EJ. Comparing two observational measures to evaluate compliance with 

tobacco-free campus policy. Health Promotion Practice. 2015 Mar;16(2):210-7. doi: 

10.1177/1524839914561060.
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 111

Indicator 2.4.g

Proportion of Multiunit Housing Residents Exposed to Secondhand Smoke 

Incursions into Their Homes from Nearby Units or Shared Areas

Indicator 2.4.g 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of multiunit housing residents reporting exposure to secondhand smoke from 

nearby housing units or shared areas

Why this indicator is 

useful

Exposure to secondhand smoke is a major cause of premature death and disease in 

children and adults who do not smoke.1-3 Because smoke can travel through walls, air 

ducts, windows, and ventilation systems,4

 about a third of multiunit housing residents 

with l smokefree home rules still experience secondhand smoke infiltration into their 

homes.5 Each year, an estimated 27.6 to 28.9 million U.S. multiunit housing residents 

with smokefree home rules experience secondhand smoke incursions in their unit from 

elsewhere in their building.

6

Example data

source(s)

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/

Social Climate Survey of Tobacco Control (SCS-TC), 2015

Information available at: http://www.socialclimate.org/

Population group(s) Multiunit housing residents

Example survey 

question(s)

From NATS

In what type of living space do you currently reside?

• A one-family house detached from any other house

• A one-family house attached to one or more houses

• A building with 2 apartments or living units

• A building with 3 to 9 apartments or living units

• A building with 10 to 49 apartments or living units

• A building with 50 or more apartments or living units

• A mobile home, boat, RV, or van

• Some other type of living space

• DON’T KNOW

• REFUSED

How often does tobacco smoke enter your living space from somewhere else in or 

around the building?

• Every day

• A few times a week

• A few times a month

• Once a month or less

• Never

• DON’T KNOW

• REFUSED
GOAL AREA 2

► Outcome 4 

112 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Modified from SCS-TC

Which of the following best describes the building in which you live? Would you say:

• A mobile home

• A one-family house detached from any other house

• A one-family house attached to one ore more houses

• An apartment or condominium building

• Other

The next series of questions are about where you live. In the past 30 days, have you 

smelled tobacco smoke...?

• In outdoor areas

o Yes

o No

• On your balcony

o Yes

o No

o Not applicable

• In indoor staircases

o Yes

o No

o Not applicable

• In elevators

o Yes

o No

o Not applicable

• Some other place

o Yes

o No

Comments Evaluators can compare responses to measures of this indicator among those with and 

without smokefree home rules.

As with other indicators in Outcome 4, exposure to secondhand smoke can be measured 

in a variety of ways. Using mixed methods to evaluate exposure to secondhand smoke is 

important to consider for very young children to improve validity and reliability of selfreported data. In these cases, the use of biomarkers, air quality monitoring, and 

observation methods may be warranted.

Resident surveys of secondhand smoke exposure in the home from external sources 

have been measured in a variety of ways, from secondhand smoke drifting into the 

apartment from outside, to asking whether or how often respondents have smelled, 

breathed, or noticed tobacco smoke in their living spaces, or whether tobacco smoke has 

entered or come into their unit.7 When relying on self-report, items that measure 

frequency of exposure to any combustible tobacco product provide the best measure of 

exposure.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 113

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. U.S. Department of Health and Human Services. A report of the Surgeon General: how tobacco smoke causes 

disease: what it means to you. 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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

4. Bohac DL, Hewett MJ, Hammond SK, Grimsrud DT. Secondhand smoke transfer and reductions by air sealing 

and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air. 2011;21(1):36–44. doi: 

10.1111/j.1600-0668.2010.00680.x

5. Nguyen K, Gomez Y, Homa DM, King BA. Tobacco use, secondhand smoke, and smoke-free home rules in 

multiunit housing. Am J Pre Med. 2016 Nov;51(5):682-692. doi: 10.1016/j.amepre.2016.05.009.

6. King BA, Babb SD, Tynan MA, Gerzoff RB. National and state estimates of secondhand smoke infiltration 

among U.S. multiunit housing residents. Nicotine & Tobacco Research. 2013;15(7):1316–21. doi: 

10.1093/ntr/nts254

7. Snyder K, Vick JH, King BA. Smoke-free multiunit housing: a review of the scientific literature. Tobacco 

Control. 2016;25(1):9–20. doi: 10.1136/tobaccocontrol-2014-051849.
GOAL AREA 2

► Outcome 4 

114 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.4.h

Proportion of the Population Exposed to Secondhand Smoke Originating 

in Their Homes

Indicator 2.4.h 

KOI 2005 2.7.3

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of the population reporting exposure to secondhand smoke originating in 

their homes 

Why this indicator is 

useful

Exposure to secondhand smoke is a major cause of premature death and disease in 

children and adults who do not smoke.1-3 In the United States, the home is a major 

location for secondhand smoke exposure among adults and the primary source of 

exposure for youth.

1 Although exposure among U.S. nonsmokers declined overall 

among all population groups during the past 20 years, an estimated one quarter of U.S. 

nonsmokers were still exposed to secondhand smoke, including 15 million children aged 

3-11 years, highlighting the importance of voluntary smokefree home and vehicle rules.4

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS), 2011, Module 16

Information available at: http://www.cdc.gov/brfss/questionnaires.htm#archive

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/

National Health and Nutrition Examination Survey (NHANES), 2013–2014

Information available at: http://wwwn.cdc.gov/nchs/nhanes/search/nhanes13_14.aspx

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/

Population group(s) General population

Example survey 

question(s)

From BRFSS

Not counting decks, porches, or garages, during the past 7 days, that is, since last 

[TODAY’S DAY OF WEEK], on how many days did someone other than you smoke 

tobacco inside your home while you were at home?

• Number of days [01–07]

• None

• Don’t know/Not sure

• Refused

From NATS

Not counting decks, porches, or garages, during the past 7 days, that is, since last 

[TODAY’S DAY OF WEEK], on how many days did someone other than you smoke 

tobacco inside your home while you were at home?

• __Number of days

• None

• Don’t know/Not sure

• Refused
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 115

From NHANES

(Not counting decks, porches, or detached garages) During the past 7 days, that is since 

last [TODAY’S DAY OF WEEK], on how many days did {anyone who lives here/you}, 

smoke tobacco inside this home?

• __Number of days 0 to 7

• Don’t know

• Refused

From SCS-TC

During the past SEVEN DAYS, in which of the following places have you smelled 

secondhand smoke?

• In your home

• In your car

• In someone else’s car

• At work

• On a public sidewalk

• Outside the door way of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home

Comments Evaluators could consider adding a question about children living in the home to 

estimate exposure among children.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

 better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. U.S. Department of Health and Human Services. A report of the Surgeon General: how tobacco smoke causes 

disease: what it means to you. 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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

4. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke—

United States, 1999–2012. Morbidity and Mortality Weekly Report. 2015 Feb 6;64(4):103–8.
GOAL AREA 2

► Outcome 4 

116 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.4.i

Proportion of the Population Exposed to Secondhand Smoke in Vehicles

Indicator 2.4.i 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 4 Reduced exposure to secondhand smoke

What to measure Proportion of the population reporting exposure to secondhand smoke in vehicles

Why this indicator is 

useful

Exposure to secondhand smoke is a major cause of premature death and disease in 

children and adults who do not smoke.1-3 Although exposure among U.S. nonsmokers 

declined overall among all population groups in the U.S. during the past 20 years, an 

estimated one quarter of U.S. nonsmokers were still exposed to secondhand smoke, 

including 15 million children aged 3–11 years, highlighting the importance of voluntary 

smokefree home and vehicle rules.4 Because of the confined space within them, vehicles 

are an important environment for secondhand smoke exposure, posing health risks for 

passengers.5-6 

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS), 2011, Module 16

Information available at: http://www.cdc.gov/brfss/questionnaires.htm#archive

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/

National Youth Tobacco Survey (NYTS), 2015

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

Social Climate Survey of Tobacco Control (SCS-TC), 2014

Information available at: http://www.socialclimate.org/

Population group(s) General Population

Example survey 

question(s)

From BRFSS

During the past 7 days, that is, since last [TODAY‟S DAY OF WEEK], on how many 

days did you ride in a vehicle where someone other than you was smoking tobacco?

• Number of days [01-07]

• None

• Don’t know / Not sure

• Refused

From NATS

During the past 7 days, that is, since last [TODAY’S DAY OF WEEK], on how many 

days did you ride in a vehicle where someone other than you was smoking tobacco?

• __Number of days

• None

• Don’t know/Not sure

• Refused

From NYTS

During the past 7 days, on how many days did you ride in a vehicle where someone was 

smoking a tobacco product?

• 0 days

• 1 day

• 2 days
GOAL AREA 2

► Outcome 4 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 117

• 3 days

• 4 days

• 5 days

• 6 days

• 7 days

From SCS-TC

During the past SEVEN DAYS, in which of the following places have you smelled 

secondhand smoke?

• In your home

• In your car

• In someone else’s car

• At work

• On a public sidewalk

• Outside the door way of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home 

Comments None noted

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. U.S. Department of Health and Human Services. A report of the Surgeon General: how tobacco smoke causes 

disease: what it means to you. 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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 

4. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke—

United States, 1999–2012. Morbidity and Mortality Weekly Report. 2015 Feb 6;64(4):103–8.

