Preventing Initiation of Tobacco Use: 

Outcome Indicators for Comprehensive 

Tobacco Control Programs–2014

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 book was developed as the first part of a three part series of technical 

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

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

health departments plan and evaluate state tobacco control programs. We would like to extend special 

thanks to the Expert Panel Members and Outcome Indicator Workgroup (Please see members listed in 

Appendix B) for their assistance in preparing and reviewing this publication.

Online

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

call toll free 1-800-CDC-INFO (1-800-232-4636).

TTY: 1-888-232-6348

For More Information

For more information about tobacco control and prevention, visit CDC’s Smoking & Tobacco Use

Web site at http://www.cdc.gov/tobacco.

Disclaimer

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

address does not constitute an endorsement of this organization by CDC or the federal government, and 

none should be inferred. CDC is not responsible for the content of other organizations’ Web pages. 

Suggested Citation

Preventing Initiation of Tobacco Use: Outcome Indicators for Comprehensive Tobacco Control 

Programs–2014. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
PREFACE 

iii

Preface

Purpose 

Preventing the initiation of tobacco use is a national public health priority.1

Tobacco use is the single most preventable cause of disease, disability, and death 

in the United States, and nearly all tobacco use begins during youth and young 

adulthood.1-3 Furthermore, cigarette smoking by young people has immediate 

adverse health consequences, including addiction, and accelerates the 

development of chronic diseases across the life course. Several studies have 

concluded that comprehensive state tobacco control programs are effective at 

reducing tobacco use by youth and young adults and have resulted in overall 

reductions in smoking prevalence, as well as concomitant decreases in state 

spending on tobacco-related health care.4-10

To sustain comprehensive tobacco control programs, it is important to 

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

To produce such evidence, state tobacco control programs must continue to 

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

designing a rigorous evaluation. That is where this guide will help. 

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

by the Office on Smoking and Health (OSH), Key Outcome Indicators for 

Evaluating Comprehensive Tobacco Control Programs,

11 hereafter referred to as 

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

Evaluation for Comprehensive Tobacco Control Programs,

12 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 1 of the National Tobacco Control Program, 

which addresses preventing initiation of tobacco use. Although the focus of this 

update is on the prevention of tobacco use, comprehensive tobacco control 

programs that simultaneously address initiation, the elimination of secondhand 

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

isolation. Therefore, until additional updates are available, this resource should be 

used in combination with outcome indicators from KOI 2005 that address 

eliminating nonsmokers’ exposure to secondhand smoke and promoting quitting 

among adults and young people. Additionally, as with KOI 2005, this update 

supports application of the Centers for Disease Control and Prevention’s (CDC’s) 

Framework for Program Evaluation in Public Health Practice,

13 which consists 

of the following six steps of good evaluation: 
iv

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs‒2014

1. Engage stakeholders.

2. Describe the program.

3. Focus the evaluation.

4. Gather credible evidence.

5. Justify your conclusions.

6. Ensure that evaluation findings are 

used and share lessons learned.

This publication provides new and updated 

indicators and supporting information 

relevant to recent changes in the landscape 

of comprehensive tobacco control efforts 

to prevent initiation. The passage of the Family Smoking Prevention and Tobacco 

Control Act in 2009 expanded federal, state, and local governments’ opportunities 

to regulate tobacco through the application of prevention education and policy 

efforts. Specifically, the law allowed for increased limitations on tobacco 

marketing, pricing, and promotions. Given these changes in the policy 

environment, OSH recognized the need to revisit and update the outcome

indicators, beginning with Goal Area 1.

Tobacco 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 will inform the selection of indicators and enable linkage 

of indicators to outcomes. The guide also assists in gathering credible evidence 

(step 4 of the Framework for Program Evaluation) and establishes the value of 

each indicator for measuring the progress of state tobacco control program efforts

by providing a summary of scientific evidence, example questions, and data 

sources for each indicator.

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

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

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

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

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

indicators can be measured within budget or which indicators are likely to carry 

the most weight with policy makers. In essence, this publication is a consumer’s 

guide to tobacco control outcome indicators for program managers and 

evaluators.