5. Jones MR, Navas-Acien A, Yuan J, Breysse PN. Secondhand tobacco smoke concentrations in motor vehicles: 

a pilot study. Tobacco Control. 2009;18:399–404. doi: 10.1136/tc.2009.029942

6. Sly PD, Deverell M, Kusel MM, et al. Exposure to environmental tobacco smoke in cars increases the risk of 

persistent wheeze in adolescents. Medical Journal of Australia. 2007;186(6):322.
GOAL AREA 2

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118 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Outcome 5 

Reduced Tobacco Consumption

In addition to protecting nonsmokers from exposure to secondhand smoke, smokefree policies 

can reduce tobacco use prevalence, increase tobacco use cessation, reduce cigarette use by 

continuing users, and decrease initiation among youth and young adults.1 Smoking rates are 

significantly lower among young people in communities with comprehensive smokefree 

policies.1 Research has found that comprehensive smokefree policies are more effective than 

partial policies at reducing tobacco consumption.2 In addition, the connection between smokefree 

policies and tobacco use reduction is enhanced if smokefree policies are part of well-planned and 

well-funded tobacco control efforts.3-5

Comprehensive smokefree policies may affect tobacco consumption through a number of 

pathways. Smokefree policies mean that smokers have fewer opportunities to smoke, which 

results in reduced consumption.6 For smokers trying to reduce their consumption or quit 

altogether, smokefree policies can reduce environmental cues, such as seeing others smoking and 

being exposed to secondhand smoke, which can result in relapse.7 For youth and young adults, 

smokefree laws also decrease the social acceptability of smoking by establishing a smokefree 

norm and limiting exposure to role models using tobacco.6,8 Messages of social disapproval may 

be especially effective with youth and young adults. 

Policies that reduce secondhand smoke exposure are a priority to reduce tobacco-related 

disparities.9

 Smokefree policies result in equivalent reductions in smoking in higher and lower 

education and income groups. However, compared to high socioeconomic status (SES) groups, a 

higher proportion of lower SES groups continue to use tobacco and are less likely to have 

smokefree policies in the home.6 Smokefree home rules can be especially important for reducing 

tobacco use disparities. Low-income current smokers with smokefree home rules have tobacco 

consumption and quit rates similar to those of high-income smokers.10 Research among youth 

also suggests that smokefree home rules could have a positive impact on youth perceptions of the 

social acceptability of smoking and smoking initiation independent of parental smoking 

status.8,11,12

The following indicators are associated with this outcome:

► 2.5.a Per capita consumption of tobacco products 

► 2.5.b Average number of each tobacco product used per day by tobacco users 

► 2.5.c Tobacco use prevalence

► 2.5.d Proportion of young people who have never tried a tobacco product 

► 2.5.e Proportion of tobacco users who have sustained abstinence from tobacco use 

References

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

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

updated: November 10, 2014. 
GOAL AREA 2

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CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 119

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

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

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

for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. 

Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer 

Prevention, Tobacco Control, Vol. 13: Evaluating the effectiveness of smoke-free policies.

Lyon, France: IARC; 2009.

4. Farrelly MC, Loomis BR, Kuiper N, et al. Are tobacco control policies effective in reducing 

young adult smoking? The Journal of Adolescent Health. 2014;54(4):481–6. doi: 

10.1016/j.jadohealth.2013.09.015 

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. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm. 

6. 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. 

Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fullreport.pdf. 

7. 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. 

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. Centers for Disease Control and Prevention. Best practices user guide: health equity. Atlanta, 

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

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

Smoking and Health; 2014. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-healthequity.pdf. 

10. 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;103(12):2276–83. doi: 10.2105/AJPH.2013.301300 
GOAL AREA 2

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120 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

11. Albers AB, Biener L, Siegel M, Cheng DM, Rigotti N. Household smoking bans and 

adolescent antismoking attitudes and smoking initiation: findings from a longitudinal study 

of a Massachusetts youth cohort. American Journal of Public Health. 2008;98(10):1886–93. 

doi: 10.2105/AJPH.2007.129320. 

12. Voorhees CC, Ye C, Carter-Pokras O, et al. Peers, tobacco advertising, and secondhand 

smoke exposure influences smoking initiation in diverse adolescents. American Journal of 

Health Promotion. 2011;25(3):e1–11. doi: 10.4278/ajhp.090604-QUAN-180 

For Further Reading

Orzechowski and Walker. Tax burden on tobacco, historical compilation, Vol 49. Arlington, 

VA: Orzechowski and Walker; 2014. Available at: 

http://www.taxadmin.org/assets/docs/Tobacco/papers/tax_burden_2014.pdf. 
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 121

Outcome 5

Reduced Tobacco Consumption

Indicator Rating

better

Number Indicator

Overall Quality

low high

Resources Needed

Strength of Evaluation 

Evidence

Utility

Face 

Validity

Accepted Practice

2.5.a Per capita consumption of tobacco 

products

$$

2.5.b Average number of each 

combustible or heated tobacco 

product used per day by tobacco 

users

$ 

2.5.c Tobacco use prevalence $ 

2.5.d Proportion of young people who 

have never tried a tobacco product

$ 

2.5.e Proportion of tobacco users who 

have sustained abstinence from 

tobacco use

$ 

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

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

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

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

 Denotes no data.

NR Denotes an indicator that is not rated (see Appendix C for an explanation).
GOAL AREA 2

► Outcome 5 

122 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.5.a

Per Capita Consumption of Tobacco Products

Indicator 2.5.a 

KOI 2005 2.8.1

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 5 Reduced tobacco consumption

What to measure Number of tobacco products sold per adult aged 18 or older in the state, by type

Why this indicator is 

useful

Smokefree policies can decrease consumption of tobacco products and nonsmokers’ 

exposure to secondhand smoke.1-3 Moreover, per capita consumption of tobacco 

products provides estimates of tobacco use4 and can indirectly indicate potential 

exposure to secondhand smoke.

Example data 

source(s)

Excise tax data from the U.S. Department of Treasury’s Alcohol and Tobacco Tax 

and Trade Bureau

State departments of revenue

The Tax Burden on Tobacco5 

Available at: 

http://www.taxadmin.org/assets/docs/Tobacco/papers/tax_burden_2014.pdf. 

Population group(s) Not applicable. This indicator is best measured by examining tax records to assess state 

tobacco sales. 

Example survey 

question(s)

Not applicable

Comments The three standard approaches for measuring consumption are (1) analyzing tobacco 

excise tax data; (2) analyzing retail sales scanner data compiled by commercial vendors, 

such as the Nielsen Company; and (3) 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 (see

https://ttb.gov/tobacco/index.shtml).

Evaluators need to measure statewide consumption of cigarettes, smokeless tobacco, and 

other tobacco products separately, including e-cigarettes.

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

better

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 123

2. Hopkins DP, Razi S, Leeks KD, et al. Task Force on Community Preventive Services. Smoke-free policies to 

reduce tobacco use: a systematic review. American Journal of Preventive Medicine. 2010;38(2 Suppl):S275–89.

3. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

4. Tynan MA, McAfee T, Promoff G, Pechacek T. Consumption of cigarettes and combustible tobacco — United 

States, 2000–2011. Morbidity and Mortality Weekly Report. 2012;61(30);565–9. 

5. Orzechowski and Walker. Tax burden on tobacco, historical compilation, Vol 49. Arlington, VA: Orzechowski 

and Walker; 2014. Available at: http://www.taxadmin.org/assets/docs/Tobacco/papers/tax_burden_2014.pdf. 
GOAL AREA 2

► Outcome 5 

124 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.5.b

Average Number of Each Combustible or Heated Tobacco Product 

Consumed per Day by Tobacco Users

Indicator 2.5.b 

KOI 2005 2.8.2

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 5 Reduced tobacco consumption

What to measure The average number of each combustible or heated aerosol tobacco products consumed 

per day by tobacco users. Combustible tobacco products include cigarettes, cigars, little 

cigars, cigarillos, regular pipes, and hookah (water pipe). Heated products include a 

variety of e-cigarette products, including vape pens, and e-hookahs.

Why this indicator is 

useful

Monitoring the number of combustible product units consumed is important for planning 

and evaluation of tobacco control efforts and reduction of secondhand smoke 

exposure.1-3

Example data 

source(s)

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), 2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

Population Assessment of Tobacco and Health (PATH) Study, 2015

Information available at: 

http://www.reginfo.gov/public/do/PRAViewIC?ref_nbr=201506-0925-

002&icID=212557

Tobacco Use Supplement to the Current Population Survey (TUS-CPS), 2010–2011

Information available at: http://riskfactor.cancer.gov/studies/tus-cps/

Youth Risk Behavior Surveillance System (YRBSS), 2015 

Information available at: http://www.cdc.gov/healthyyouth/yrbs/index.htm

Population group(s) Tobacco users

Example survey 

question(s)

From NATS

On average, about how many cigarettes do you now smoke each day?

• ___Number of cigarettes

• Less than one cigarette a day

• None

• Don’t know/Not sure

• Refused

Someday smokers: “On the day that you smoked, how many cigarettes did you smoke?,” 

“On the average, on those days, how many cigarettes did you usually smoke each day?”] 

• ___Number of cigarettes

• Less than one cigarette a day

• None

• Don’t know/Not sure

• Refused
GOAL AREA 2

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CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 125

From NHIS

On the average, how many cigarettes do you now smoke a day?

• ___Number of cigarettes

• Enter “1” if less than 1 cigarette.

• Enter “95” if 95 or more cigarettes.

• Refused

• Don’t know

Someday smokers: On the average, when you smoked during the PAST 30 DAYS, 

about how many cigarettes did you smoke a day?

• ___Number of cigarettes

• Enter “1” if less than 1 cigarette.

• Enter “95” if 95 or more cigarettes.

• Refused

• Don’t know

From NYTS

During the past 30 days, on the days you smoked, about how many cigarettes did you 

smoke per day?

• I did not smoke cigarettes during the past 30 days

• Less than one cigarette per day

• 1 cigarette per day

• 2 to 5 cigarettes per day

• 6 to 10 cigarettes per day

• 11 to 20 cigarettes per day

• More than 20 cigarettes per day

From PATH

When did you last smoke a pipe filled with tobacco?

• In the past hour

• Sometime today

• Yesterday

• Day before yesterday

• Three or more days ago

• Don’t know

• Refused

How many bowls filled with pipe tobacco have you smoked/did you smoke since [insert 

time based on previous question]?

When did you last smoke hookah?