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

national evaluation and surveillance efforts by encouraging managers and 

evaluators to focus on evidence-based outcome indicators and to measure and 

report these using protocols and operational definitions drawn from widely 

available state or national data collection systems. In this publication, we provide 

examples of data sources, survey questions, and protocols that evaluators can use 
PREFACE

v

to measure each outcome indicator. Special care was taken to choose example 

data sources and survey questions; most are drawn from common state and 

national surveys and surveillance systems, and using them may allow managers 

and evaluators to compare their findings to data collected across states and 

nationally.

Employing optimally rigorous evaluation designs and methods to the ongoing 

surveillance and evaluation of program impacts on outcome indicators will enable 

state tobacco control program staff to assess progress toward expected outcomes 

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

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

guide), all who are engaged in tobacco control planning and evaluation will be 

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

Technical Assistance

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

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

e-mail at tobaccoinfo@cdc.gov.

References

1. U.S. Department of Health and Human Services, Office of Disease Prevention

and Health Promotion. Healthy people 2020. Washington, DC: Government 

Printing Office. Available at: http://www.healthypeople.gov. Accessed 

September 10, 2012.

2. Centers for Disease Control and Prevention. Tobacco use. Targeting the 

nation’s leading killer. Atlanta, GA: Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health; 2011. Available at:

http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Toba

cco_AAG_2011_508.pdf

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

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

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

for Chronic Disease Prevention and Health Promotion, Office on Smoking 

and Health; 2000.

5. Rigotti NA, Regan S, Majchrzak NE, Knight JR, Wechsler H. Tobacco use by 

Massachusetts public college students: long term effect of the Massachusetts 

Tobacco Control Program. Tobacco Control. 2002;11(Suppl 2):ii20–ii24.
vi

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs‒2014

6. Soldz S, Clark TW, Stewart E, Celebucki C, Walker DK. Decreased youth

tobacco use in Massachusetts 1996 to 1999: evidence of tobacco control

effectiveness. Tobacco Control. 2002;11(Suppl 2):ii14–ii19.

7. Pierce JP, White MM, Gilpin EA. Adolescent smoking decline during 

California’s tobacco control programme. Tobacco Control. 2005;14(3):207–

12.

8. Institute of Medicine (IOM). Ending the tobacco problem: a blueprint for the 

nation. Washington, DC: The National Academies Press; 2007.

9. Lightwood JM, Dinno A, Glantz SA. Effect of the California tobacco control 

program on personal health care expenditures. PLoS Medicine.

2008;5(8):e178. doi:10.1371.journal.pmed.0050178

10. Lightwood J, Glantz S. Effect of the Arizona tobacco control program on 

cigarette consumption and healthcare expenditures. Social Science & 

Medicine. 2011;72(2):166–72.

11. 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.

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

Introduction to program evaluation for comprehensive tobacco control 

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

Centers for Disease Control and Prevention, National Center for Chronic 

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

2001.

13. 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.
TABLE OF CONTENTS 

 vii 

Table of Contents 

Preface iii

Chapter 1 ► Introduction 1

Chapter 2 ► Goal Area 1: Preventing Initiation of Tobacco Use 19

Goal Area 1: Preventing Initiation of Tobacco Use ............................... 21

Outcome 1: Increased Knowledge of the Dangers of Tobacco 

Use, Attitudes Against Tobacco Use, and Support 

for Policies to Reduce Tobacco Use Initiation.................. 29

Outcome 2: Increased Restriction of Tobacco Use and 

Enforcement of Anti-tobacco Policies and Programs

in Schools and on College/University Campuses.............. 47

Outcome 3: Increased Restriction and Enforcement of Tobacco 

Product Sales, Availability, and Use ................................ 63

Outcome 4: Increased Policy and Enforcement Efforts to Reduce 

Tobacco Industry Influence.............................................. 83

Outcome 5: Reduced Susceptibility to Experimentation with 

Tobacco Products .......................................................... 105

Outcome 6: Decreased Exposure to Tobacco Marketing and 

Availability of Tobacco Products................................... 121

Outcome 7: Reduced Tobacco Industry Influence ............................. 141

Outcome 8: Increased Price of Tobacco Products.............................. 165

Outcome 9: Reduced Initiation of Tobacco Use ................................ 177