• In the past hour

• Sometime today

• Day before yesterday

• Three or more days ago

• Don’t know

• Refused
GOAL AREA 2

► Outcome 5 

126 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

How many puffs from a hookah have you taken/did you take since [insert time based on 

previous question]?

When did you last use an e-cigarette?

• In the past hour

• Sometime today

• Yesterday

• Day before yesterday

• Three or more days ago

• Don’t know

• Refused

How many puffs from an e-cigarette have you taken/did you take since [insert time 

based on previous question]?

From TUS-CPS

On the average, about how many cigarettes do you now smoke each day?

__ Enter number of cigarettes per day (1–99)

Would you say that, on average, you now smoke more or less than 20 cigarettes each 

day?

• More

• Less

• About 20 (one pack)

I have recorded that on the average, you now smoke [fill entry B1] cigarettes a day. Is 

that correct?

• Yes

• No

From YRBSS

During the past 30 days, on the days you smoked, how many cigarettes did you smoke 

per day?

• I did not smoke cigarettes during the past 30 days

• Less than one cigarette per day

• 1 cigarette per day

• 2 to 5 cigarettes per day

• 6 to 10 cigarettes per day

• 11 to 20 cigarettes per day

• More than 20 cigarettes per day

Comments Calculating the average number of cigarettes smoked per day by adults requires 

combining data for everyday smokers and someday smokers. Evaluators could stratify 

estimates by daily versus non-daily users.

For poly users (people who use more than one tobacco product), it is important to 

measure the number of each product used.

Evaluators should be advised that measures and methods to monitor e-cigarette

consumption are under development. Existing questions on ever and current use of 

e-cigarette limit the ability to distinguish between trial or experimental users and more 

frequent and routine users of various types of e-cigarettes.
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 127

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

 better

References

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a 

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

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

on Smoking and Health; 2012.

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

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. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/full-report.pdf. 
GOAL AREA 2

► Outcome 5 

128 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Indicator 2.5.c

Tobacco Use Prevalence

Indicator 2.5.c 

KOI 2005 2.8.3

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 5 Reduced tobacco consumption

What to measure The proportion of the population using tobacco products that contribute to secondhand 

smoke exposure, including the following: 

• For cigarettes: proportion of adults aged 18 years or older who have smoked at 

least 100 cigarettes in their lifetime and who now report smoking cigarettes 

every day or some days and proportion of youth who report smoking on at least 

1 day of the past 30 days. 

• For cigars/cigarillos/little cigars: proportion of adults aged 18 years or older 

who report smoking cigars/cigarillos/little cigars every day or some days and 

proportion of youth who report smoking cigars/cigarillos/little cigars n at least 

1 day of the past 30 days.

• For regular pipes/water pipes/hookah: proportion of adults aged 18 years or 

older who report using smoked regular pipes/water pipes/hookah every day or

some days and proportion of youth who have used regular pipes/water 

pipes/hookah on at least 1 day of the past 30 days.

• E-Cigarettes: proportion of adults aged 18 years or older who report using 

e-cigarettes every day or some days and proportion of youth who have used 

e-cigarettes at least 1 day of the past 30.

Why this indicator is 

useful

Reducing the prevalence of combustible tobacco use is necessary to improve air quality 

and reduce exposure to secondhand smoke from tobacco products.1-2 Research has 

shown that smokefree policies reduce the prevalence of tobacco use.3

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS): Core Module, 2011 and 

2013

Information 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 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 Assessment of Tobacco and Health (PATH), 2015

Information available at:

http://www.reginfo.gov/public/do/PRAViewIC?ref_nbr=201506-0925-

002&icID=212557

Youth Risk Behavior Surveillance System (YRBSS), 2015

Information available at: http://www.cdc.gov/healthyyouth/yrbs/index.htm

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
GOAL AREA 2

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CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 129

• 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

• Don’t know/Not sure

• Refused

From NATS:

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 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 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
GOAL AREA 2

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130 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• Not at all

• 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 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
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 131

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

• 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

From PATH

In the past 30 days, have you used an electronic nicotine product, even one or two 

times? (Electronic nicotine products include e-cigarettes, vape pens, hookah pens, 

personal vaporizers and mods, e-cigars, epipes, and e-hookahs.)

• Yes

• No

From YRBSS

Have you ever tried cigarette smoking, even one or two puffs?

• Yes

• No

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 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

Comments Prevalence of total tobacco use will include smokeless tobacco and other 

noncombustible tobacco products, but because this goal area focuses on secondhand 

smoke, only measures for tobacco products that emit smoke or aerosol are presented.

To maintain consistency with some previously published studies, the use of lifetime 

thresholds for non-cigarette tobacco products could also be considered in the calculation 

of current use of these products (e.g., used at least once in their lifetime and now report 

use on at least 1 day of the past 30 days) 
GOAL AREA 2

► Outcome 5 

132 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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 (Indicator 

2.5.b). This information can be useful in considering population-attributable risk.

This indicator can be used to measure progress toward achieving Objective TU-1 of 

Healthy People 2020 Objective: “Reduce tobacco use by adults and TU-2 Reduce 

tobacco use by adolescents.”4

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

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 involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

3. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smoke-free 

policies. Available at: www.thecommunityguide.org/tobacco/smokefreepolicies.html. Last updated: September 

22, 2014. 

4. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 133

Indicator 2.5.d

Proportion of Young People Who Have Never Tried a Tobacco Product

Indicator 2.5.d 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 5 Reduced tobacco consumption

What to measure As a measure of social norm change related to smokefree interventions, the proportion 

of youth and young adults who have never tried smoking or using any other tobacco 

products

Why this indicator is 

useful

Smoking initiation primarily occurs during adolescence.1-2 Reducing the number of 

youth who experiment with tobacco products reduces tobacco use prevalence and can be 

indicative of social norm changes related to smokefree interventions.2-3 

Example data 

source(s)

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nats/

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 

2014

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

Youth Risk Behavior Surveillance System (YRBSS), 2015 

Information available at: http://www.cdc.gov/healthyyouth/yrbs/index.htm

Population group(s) Youth younger than age 18 and young adults aged 18 to 25

Example survey 

question(s)

From NATS

Have you ever tried cigarette smoking, even one or two puffs?

• Yes

• No

Have you ever tried smoking cigars, cigarillos, or very small cigars that look like 

cigarettes in your entire life, even one or two puffs?

• Yes

• No

• Don’t know/Not sure

• Refused

Have you ever tried smoking tobacco in a water pipe in your entire life, even one or two 

puffs?

• Yes

• No

• Don’t know/Not sure

• Refused

Have you ever smoked tobacco in a pipe other than a water pipe in your entire life, even 

one or two puffs?

• Yes

• No

• Don’t know/Not sure

• Refused
GOAL AREA 2

► Outcome 5 

134 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

From NYTS

Have you ever tried cigarette smoking, even one or two puffs?

• Yes

• No

Have you ever tried smoking cigars, cigarillos, or little cigars, such as Black and Mild, 

Swisher Sweets, Dutch Masters, White Owl, or Phillies Blunts, even one or two puffs?

• Yes

• No

Which of the following tobacco products have you ever tried, even just one time?

• Smoking tobacco from a hookah or a waterpipe

• Pipe filled with tobacco (not waterpipe)

• Snus, such as Camel or Marlboro Snus

• Bidis (small brown cigarettes wrapped in a leaf)

• I have never tried any of the products listed above

From YRBSS

Have you ever tried cigarette smoking, even one or two puffs?

• Yes

• No

Comments Given the application of this outcome indicator for reducing exposure to secondhand 

smoke, evaluators could consider capturing information on the reach and dose of related 

smokefree policies/interventions as well as more proximal measures of knowledge and 

attitude change among the population of focus.

Example survey items in this profile cover combustible tobacco products only, But 

evaluators can also include measures of noncombustible tobacco products. 

Rating

Overall quality

low high

Resources

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. 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; 1994.

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. Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smoke-free 

policies. Available at: www.thecommunityguide.org/tobacco/smokefreepolicies. Last updated: September 22, 

2014.
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 135

Indicator 2.5.e

Proportion of Tobacco Users Who Have Sustained Abstinence from 

Tobacco Use

Indicator 2.5.e 

KOI 2005 New

Goal Area 2 Eliminating exposure to secondhand smoke

Outcome 5 Reduced tobacco consumption

What to measure As a measure of social norm change and direct effects related to smokefree 

interventions, the proportion of former tobacco users who have sustained abstinence 

from tobacco use for 6 months or longer 

Why this indicator is 

useful

Abstinence from tobacco use reduces tobacco use prevalence and exposure to 

secondhand smoke. Studies have found that smokefree policies support and increase 

tobacco use cessation.1-2

Example data 

source(s)

Behavioral Risk Factor Surveillance System (BRFSS): Tobacco Use Module, 2011

Information 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 Health Interview Survey (NHIS): Adult Survey, 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) 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 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
GOAL AREA 2

► Outcome 5 

136 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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 NHIS

Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

• Yes

• No

• Refused

• Don’t know

Do you NOW smoke cigarettes every day, some days, or not at all?

• Every day

• Some days

• Not at all

• Refused

• Don’t know

How long has it been since you quit smoking cigarettes? ______

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

Comments Evaluators can modify the example questions to measure sustained abstinence from all 

tobacco products and ask current smokers about their last quit attempt or longest quit 

attempt, since an increase in the duration of a quit attempt (even if the smoker begins 

smoking again) could indicate progress toward cessation.
GOAL AREA 2

► Outcome 5 

CHAPTER 2 ► Goal Area 2: Eliminating Exposure to Secondhand Smoke 137

To date, research is limited on the effectiveness of e-cigarettes as a cessation aid. There 

is currently no conclusive scientific evidence that e-cigarettes promote long-term 

cessation. Nevertheless, some people who use e-cigarettes are using it to quit. Evaluators 

can calculate cessation rates by including continuing e-cigarettes users as quit or by

classifying people as quit only if they are not using any tobacco products, including 

e-cigarettes.

“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).

This indicator can be used to measure progress toward achieving Objective TU-5.1 of 

Healthy People 2020 Objective: “Increase recent smoking cessation success by adult 

smokers.”3 

Rating

Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$ 

better

References

1. Hopkins DP, Razi S, Leeks KD, et al. Task Force on Community Preventive Services. Smoke-free policies to 

reduce tobacco use: a systematic review. American Journal of Preventive Medicine. 2010;38(2 Suppl):S275–89.

2. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco 

Control, Vol. 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: IARC; 2009.

3. Healthy People 2020. Tobacco use objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives. 

ADDENDUM

Electronic Cigarettes (E-Cigarettes) 

GOAL AREA 2

► E-Cigarette

Addendum

ADDENDUM ► Goal Area 2: Electronic Cigarette Addendum 141

Addendum: Electronic Cigarettes

The indicators presented in this guide are particularly useful for measuring progress toward 

reducing cigarette smoking and exposure to smoke from burning tobacco products, such as 

cigarettes, cigars, and pipes. Although exposure to secondhand smoke from combustible tobacco 

products remains the primary health hazard for nonsmokers exposed to the harmful chemicals 

emitted in the air from tobacco products,

1

 the diversification of the tobacco product landscape 

presents new challenges to public health policy and practice. Emerging tobacco products are 

being heavily developed and marketed.

2,3 While cigarette smoking has declined over the past 

several decades, the use of electronic cigarette (e-cigarettes) products has become prominent, 

particularly among youth.3-8 Furthermore, the product characteristics and marketing landscape

for e-cigarette products continues to evolve. Significant questions remain about the long-term 

health effects of e-cigarette use and its impact on patterns of conventional tobacco use, including 

understanding how e-cigarette may influence tobacco use, cessation, and tobacco-related polices 

and social norms. 

E-cigarettes include a diverse group of devices designed to deliver aerosolized nicotine and 

additives to users. These devices are referred to, by companies, the media, and by consumers by 

a variety of terms, including “e-cigarettes,” “e-cigs,” “cigalikes,” “e-hookahs,” “mods,” “vape 

pens,” “vapes,” and “tank systems.” In this guide, the term “e-cigarette” is used to represent all 

the various products in this continually evolving product category. Since their introduction to the 

United States in 2007, marketing and sales of e-cigarettes has expanded rapidly.3,5-6 While 

cigarette smoking among youth and adults has decreased considerably over the past several 

decades, reported use of e-cigarettes has markedly increased.5-9 The use of e-cigarettes among 

U.S. high school students increased 900% during 2011-2015, before declining for the first time 

in 2016. E-cigarettes have been the most commonly used tobacco product among youth since 

2014.5,6 In 2016, 11.3% of U.S. high school students and 4.3% of middle school students had 

used e-cigarettes within the past 30 days.10 Among adults, current e-cigarette use nearly tripled 

from 2010 (1.3%) to 2014 (3.8%), with use being primarily among current and former cigarette 

smokers.8 

The U.S. Surgeon General has concluded that e-cigarette aerosol is not harmless; it can contain 

harmful and potentially harmful constituents, including nicotine, carbonyl compounds, and 

volatile organic compounds.3,11-13 Nicotine exposure poses dangers to youth, pregnant women, 

and fetuses.1,3 Air free of secondhand combusted tobacco smoke and e-cigarette aerosol remains 

the standard to protect health.3 States and local jurisdictions play a critical role in protecting the 

public from secondhand smoke and secondhand e-cigarette aerosol exposure. Clean indoor air or 

smokefree policies prohibits the use of conventional tobacco products in indoor places, including 

worksites, restaurants, and bars. However, many of these policies do not extend to e-cigarette 

use. In 2016, the U.S. Surgeon General recommended including e-cigarettes in smokefree indoor 

air policies to protect the public from both secondhand smoke and secondhand aerosol exposure.3

These policies help maintain current standards for clean indoor air, prevent involuntary exposure 
GOAL AREA 2

► E-Cigarette

Addendum

142 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

to nicotine and other potentially harmful emissions from e-cigarettes, and help sustain tobaccofree norms.3

Studies have found lower levels of public support for prohibiting e-cigarette use indoors 

compared with public support for prohibiting the use of combustible tobacco indoors.3,14-15 This 

lower level of public support may be due to perceptions that e-cigarettes have minimal health 

risks.14-15 Furthermore, enforcement of existing smoke-free laws may also become complicated if 

the public is confused about which product is being used if they observe either e-cigarettes or 

combustible tobacco use indoors. Accordingly, efforts to educate the public about the harmful 

and potentially harmful effects of secondhand e-cigarette aerosol exposure are warranted.3

Tobacco control programs should consider all tobacco product use within their community, 

including e-cigarettes, when making decisions regarding surveillance and evaluation activities. 

When the revised Goal 2 indicators were developed and reviewed by the expert panel, scientific

literature for e-cigarettes was still emerging. Since then, growing evidence on the potential health 

effects of e-cigarette use and its impact on patterns of tobacco use prompted the need to create a 

set of developmental indicators to actively monitor and assess e-cigarette perceptions, exposure, 

and policy-related activities within the context of tobacco prevention and control efforts. These 

indicators were not reviewed by the expert panel, and thus, the indicator profiles do not include 

criteria ratings. These indicators are presented to stimulate advancement of e-cigarette-related 

surveillance and evaluation efforts in tobacco control programs. 

Listed below are the e-cigarette developmental indicators addressed in the addendum, limited to 

secondhand e-cigarette aerosol exposure outcomes relevant to this Goal 2 indicator guide. 

E-Cigarette 2.1 and E-Cigarette 2.4 focus on perceived harm and exposure for e-cigarette only, 

so they should be used in conjunction with indicators 2.1.a and 2.4.a. In contrast, E-Cigarette 2.2 

and E-Cigarette 2.3 focus on broader smokefree policies, so they may serve as “replacement” 

indicators for 2.2.a and 2.3.a, respectively. 

► E-Cigarette 2.1 Proportion of the population that thinks secondhand e-cigarette aerosol is 

harmful

► E-Cigarette 2.2 Proportion of jurisdictions with comprehensive smoke-free policies, 

including e-cigarettes, for indoor public places 

► E-Cigarette 2.3 Compliance with smoke-free policies, including e-cigarettes, in public 

places and workplaces

► E-Cigarette 2.4 Proportion of non-users exposed to secondhand e-cigarette aerosol

References

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

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

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

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

Promotion, Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 
GOAL AREA 2

► E-Cigarette

Addendum

ADDENDUM ► Goal Area 2: Electronic Cigarette Addendum 143

2. Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and 

counting: implications for product regulation. Tobacco Control. 2014;23 Suppl 3:iii3–9. doi: 

10.1136/tobaccocontrol-2014-051670 

3. U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young 

Adults. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. 

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. 

Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fullreport.pdf. 

5. Singh T, Arrazola RA, Corey CG, et al. Tobacco use among middle and high school 

students—United States, 2011–2015. Morbidity and Mortality Weekly Report. 

2016;65(14):361–7. 

6. Centers for Disease Control and Prevention. Trends in current cigarette smoking among high 

school students and adults, United States, 1965–2014. Available at: 

http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/. Last updated March 

16, 2016.

7. King BA, Patel R, Nguyen KH, Dube SR. Trends in awareness and use of electronic 

cigarettes among U.S. adults, 2010–2013. Nicotine & Tobacco Research. 2015 

Feb;17(2):219–27. doi: 10.1093/ntr/ntu191. 

8. Syamlal G, Jamal A, King BA, Mazurek JM. Electronic cigarette use among working 

adults—United States, 2014. Morbidity and Mortality Weekly Report. 2016;65(22):557–61. 

9. Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. 

NCHS Data Brief. October 2015;217. Available at: 

http://www.cdc.gov/nchs/data/databriefs/db217.pdf. 

10. Jamal A, Gentzke A, Hu SS, et al. Tobacco Use Among Middle and High School Students — 

United States, 2011–2016. MMWR Morb Mortal Wkly Rep 2017;66:597–603. DOI: 

http://dx.doi.org/10.15585/mmwr.mm6623a1. 

11. Cheng T. Chemical evaluation of electronic cigarettes. Nicotine & Tobacco Research. 2014; 

23: ii11–17. doi: 10.1136/tobaccocontrol-2013-051482. 

12. Goniewicz, ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in 

vapour from electronic cigarettes. Tobacco Control. 2014;23(2):133–9. doi: 

10.1136/tobaccocontrol-2012-050859. 

13. Callahan-Lyon P. Electronic cigarettes: human health effects. Tobacco Control. 

2014;23(Suppl 2):ii36–40. doi: 10.1136/tobaccocontrol-2013-051470. 
GOAL AREA 2

► E-Cigarette

Addendum

144 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

14. Tan AS, Bigman CA, Sanders-Jackson A. Sociodemographic correlates of self-reported 

exposure to e-cigarette communications and its association with public support for smokefree and vape-free policies: results from a national survey of US adults. Tobacco Control. 

2015;24(6):574–81. doi: 10.1136/tobaccocontrol-2014-051685. 

15. Wackowski OA, Delnevo CD. Smokers’ attitudes and support for e-cigarette policies and 

regulation in the USA. Tobacco Control. 2015;24(6):543–6. doi: 10.1136/tobaccocontrol2014-051953 

For Further Reading

Centers for Disease Control and Prevention, Office on Smoking and Health. CDC Office on 

Smoking and Health E-cigarette Information, November 2015. Available at: 

https://www.cdc.gov/tobacco/stateandcommunity/pdfs/cdc-osh-information-on-e-cigarettesnovember-2015.pdf. 