Outcome 10: Reduced Tobacco-Use Prevalence Among Young 

People............................................................................ 187

Appendices and Glossary 203

Appendix A: National Tobacco Control Program ................................. 205

Appendix B: Expert Panel Members..................................................... 207

Appendix C: Selecting and Rating the Indicators.................................. 211

Appendix D: Data Source Indicator Table ............................................ 221

Glossary ............................................................................................... 227
KEY OUTCOME INDICATORS for Evaluating Tobacco Control Programs: Goal Area 1 Update

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CHAPTER 1 

Introduction
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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 control programs. This publication 

provides an updated logic model linking activities to outcomes for Goal Area 1—

Preventing Initiation of Tobacco Use—of the National Tobacco Control Program 

(NTCP). It contains in-depth information on indicators to measure progress 

toward outcomes, including Consumer Reports®–type ratings to allow for 

tailored selection of indicators at local, state, and territorial levels. Finally, it 

highlights how to use indicators to integrate program and evaluation planning. 

This guide may be used in coordination with CDC’s recently released workbook, 

Developing an Effective Evaluation Plan: Setting the Course for Effective 

Program Evaluation,

1

as well as other OSH surveillance and evaluation resources,

which can be accessed at 

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

ndex.htm.

Audience 

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

evaluators of state tobacco control programs. 

The National Tobacco Control Program 

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

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

► Preventing initiation of tobacco use. 

► Eliminating nonsmokers’ 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 
2

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

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

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

To help tobacco 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 long-term outcomes. 

► To identify relevant short-term, 

intermediate, and long-term outcomes. 

► To assist in selecting indicators to 

measure outcomes. 

In this update, we have expanded the age range of the target population for 

preventing initiation to include youth younger than age 18 years as well as young 

adults aged 18 to 25 years. This change was made in response to recent evidence 

suggesting that initiation of regular tobacco use is increasing among young 

adults.3-5 This change in scope has substantive implications for the Goal Area 1 

logic model. For example, the earlier short-term outcome titled “Increased 

restriction and enforcement of restrictions on tobacco sales to minors” has been 

revised to “Increased restriction and enforcement of tobacco product sales, 

availability, and use” of tobacco products for youth and young adults through age 

25 years.

Outcome Components 

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

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

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

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

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

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

changes in short-term Outcomes 1 through 4 (linked vertically on the logic model) 

should lead to changes in Outcome 5 (linked vertically with Outcomes 6, 7, and 8

on the logic model). Indeed, not only will changes to Outcomes 1 through 4 affect 

Figure 1: Example of Logic Model 

Generic Logic Model 
CHAPTER 1 ► Introduction

 3 

Outcome 5, but they will also affect intermediate Outcomes 6 through 8, as well 

as long-term Outcomes 9, 10, 11, and 12.

The revised Goal Area 1 logic model includes the following changes to outcomes 

from the 2005 Key Outcome Indicators for Evaluating Comprehensive Tobacco 

Control Programs (KOI 2005 hereafter). 

► Changed the outcome “Increased anti-tobacco 

policies and programs in schools” to “Increased 

restriction of tobacco use and enforcement of antitobacco policies and programs in schools and on 

college/university campuses” (Outcome 2). This 

modification was intended to recognize the 

importance of comprehensive policies across a 

broader age range to achieve subsequent 

intermediate outcomes.

► Changed the outcome “Increased restriction and 

enforcement of restrictions on tobacco sales to 

minors” to “Increased restriction and enforcement 

of tobacco product sales, availability, and use” 

(Outcome 3). This modification was intended to 

broaden the scope of the outcome beyond a limited 

focus on sales to minors.

► Moved “Reduced tobacco industry influence” 

(Outcome 7) from a short-term to an intermediate 

outcome and included an additional short-term 

outcome that explicitly addresses “Increased policy

and enforcement efforts to reduce tobacco industry 

influence” (Outcome 4). This modification was 

intended to better clarify the implied logic and order 

of effects.

► Included an additional intermediate outcome, 

“Decreased exposure to tobacco marketing and 

availability of tobacco products” (Outcome 6). This 

modification was intended to highlight the 

importance of the outcome in achieving reduced 

susceptibility to experimentation with tobacco 

products.