Durmowicz EL. The impact of electronic cigarettes on the paediatric population. Tobacco 

Control. 2014;23 Suppl 2:ii41–46. doi: 10.1136/tobaccocontrol-2013-051468 

Gourdet CK, Chriqui JF, Chaloupka FJ. A baseline understanding of state laws governing 

e-cigarettes. Tobacco Control. 2014;23 Suppl 3:iii37–40. doi: 10.1136/tobaccocontrol-2013-

051459 

Lempert LK, Grana R, Glantz SA. The importance of product definitions in US e-cigarette laws 

and regulations. Tobacco Control. 2016;25(e1):e44–51. doi: 10.1136/tobaccocontrol-2014-

051913 

Marynak K, Holmes CB, King BA, Promoff G, Bunnell R, McAfee T. State laws prohibiting 

sales to minors and indoor use of electronic nicotine delivery systems—United States, November 

2014. Morbidity and Mortality Weekly Report. 2014;63(49):1145–50. 
GOAL AREA 2

► E-Cigarette

Addendum

ADDENDUM ► Goal Area 2: Electronic Cigarette Addendum 145

Eliminating Exposure to Secondhand E-Cigarette Aerosol: Outcome 

Indicators for Comprehensive Tobacco Control Programs‒2016

E-Cigarette 2.1

Proportion of the Population that Thinks Secondhand Aerosol from 

E-Cigarettes Is Harmful

Indicator E-Cigarette 2.1 

What to measure Proportion of the population that thinks exposure to secondhand aerosol from 

e-cigarettes is harmful to health 

Why this indicator is 

useful

Research on combustible tobacco products has shown that perceptions and beliefs 

regarding the harmfulness of exposure to secondhand smoke influences public attitudes 

toward smoke-free restrictions.1-4 This evidence suggests that perceptions of harm 

related to e-cigarette aerosol may affect public attitudes toward smokefree policies that 

include e-cigarettes. Although knowledge of the harms of secondhand smoke from 

combustible tobacco products is widespread,

5 little is known about public perceptions of 

the harm associated with secondhand e-cigarette aerosol. 

Example data 

source(s)

No commonly used data sources were found.

Population group(s) General population

Example survey 

question(s)

Modified from the National Adult Tobacco Survey to address secondhand e-cigarette 

aerosol exposure, not just exposure to secondhand smoke from combustible tobacco 

products (as in Tan et al.6 and Mello et al.7

).

Do you think that breathing vapor from other people’s electronic cigarettes is...

• Very harmful to my health

• Somewhat harmful to my health

• Not at all harmful to my health

• Don’t know/Not sure

• Refused

How concerned would you be about the impact on your health of breathing vapor from 

other people’s electronic cigarettes if you were regularly exposed to secondhand vapor? 

Would you be...

• Not at all concerned

• A little concerned

• Very concerned

• Don’t know/Not sure

• Refused

Modified from the National Youth Tobacco Survey to address secondhand e-cigarette 

aerosol exposure, not just exposure to secondhand smoke from combustible tobacco 

products.

Do you think that breathing vapor from other people’s electronic cigarettes causes...

• No harm

• Little harm

• Some harm
GOAL AREA 2

► E-Cigarette

Addendum

146 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

• A lot of harm

Comments This indicator should be used in conjunction with Indicator 2.1.a, which measures 

perceived harm from combusted secondhand tobacco smoke.

Evaluators might ask specifically about perceived harm of ENDS aerosol exposure to 

children, pregnant women, and other populations particularly vulnerable to the harms of 

exposure to nicotine and secondhand tobacco smoke.8 

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

2. Borland R, Yong H, Siahpush M, et al. Support for and reported compliance with smoke‐free restaurants and 

bars by smokers in four countries: findings from the International Tobacco Control (ITC) Four Country Survey. 

Tobacco Control. 2006;15(Suppl 3):iii34–iii41. doi: 10.1136/tc.2004.008748.

3. Blake KD, Viswanath K, Blendon RJ, Vallone D. The role of tobacco-specific media exposure, knowledge, and 

smoking status on selected attitudes toward tobacco control. Nicotine & Tobacco Research. 2010;12(2):117–26.

doi: 10.1093/ntr/ntp184

4. Wilson N, Weerasekera D, Blakely T, Edwards R, Thomson G, Gifford H. What is behind smoker support for 

new smokefree areas? National survey data. BMC Public Health. 2010;10:498. doi: 10.1186/1471-2458-10-498

5. Kruger J, Patel R, Kegler M, Babb SD, King BA. Perceptions of harm from secondhand smoke exposure among 

U.S. adults, 2009–2010. Tobacco Induced Diseases. 2016;14:3. doi: 10.1186/s12971-016-0069-8.

6. Tan AS, Bigman CA, Sanders-Jackson A. Sociodemographic correlates of self-reported exposure to e-cigarette 

communications and its association with public support for smoke-free and vape-free policies: results from a 

national survey of US adults. Tobacco Control. 2015;24(6):574–81. doi: 10.1136/tobaccocontrol-2014-051685

7. Mello S, Bigman CA, Sanders-Jackson A, Tan AS. Perceived harm of secondhand electronic cigarette vapors 

and policy support to restrict public vaping: results from a national survey of US adults. Nicotine & Tobacco 

Research. 2016;18(5):686–93. doi: 10.1093/ntr/ntv232

8. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke—

United States, 1999–2012. Morbidity and Mortality Weekly Report. 2015 Feb 6;64(4):103–8.
GOAL AREA 2

► E-Cigarette

Addendum

ADDENDUM ► Goal Area 2: Electronic Cigarette Addendum 147

E-Cigarette 2.2

Proportion of Jurisdictions with Comprehensive Smokefree Policies 

Including E-Cigarettes for Indoor Public Places

Indicator E-Cigarette 2.2 

What to measure Proportion of local jurisdictions that have policies prohibiting smoking and e-cigarette

use in all indoor areas of worksites, restaurants, and bars

Why this indicator is 

useful

Modernizing smokefree policies to include e-cigarettes protects people from the harms 

of both secondhand smoke and secondhand aerosol in these environments.

1 An 

increasing number of states and municipalities have comprehensive smokefree laws that 

also prohibit the use of e-cigarettes.

2 State and local laws vary regarding the definition 

of e-cigarette and venue exemptions.3-4 

Example data 

source(s)

American Nonsmokers’ Rights Foundation. States and Municipalities with Laws 

Regulating Use of Electronic Cigarettes (updated quarterly). 

Information available at: http://no-smoke.org/pdf/ecigslaws.pdf

State Tobacco Activities Tracking and Evaluation (STATE) System

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, and regulations. 

Example survey 

question(s)

Not applicable.

Comments A comprehensive smokefree policy is defined by the Office on Smoking and Health 

(OSH) as a policy that does not allow smoking in any indoor areas of workplaces, 

restaurants, and bars, with no exceptions.5 Evaluators may wish to include additional 

worksites, such as casinos.

Tracking the proportion of jurisdictions with smokefree policies in the evaluation of 

tobacco control programs should primarily focus on the adoption of comprehensive 

smokefree policies as defined by OSH; however, evaluators are encouraged to assess the 

inclusion of e-cigarettes in comprehensive smokefree policies where appropriate. For 

states or jurisdictions that have already adopted comprehensive smokefree policies or 

for states or jurisdictions attempting to adopt comprehensive policies to include 

e-cigarettes, this indicator may serve as a “replacement” for Indicator 2.2.a.

References

1. U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A report of 

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

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

Smoking and Health; 2016.

2. Centers for Disease Control and Prevention. State laws prohibiting sales to minors and indoor use of electronic 

nicotine delivery systems—United States. Morbidity and Mortality Weekly Report. 2014 Nov. 63(49);1145–50.

3. Gourdet CK, Chriqui JF, Chaloupka FJ. A baseline understanding of state laws governing e-cigarettes. Tobacco 

Control. 2014;23(Suppl 3):iii37–iii40. doi: 10.1136/tobaccocontrol-2013-051459

4. Lempert LK, Grana R, Glantz SA. The importance of product definitions in US e-cigarette laws and regulations. 

Tobacco Control. 2016;25(e1):e44–51. doi: 10.1136/tobaccocontrol-2014-051913

5. Centers for Disease Control and Prevention. Comprehensive smoke-free laws—50 largest U.S. cities, 2000 and 

2012. Morbidity and Mortality Weekly Report. 2012 Nov 16;61(45):914–7.
GOAL AREA 2

► E-Cigarette

Addendum

148 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

E-Cigarette 2.3

Compliance with Smokefree Policies Including E-Cigarettes in Public 

Places and Workplaces

Indicator E-Cigarette 2.3 

What to measure Proportion of the population that reports compliance with smokefree policies, including 

e-cigarettes, in public places (e.g., bars, restaurants, and sporting arenas)

Proportion of the population employed outside the home that reports compliance with 

smokefree policies including e-cigarettes in their workplaces

Why this indicator is 

useful

To reduce exposure to e-cigarette aerosol in public places and workplaces, users must

comply with e-cigarette restrictions in these settings. A majority of the general public 

supports at least some restrictions on e-cigarette use in public places.1 Support for these 

restrictions is lower among current cigarette smokers and among those who believe that 

secondhand aerosol is less harmful than secondhand smoke from combusted tobacco 

products.1-3

Example data 

source(s)

No commonly used data sources were found.

Population group(s) General population 

Example survey 

question(s)

Modified from the National Adult Tobacco Survey to address secondhand e-cigarette 

aerosol use in covered venues, not just exposure to secondhand smoke from combustible 

tobacco products.

Not counting times while you were at work, to your knowledge, during the past 7 days, 

that is, since last [TODAY’S DAY OF WEEK], has anyone, including yourself, used 

e-cigarettes in an indoor or outdoor public place when he or she was not supposed to?

• Yes

• No

• Don’t know/Not sure

• Refused

At your workplace, is e-cigarette use ....?

• Allowed in both indoor and outdoor areas

• Allowed in outdoor areas, but never allowed in any indoor areas

• Allowed in indoor areas, but never allowed in any outdoor areas

• Never allowed in any indoor or outdoor area

• Don’t know

To your knowledge, during the past 30 days, that is, since [DATE FILL], has anyone, 

including yourself, used e-cigarettes at your work when he or she was not supposed to?

• Yes

• No

• Don’t know/Not sure

• Refused

Comments For smokefree policies that include e-cigarette products, this indicator may serve as a 

“replacement” for Indicator 2.3.a to assess compliance with policies that include 

e-cigarettes. 

When reporting compliance, the general public may not be able to distinguish between 

combustible tobacco products and e-cigarettes, because some e-cigarettes are designed 

to mimic conventional cigarette smoking. This poses a challenge for evaluators. In 
GOAL AREA 2

► E-Cigarette

Addendum

ADDENDUM ► Goal Area 2: Electronic Cigarette Addendum 149

addition, the public may not be aware of where e-cigarette use is permitted given the 

rapidly evolving regulatory environment for these products.

Compliance data for workplaces can be analyzed by workplace size or type.

In addition to gathering data on reported compliance, evaluators can measure 

compliance through observation.4

References

1. Tan AS, Bigman CA, Sanders-Jackson A. Sociodemographic correlates of self-reported exposure to e-cigarette 

communications and its association with public support for smoke-free and vape-free policies: results from a 

national survey of US adults. Tobacco Control. 2015;24(6):574–81. doi: 10.1136/tobaccocontrol-2014-051685

2. Wackowski OA, Delnevo CD. Smokers’ attitudes and support for e-cigarette policies and regulation in the 

USA. Tobacco Control. 2015;24(6):543–6. doi: 10.1136/tobaccocontrol-2014-051953

3. U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A report of 

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

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

Smoking and Health; 2016.

4. Skeer M, Land ML, Cheng DM, Siegel MB. Smoking in Boston bars before and after a 100% smoke-free 

regulation: an assessment of early compliance. Journal of Public Health Management and Practice. 2004;10(6), 

501–7.
GOAL AREA 2

► E-Cigarette

Addendum

150 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

E-Cigarette 2.4

Proportion of Non-Users Exposed to Secondhand E-Cigarette Aerosol

Indicator E-Cigarette 2.4 

What to measure Exposure to secondhand e-cigarette aerosol in workplaces, public places, homes, and 

vehicles

Why this indicator is 

useful

Exposure to e-cigarette aerosol has the potential to involuntarily expose bystanders, 

including vulnerable populations, such as children and pregnant women, to aerosolized 

nicotine and other harmful and potentially harmful substances.1 Social norms concerning 

secondhand tobacco smoke have shifted significantly in the past several decades,2 and 

tracking e-cigarette aerosol exposure will allow for similar assessments of e-cigarette

use in locations that could place non-users at risk. 

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2016

Information available at: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/

Population group(s) General Population

Example survey 

question(s)

From NYTS

During the past 30 days, on how many days did you breathe the vapor from someone 

who was using an e-cigarette in an indoor or outdoor public place? Examples of indoor 

public places are school buildings, stores, restaurants, and sports arenas. Examples of 

outdoor public places are school grounds, parking lots, stadiums, and parks?

• 0 days

• 1 or 2 days

• 3 to 5 days

• 6 to 9 days

• 10 to 19 days

• 20 to 29 days

• All 30 days

Modified from the California Adult Tobacco Survey (CATS), 2008, to address 

secondhand e-cigarette aerosol exposure, not just exposure to secondhand smoke from 

combustible tobacco products.

In the past week, about how many minutes or hours were you exposed to other people’s 

e-cigarette vapor in all environments?

• ____Enter response

• None at all

• Don’t know / Not sure

• Refused

Modified from the U.S. Social Climate Survey of Tobacco Control (SCS-TC), 2014,

to address secondhand e-cigarette aerosol exposure, not just exposure to secondhand 

smoke from combustible tobacco products. 

During the past seven days, in which of the following places have you smelled vapor 

from other people’s electronic cigarettes?

• In your home

• In your car

• In someone else’s car

• At work

• On a public sidewalk
GOAL AREA 2

► E-Cigarette

Addendum

ADDENDUM ► Goal Area 2: Electronic Cigarette Addendum 151

• Outside the doorway of a building

• In an indoor public place, such as a restaurant or salon

• On other public transport

• In some other indoor place, such as a friend’s home 

Comments This indicator can be used in conjunction with Indicator 2.4.a, which measures exposure 

to combusted secondhand tobacco smoke.

Evaluators should carefully consider evaluation objectives, available resources, and 

population of interest when selecting a data collection approach. 

References

1. Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality 

and increases FeNO levels of e-cigarette consumers. International Journal of Hygiene and Environmental 

Health. 2014;217(6):628–37. doi: 10.1016/j.ijheh.2013.11.003 

2. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco 

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

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

Office on Smoking and Health; 2006. Available at: 

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 

Appendices and Glossary

APPENDIX A 155

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,

► six national networks, and 

► eight tribal support centers. 

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 of tobacco use, 

► eliminate exposure to secondhand smoke, 

► promote quitting among adults and youth, and 

► identify and eliminate 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. Several resources for 

effective tobacco control programs are also available on the Web site, including the following: 

► Best Practices for Comprehensive Tobacco Control Programs1

► Best Practices User Guide: Youth Engagement—State and Community Interventions2

► Designing and Implementing an Effective Tobacco Counter-Marketing Campaign3
156 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

► Surgeon General Reports related to tobacco prevention and control4-9

► The Guide to Community Preventive Services: Tobacco Use Prevention and Control10

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. Available at: 

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm. 

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

engagement—state and community interventions. 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. Centers for Disease Control and Prevention. Designing and implementing an effective 

tobacco counter-marketing 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, First Edition; October 

2003. 

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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/2000/complete_report/pdfs/fullreport.pdf. 

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. Available at: 

https://www.cdc.gov/tobacco/data_statistics/sgr/1998/complete_report/pdfs/complete_repo

rt.pdf. 
APPENDIX A 157

9. U.S. Department of Health and Human Services. The health consequences of smoking—50 

years of progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of 

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

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

2014. Available at: http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/#fullreport. 

10. 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. 

APPENDIX B 159

APPENDIX B

Expert Panel Members

We thank the following panel of expert members who rated the indicators. Without their 

generosity in sharing their expertise and donating their time, this publication would not be 

possible. 

Goal 2 Expert Reviewers

1. Carsten Baumann 

Owner

Carsten Consulting Services

2. Jean Forster 

Professor

University of Minnesota School of Public Health

3. Ellen Hahn

Professor

College of Nursing and College of Public Health

University of Kentucky

Director

Clean Indoor Air Partnership and Kentucky Center for Smoke-Free Policy

Faculty Associate

University Kentucky Prevention Research Center

Faculty Member

University of Kentucky Markey Cancer Center

4. Andrew Hyland

Chair

Department of Health Behavior

Division of Cancer Prevention and Population Sciences

Roswell Park Cancer Institute

5. Michelle Kegler

Director

Emory Prevention Research Center

Professor

Behavioral Sciences and Health Education

Emory University Rollins School of Public Health
160 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

6. Liz Klein

Assistant Professor

Center for Excellence in Regulatory Tobacco Science, Health Behavior, and Health 

Promotion

The Ohio State University College of Public Health

7. Robert McMillan

Associate Professor

Social Science Research Center 

Department of Psychology

Mississippi State University

8. Barbara Pizacani

Senior Research Scientist

Program Design and Evaluation Services 

Oregon Public Health Division 

9. Katelin Ryan 

Director of Evaluation

Indiana State Department of Health

10. Miranda Spitznagle

Director

Tobacco Prevention and Cessation Commission

Indiana State Department of Health

11. Michael Tynan

Policy Officer

Office of the State Public Health Director

Oregon Public Health Division

12. Elizabeth Williams

Project Manager

Americans for Nonsmokers Rights

13. Xueying Zhang

Senior Research Scientist 

California Tobacco Control Program

California Department of Public Health
APPENDIX B 161

Outcome Indicator Workgroup

We thank the following individuals for their assistance in preparing and reviewing this 

publication. 

From the Office of Smoking and Health, National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and Prevention: 

Erika Fulmer, MHA 

Yessica Gomez, MPH

Brian King, PhD, MPH 

Nicole Kuiper, MPH 

Rene Lavinghouze, MA 

Rebecca Murphy-Hoefer, PhD, MPH

Kimberly Nguyen, MS, MPH 

Laura Whalen, MPH 

From RTI International: 

Laurel Curry, MPH

LaShawn Glasgow, DrPH 

Sandhya Joshi, BA 

Todd Rogers, PhD 

APPENDIX C 163

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 2: Eliminating Exposure to Secondhand Smoke 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 were then 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 2 Outcome Indicators

Revising the Candidate List of Indicators

In 2014, an initial step taken to update the Goal 2 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 2 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, 

and Institute of Medicine reports published from 2005 to 2014. We also conducted targeted 
164 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

literature searches via PubMed. The 2014 literature review identified the need for additional and 

more nuanced secondhand smoke indicators like indicators related to multiunit housing or 

tobacco products other than cigarettes.

Information from the literature review was used to modify the existing Goal 2 logic model and 

indicator list. Ultimately, 11 new candidate indicators were added to the Goal 2 list, and 5 

indicators from KOI 2005 were removed. Revised materials included the revised Goal 2 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 2. Of the 13 invited 

experts, all 13 completed the indicator review. The experts assessed the indicators against several 

criteria and advised us about which data sources are most useful for measuring these indicators. 

Expert panelists were asked to rate each of the candidate indicators separately according to the 

following criteria (see expert panel review instructions and review form at the end of this 

appendix): 

► Strength of the evaluation evidence. The extent to which the literature supports use of the 

indicator for the evaluation of comprehensive, statewide tobacco control programs, as 

characterized by the logic models. Reference citations on each indicator rating form were 

intended to help inform reviewer ratings.