Indicators 

Outcome indicators are specific, observable, and measurable characteristics or 

changes that represent achievement of an outcome.6
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PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

For example, if your program is trying to “Increase restrictions and enforcement 

of tobacco product sales, availability, and use” (Outcome 3) and you measured the 

“Proportion of jurisdictions with policies that control the type, location, number, 

and/or density of tobacco retail outlets” (Indicator 1.3.c), the result would indicate 

the extent of your progress toward creating restricted availability policies in all 

jurisdictions. 

Tobacco Products Other than Cigarettes 

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

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

evidence that tobacco products other than cigarettes are being heavily marketed 

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

industry,3 we have explicitly attempted to update indicators so that they address a 

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

tobacco use patterns of their community when making decisions regarding 

surveillance and evaluation activities in terms of measuring different forms of 

tobacco use. 

Identifying and Eliminating Disparities 

We also encourage 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 populations experiencing tobacco-related disparities, ensuring culturally 

meaningful outputs, and collecting and analyzing data in a manner that allows for 

both the identification of populations experiencing tobacco-related disparities and 

the monitoring of outcomes in these populations. In considering what outcomes to 

monitor, it is important to remember that no single factor determines patterns of 

tobacco use and the impact of tobacco use in a particular population but rather 

that tobacco use involves a complex interaction of multiple factors.7 As with types 

of tobacco products, we encourage programs to consider their local context when 

making decisions regarding their need to capture information by population 

characteristics, such as race/ethnicity, 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. Programs 

should 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 the distal outcomes is well established. Therefore, tobacco control programs 
CHAPTER 1 ► Introduction

 5 

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

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

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

addressed by identifying short-term and intermediate outcome indicators. 

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

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

Tobacco Control Program; Roeseler & Burns)8have been able to show an effect 

on long-term outcomes, but most states have not had comprehensive programs in 

place and been well-funded long enough to show such effects.9-11 We also do not 

intend to imply that measuring outcomes is sufficient for evaluating a tobacco 

control program. It is not. Equally important is process evaluation, which focuses 

on measuring 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 some 

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

and engaged a panel of 12 experts (see Appendix B) in tobacco control practice, 

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

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

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

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

experts also indicated the level of resources needed to collect and analyze data on 

the indicator. In addition to rating the indicators that CDC proposed, the experts 

suggested other indicators and sources of data for those indicators. 

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

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

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

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

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

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

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

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

Indicator Rating Tables 

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

table. In each table is a list of all the indicators associated with the outcome 

component and the ratings for each indicator by criterion. Using this table makes 

it easy to compare all the indicators for one outcome. The number and name of 

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

criteria scores for each indicator. 
6

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

Figure 2: Example of Rating Table 

Outcome 1 

Increased Knowledge of the Dangers of Tobacco Use, Attitudes Against Tobacco Use, and Support for 

Policies to Reduce Tobacco Use Initiation 

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

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

ratings are based: 

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

indicator and the general worth of the indicator as it relates to evaluating 

state tobacco control programs. 

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

precise measures and to analyze appropriately 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 
CHAPTER 1 ► Introduction

 7 

the extent to which reviewers believed that the scientific literature supports 

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

control programs and considers conflicting evidence as well as concerns 

regarding the methodology of supporting studies. Indicators with the highest 

ratings have a strong demonstrated relationship between the indicator and a 

downstream logic model outcome. Indictors with moderate ratings 

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

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

this association may not be 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 policy and decision makers who 

may be users of tobacco control program evaluation results. 

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

with currently accepted, real-world tobacco control practice. 

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

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

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

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

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

rating errors (e.g., selection of two non-adjacent ratings). 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 resources needed score for 

indicator 1.7.h: Extent of tobacco industry contributions to institutions and 

groups. 

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

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

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

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

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

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

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

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

quality score for 1.9.a: Average age at which young people first smoked a 

whole cigarette. This low level of agreement represents a relatively high 

degree of variability in the raters’ responses for the criterion. 

Indicator Profiles 

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

intermediate, or long-term outcome component of the NTCP Preventing Initiation 

(Goal 1) logic model. The number of indicators for each logic model component 
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PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

varies considerably; some have three to four indicators, whereas others have 

many. 