► Resources needed for data collection and analysis. The amount of funds, time, and effort 

needed to collect reliable and precise data on the indicator and to analyze primary or 

secondary data. In making their judgments, reviewers were instructed to consider the 

availability of existing data (e.g., archival records or other secondary data) and the 

difficulties related to sampling and data collection methods. We reminded reviewers that 

many state health departments do not have extensive data collection systems for use in 

comprehensive evaluations of their tobacco control programs. However, all states have 

access to data on adults from the Behavioral Risk Factor Surveillance System, as well as 

periodic data on attitudes and policies through the Tobacco Use Supplements of the Current 

Population Survey. In addition, CDC synthesizes behavioral and policy data on the State 

Tobacco Activities Tracking and Evaluation (STATE) system. Fewer resources are needed 

for data collection and analysis when data are already available than when new data must be 

collected and analyzed.

► Utility. The extent to which the indicator would help to answer key evaluation questions for 

a comprehensive state tobacco control program. Although many indicators are also 

appropriate and useful for evaluating local tobacco control programs, reviewers were asked 

to consider the utility of each indicator for evaluating state tobacco control programs. 

► Face validity. The extent to which judgments about and measurements of the indicator 

would appear valid and relevant to policy makers and other decision makers who use the 

results of an evaluation to justify their continued support. 
APPENDIX C 165

► Uniqueness. Whether the indicator contributes distinctive information for the evaluation of 

tobacco control efforts. Reviewers who believed that an indicator was not unique were 

instructed to identify the redundant indicator. 

► Conformity with accepted practice. The degree to which use of the indicator as a measure 

of a tobacco control program’s progress is consistent with accepted, real-world tobacco 

control practice.

► Overall quality. A global rating that reflects the reviewer’s opinion of the overall quality of 

the indicator. 

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, Youth Risk Behavior 

Considering Stakeholder Input: Updating Outcome Indicators
166 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Survey (YRBS), School Health Profiles, and state tobacco prevention and control program 

evaluation reports. 

Rationale statements and supporting references for each candidate indicator were updated using 

the 2014 literature review as well as topic-specific PubMed searches for more recent evidence 

published since 2014. 

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. 

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 2.3.a: Compliance with smokefree 

policies in public places and workplaces.

► 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 Indicator 2.2.k: Number 

and type of enforcement actions issued regarding smokefree policies. 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 38 candidate indicators. After reviewing 

the expert panel ratings and comments carefully, two indicators were added and four were 

revised to address gaps identified by the expert reviewers and OSH staff. These new indicators 
APPENDIX C 167

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 two indicators. Thus, this publication contains information on a 

total of 38 Goal Area 2 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 27 

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.
168 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

CDC/OSH Key Indicators Report:

Instructions for Expert Panel Reviewers

CDC/OSH Key Outcome Indicator 2016 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 (1) planners, 

managers, and evaluators of state programs to prevent or control tobacco use and (2) CDC’s national 

partners.

Since the release of the 2005 KOI Guide, there have been substantial changes and advances in tobacco 

control. Therefore, OSH decided to revisit the key outcome indicators related to secondhand smoke. As 

a first step, indicators in OSH Goal Area 2 (Eliminating Exposure to Secondhand Smoke) 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 CDC’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 2 logic model (Figure 1). 

As part of the update process, each of the original KOI Guide Goal Area 2 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 

other national and state-specific surveys and evaluation protocols that are not widely used yet but are 

accessible to state tobacco control programs.

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. Indicators will be used in planning and evaluating 

comprehensive state tobacco control programs. The review also provides expert opinion on the data 
APPENDIX C 169

sources and measures that would be most useful for tracking these indicators. As reviewers, you are 

specifically 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 detailed summary information on each 

indicator. 

We would like you to rate the indicators based on your expertise and experience in this substantive area 

using the following criteria:

► Strength of evidence

► Costs (in money, time, and other resources) required to collect and analyze indicator data 

► Utility

► Face validity

► Uniqueness 

► Conformity with accepted practice

► Overall quality

Below you will find additional 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, 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 

In the summary information section on the rating forms, the example data sources/measures suggested 

are intended only to help operationalize the indicators and do not represent a comprehensive list of all 

possible measures for the indicators. Additionally, information included in the “Comments” section has 

been limited to what will help to provide clarity or address nuances of the specific indicator. The final, 

updated KOI Guide will include suggestions for other uses of the indicator, the indicator’s limitations 

(if any) as a measure of a program’s progress, or sources of other information on data collection 

methods. 

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 the following 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. 
170 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Rating Criteria

The following criteria are to be used to rate each indicator: 

► Strength of the evaluation evidence—Extent to which you believe that the literature supports use 

of the indicator for the evaluation of comprehensive, statewide tobacco control programs, as 

characterized by the logic model. The references included on each indicator rating form are 

intended to provide guidance on your ratings of this criterion, but your knowledge of the literature 

should also be used. Please add your comments regarding conflicting evidence, additional 

citations, and/or concerns with methodology.

► Resources required for collecting and analyzing indicator data—Your rating of the resources 

(in funds, time, or effort) to collect reliable and precise measures and to analyze appropriately 

primary or secondary data on the indicator. In making your judgments, please consider availability 

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

collection, and methodological and sampling issues. 

► 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.

► 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.

► 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. 

► 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.

► Overall quality—A summary rating that reflects your opinion of the overall quality of the 

indicator. 

Reviewer Comments

Please provide comments and suggestions regarding the 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 us to arrange for hard-copy submission. 
APPENDIX C 171

APPENDIX D 173

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

Adult Tobacco Survey 

Questions (ATS), Core Survey, 

2014

2.1.c, 2.1.d, 2.3.d ► http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5

903a1.htm

Adult Tobacco Survey 

Questions (ATS), Core Survey, 

2012

2.1.e, 2.1.f ► http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5

903a1.htm

Adult Tobacco Survey 

Questions (ATS), Supplemental 

Survey, 2014

2.3.a, 2.3.d ► http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5

903a1.htm

Americans for Nonsmokers’ 

Rights: Colleges and 

Universities with 100% 

Smokefree Policies, (Entire 

Campus, Indoors and 

Outdoors), 100% Tobacco-Free 

Policies, and E-cigarette-Free 

Policies.

2.2.e ► http://no-smoke.org/goingsmokefree.php?id=447

Americans for Nonsmokers’ 

Rights Foundation, 

Municipalities with local 100% 

smokefree laws currently in 

effect (updated quarterly)

2.2.a ► http://www.no-smoke.org/pdf/100ordlisttabs.pdf

American Nonsmokers’ Rights 

Foundation, Percent of U.S. 

State Populations Covered by 

100% Smokefree Air Laws, 

updated quarterly

2.2.d ► http://www.no-smoke.org/pdf/percentstatepops.pdf

Americans for Nonsmokers’ 

Rights (ANR), Smokefree Lists, 

Maps, and Data, Outdoor Areas

2.2.b ► http://www.nosmoke.org/goingsmokefree.php?id=519%20-

%20outdoor#outdoor
174 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Data source Indicator number For more information

Americans for Nonsmokers’ 

Rights (ANR), Smokefree Lists, 

Maps, and Data, States with 

Preemption of Smokefree Air 

Laws

2.2.l ► http://www.no-smoke.org/pdf/preemptionmap.pdf

Americans for Nonsmokers’ 

Rights Foundation. U.S. laws 

and policies restricting or 

prohibiting smoking in private 

units of multiunit housing. 

Updated quarterly.

2.2.g ► http://www.no-smoke.org/pdf/smokefreemuh.pdf

Behavioral Risk Factor 

Surveillance System (BRFSS): 

Core Module, 2011

2.5.c ► http://www.cdc.gov/brfss/

Behavioral Risk Factor 

Surveillance System (BRFSS): 

Core Module, 2013

2.5.c ► http://www.cdc.gov/brfss/

Behavioral Risk Factor 

Surveillance System (BRFSS): 

Tobacco Use Module, 2011

2.5.e ► http://www.cdc.gov/brfss/

Behavioral Risk Factor 

Surveillance System (BRFSS): 

Secondhand Smoke Module, 

2011

2.1.d, 2.2.f ► http://www.cdc.gov/brfss/

Behavioral Risk Factor 

Surveillance System (BRFSS), 

2011, Module 16

2.4.b, 2.4.c, 2.4.h, 

2.4.i

► http://www.cdc.gov/brfss/

California Adult Tobacco 

Survey (CATS) Questions, 2008

2.1.d, 2.4.a, 2.4.c, 

2.4.d

► https://www.cdph.ca.gov/data/surveys/Pages/Califo

rniaTobaccoSurveys.aspx

California Adult Tobacco 

Survey (CATS) Questions, 2002

2.1.e ► https://www.cdph.ca.gov/data/surveys/Pages/Califo

rniaTobaccoSurveys.aspx

California Tobacco Control 

Program (CTCP): Secondhand 

Smoke Law Enforcement 

Survey, 2007

2.2.k ► http://www.cdph.ca.gov/programs/tobacco/Docum

ents/Resources/Publications/Enforcement%20Repo

rt%202007%20-%20Final%20Submitted.pdf

CDC State Tobacco Activities 

Tracking and Evaluation 

(STATE) system

2.2.a, 2.2.e, 2.2.g, 

2.2.h, 2.2.l

► http://www.cdc.gov/statesystem/

CDC Tips From Former 

Smokers Campaign, Pilot 

Campaign Survey, 2014

2.1.a ► http://www.cdc.gov/tobacco/campaign/tips/

Early Childhood Environment 

Rating Scale (ECERS), Health 

Practice Subscale

2.2.e, 2.4.e ► http://ers.fpg.unc.edu/early-childhoodenvironment-rating-scale-ecers-r
APPENDIX D 175

Data source Indicator number For more information

Evaluation of the National 

Tobacco Prevention and 

Control Public Education 

Campaign, Wave 2 Smoker 

Follow-up Questionnaire, 2014 

(NTP)

2.1.a, 2.1.b ► http://www.reginfo.gov/public/do/PRAViewIC?ref

_nbr=201411-0920-011&icID=210357

Excise tax data from the U.S. 

Department of Treasury’s 

Alcohol and Tobacco Tax and 

Trade Bureau

2.5.a

Harvard School of Public 

Health College Alcohol Study

2.1.f ► http://tobaccocontrol.bmj.com/content/12/3/251.ful

l

Los Angeles County 

Department of Public Health 

(LAC DPH), Tobacco Control 

& Prevention Program, Healthy 

Housing Solutions, Inc., Westat, 

& CDC, Smoke-Free Multi-Unit 

Housing Policy Study: Operator 

Survey

2.2.i ► http://www.reginfo.gov/public/do/PRAViewICR?r

ef_nbr=201309-0920-011

Maine Center for Public Health 

“Wherever You Live and 

Breathe, Go Smoke-free” Media 

Campaign Evaluation Survey, 

2010

2.1.a

National Adult Tobacco Survey 

(NATS), 2010

2.4.c, 2.4.d ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nats/

National Adult Tobacco Survey 

(NATS), 2012–2013

2.4.h, 2.4.i, 2.5.d ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nats/

National Adult Tobacco Survey 

(NATS), 2013–2014

2.2.f, 2.3.c, 2.3.d, 

2.3.e, 2.4.b, 2.4.g, 

2.5.b, 2.5.c, 2.5.e

► http://www.cdc.gov/tobacco/data_statistics/surveys

/nats/

National Health and Nutrition 

Examination Survey 

(NHANES), 2013–2014

2.4.a, 2.4.h ► http://www.cdc.gov/nchs/nhanes/about_nhanes.htm

National Health Interview 

Survey (NHIS), 2014

2.5.b, 2.5.c, 2.5.e ► http://www.cdc.gov/nchs/nhis.htm

National Youth Tobacco Survey 

(NYTS), 2011

2.5.e ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2013

2.1.g ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2014

2.1.c, 2.5.c, 2.5.d ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/
176 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Data source Indicator number For more information

National Youth Tobacco Survey 

(NYTS), 2016

2.4.a ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS), 2013

2.2.c, 2.4.b, 2.4.e, 

2.5.b

► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS), 2015

2.4.i ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

Oregon Department of Human 

Services Survey, 1997

2.3.d

Oregon Public Health Division 

Tobacco Prevention and 

Education Program (TPEP) 

Guardian Management study5

2.2.j

Population Assessment of 

Tobacco and Health (PATH) 

Study, 2015

2.5.b, 2.5.c ► http://www.reginfo.gov/public/do/PRAViewIC?ref

_nbr=201506-0925-002&icID=212557

School Health Policies and 

Practices Study (SHPPS), 2014

2.3.b ► http://www.cdc.gov/healthyyouth/shpps/index.htm

School Health Profiles 

(Profiles), 2014, Principal 

Questionnaire

2.2.e ► http://www.cdc.gov/healthyyouth/profiles/

Smoke-Free Policies in 

Multiunit Housing: Smoking 

Behavior and Reactions to 

Messaging Strategies in Support 

or in Opposition.

2.2.j

Social Climate Survey of 

Tobacco Control (SCS-TC), 

2014

2.1.c, 2.1.g, 2.2.e, 

2.2.f, 2.2.j, 2.3.c, 

2.3.e, 2.4.a, 2.4.b, 

2.4.c, 2.4.d, 2.4.g, 

2.4.h, 2.4.i

► http://www.socialclimate.org/

Social Climate Survey of 

Tobacco Control (SCS-TC), 

2008

2.1.e ► http://www.socialclimate.org/

State departments of revenue 2.5.a

The Tax Burden on Tobacco 2.5.a ► http://www.taxadmin.org/fta/tobacco/papers/Tax_B

urden_2011.pdf

Tobacco-Free College 

Assessment Survey for Staff, 

Faculty and Students

2.2.e, 2.4.f ► http://www.wakehealth.edu/uploadedFiles/User_C

ontent/Research/Departments/Public_Health_Scien

ces/Tobacco_Free_Colleges/TobaccoFree%20Manual_Appendix%207.pdf

Tobacco Use Supplement to the 

Current Population Survey 

(TUS-CPS), 2010–2011

2.1.g, 2.5.b ► http://appliedresearch.cancer.gov/tus-cps/
APPENDIX D 177

Data source Indicator number For more information

UC Davis, Center for 

Evaluation and Research, 

Tobacco Control Evaluation 

Center, Multiple Housing Unit 

Owner/Manager Survey 

(MHUOS)

2.2.i ► http://tobaccoeval.ucdavis.edu/index.html

University of California San 

Francisco (UCSF) California 

campus survey, 2014

2.4.f

University of Cambridge 

Smoke-free Hospital Study, 

2008

2.3.b

Youth Risk Behavior 

Surveillance System (YRBSS), 

2015

2.5.b, 2.5.c, 2.5.c, 

2.5.d

► http://www.cdc.gov/healthyyouth/yrbs/index.htm

Youth Risk Behavior 

Surveillance System (YRBSS), 

2013

2.3.b ► 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. Yee SL, Schooley M. Surveillance and evaluation data resources for comprehensive tobacco control 

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

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

Health; 2001.

GLOSSARY AND ACRONYMS 179

Glossary and Acronyms

Activities

The events or actions that are part of a tobacco control program. 

Aerosol

Emissions of electronic nicotine delivery systems.

Allowances paid to retailers

Payments from manufacturers to retailers to promote increased sales volume or secure 

preferred placement of their brands, such as volume rebates, “slotting fees” and other 

payments for stocking, shelving, displaying and merchandising brands in a certain manner, 

and other incentive payments.1

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. 

Consumption

The number of tax-paid cigarettes (pack of 20) purchased by consumers in a particular 

calendar year.

Data

Documented information or evidence. 

Data sources

Surveys or surveillance systems used to gather data. 

 

1 Tobacco Control Legal Consortium (TCLC). Price-related promotions for tobacco products: an introduction to key terms and 

concepts; 2011. Available at: http://publichealthlawcenter.org/sites/default/files/resources/tclc-fs-pricerelatedpromotions2011_0.pdf
180 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

E-Cigarettes

Battery-powered devices designed to deliver aerosolized nicotine and additives to users. 

These devices are referred to as “e-cigarettes,” “e-cigs,” “cigalikes,” “e-hookahs,” “mods,” 

“vape pens,” “vapes,” and “tank systems.”

ESW

Evaluation stakeholder workgroup: engaged throughout the evaluation planning and 

implementation process to 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. 

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. 

Ever-smoker

Youth: A person who answers yes to the question, “Have you tried cigarette smoking, even 

one or two puffs?” 

Adults: A person who answers yes to the question, “Have you smoked at least 100 cigarettes 

in your entire life?”

Example data source

Surveys or surveillance systems used to measure an indicator and the population on which 

the data are needed.

Face validity

The degree to which data on an indicator appear reliable to stakeholders and policy makers. 

Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act)

Signed into law on June 22, 2009, it gives the Food and Drug Administration (FDA) the 

authority to regulate the manufacture, distribution, and marketing of tobacco products to 

protect public health. 

FDA

U.S. Food and Drug Administration. 

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. 
GLOSSARY AND ACRONYMS 181

Indicator profile

The term used in this manual for a table with detailed information on one indicator listed in 

this publication (see page 28 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 27 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). 

Minors

Persons younger than 18 years of age. 

Modified Survey Question

Question adapted from another survey to serve as an example of a question that can be used

to measure the outcome indicator. 

Morbidity

Disease or disease rate.

NCI

National Cancer Institute.

Never-smoker

Youth: A person who answers no to the question, “Have you tried cigarette smoking, even 

one or two puffs?” 

Adults: A person who answers no to the question, “Have you smoked at least 100 cigarettes 

in your entire life?” 

NIH

National Institutes of Health.

NTCP

National Tobacco Control Program. 
182 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

Observation

A method of collecting data that does not involve any communication with the subjects being 

studied. The investigators merely watch for particular behaviors and record what they see. 

Outcome

The results of an activity such as a countermarketing campaign or an effort to reduce 

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 24 for an example).

Outputs

The direct products of a program (e.g., the materials needed for a media campaign).

Population group

Individuals from which data about a given indicator can most commonly be collected. 

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 amount of a factor of interest (e.g., tobacco use, awareness of a media campaign) present 

in a specified population at a specified time.

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. 
GLOSSARY AND ACRONYMS 183

Public housing

Affordable rental housing managed by the U.S. Department of Housing and Urban 

Development (HUD) for eligible low-income families, elderly persons, and persons with 

disabilities. Type of housing varies from single family homes to high rise apartments. 

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 have quit in the previous 12 months. 

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. 

SMART

Specific, measurable, achievable, relevant, and time-bound. 

Some-day smoker

A current smoker who answers “some days” when asked whether they smoke every day or 

some days. 

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. 

Subsidized multiunit housing

There are two forms of subsidized housing. In one form, landowners receive subsidies from 

the government to partially cover the cost of the mortgage and other expenses to make units 

available to individuals with low to moderate income. In the second form, eligible 

individuals receive vouchers from the government to put toward rent. 

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. 
184 ELIMINATING EXPOSURE TO SECONDHAND SMOKE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2017

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. 

Utility

The extent to which evaluation produces reports that are disseminated to relevant audiences, 

that inform program decisions, and that have a beneficial effect. 
Figure 2: How to Use the Rating Table

Outcome 1

Increased Knowledge of the Dangers of Secondhand Smoke and Support for Policies to 

Reduce Secondhand Smoke

2.1.a

Indicator number

2.1.a

Goal area Outcome component 

within the goal area

Indicator

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

relates to evaluating state tobacco prevention and control programs.

Resources needed: Intensity of resources warranted to collect reliable and precise measures and to analyze 

primary or secondary data on the indicator. Considerations affecting cost include availability of existing data 

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

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

and analyze data on the indicator using the most commonly available data source: 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 prevention and control programs, and 

considers conflicting evidence and concerns regarding the methodology of supporting studies. Indicators 

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

logic model outcome. 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 strong. Indicators with low ratings may have substantial conflicting literature 

and/or weak methodological designs.

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 decision makers who may be users of tobacco prevention and control program 

evaluation results.

Accepted practice: The degree to which use of the indicator is consistent with currently accepted, realworld tobacco control practice.
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