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

information about each indicator, as follows: 

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

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

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

model, and the letter represents the indicator. For example, indicator 1.1.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 1. 

► 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 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 non-standardized, topic-specific data sources (e.g., 

media tracking, policy tracking, worksite surveys, environmental scans, and 

other tobacco-related state surveys) that may not be as widely used by state 

tobacco programs but can be useful for evaluation. If similar survey 

questions are included in multiple data sources, we list the data sources most 

commonly available to state tobacco control programs. 

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

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

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

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

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

national survey has an appropriate question, we, 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 

suggest instances where it may enhance the utility of the indicator to collect 

sociodemographic data (e.g., survey respondents’ age, sex, race, ethnicity, 

city or county of residence, educational status, and income). For indicators 
CHAPTER 1 ► Introduction

 9 

with survey items specific to cigarettes, we speak to the issue of capturing 

information about broader groups or different types of tobacco products.

Please note that changes to existing survey items should be made with 

caution. Sufficient cognitive testing should be used to ensure that the 

modified item captures the original intent of the question and still makes 

sense to the respondent. 

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

the indicator by the panel of experts. 

Using This Guide to Plan a State Tobacco Control Program 

Outcome Evaluation 

Engaged data is one of the five essential core components of infrastructure 

according to the evidence-based Component Model of Infrastructure.15 State 

representatives need accurate and timely evaluation data to engage stakeholders 

and decision makers. Evaluation is essential for state tobacco control program 

managers to demonstrate the effects of the program, account for funding, and 

improve programs. Effective tobacco control programs require careful planning, 

implementation, and evaluation. To develop a successful program and a useful 

evaluation, program staff and program evaluators must work collaboratively on 

program planning and evaluation planning. A strong evaluation will not salvage a 

weak program, and a strong program cannot be proven effective without a 

defensible evaluation. 

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

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

appropriate program outcomes and indicators. 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 

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

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

Setting the Course for Effective Program Evaluation.

1 This book provides 

assistance for facilitating and developing a written evaluation plan as well as 

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

Public Health Practice.

Step 1. Engage stakeholders 

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

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

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

engagement of an Evaluation Stakeholder Workgroup (ESW) throughout the 

entire planning and implementation process will aid the program in determining 
10

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

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 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 both 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 critical exercise, done in coordination with the ESW, will help to 

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

complete step 2, describe the program. 

Program staff and stakeholders must agree upon the program description,

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

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

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

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

program planning and evaluation. 

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

components to obtain information regarding the rationale and empirical support 

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

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

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

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

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

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

Step 3. Focus the evaluation 

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

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

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

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

intermediate, and long-term outcomes. 

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

long-term outcomes you have selected. Compare ratings pertaining to the 
CHAPTER 1 ► Introduction

11

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 needs of the evaluation. Use the example data source 

and survey questions included in the indicator profiles to help create a detailed 

plan for gathering evidence. 

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. 
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PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

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

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

increasing the proportion of young people who think that the tobacco companies 

try to get young people to use tobacco products (Indicator 1.1.e) from 50% in 

January 2013 to 75% in January 2014. For more information on creating SMART 

objectives, see Introduction to Program Evaluation for Comprehensive Tobacco 

Control Programs.

2

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

Example 

It is important to effectively evaluate the entire comprehensive tobacco control 

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

following example focuses on preventing initiation of tobacco use. In practice, 

concurrent evaluation efforts of work related to the other goal areas would be 

occurring, providing numerous synergies in terms of both program and evaluation 

planning.

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

increase in tobacco use prevalence among young people, and state legislators are 

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

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

in reducing tobacco use prevalence among young people. 

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

evaluation planning steps previously described as follows: 

Step 1: Engage stakeholders 

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

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

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

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

prevention program. The program organizes an ESW of 10 members who will 

serve a consultative role on all phases of the evaluation. 

Step 2. Describe the program

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

funds specifically to prevent initiation. Therefore, the ESW chooses NTCP Goal 

Area 1: Preventing Initiation of Tobacco Use and reviews the logic model. The 

group then selects the long-term outcome of focus: Outcome 9 (reduced initiation 

of tobacco use). To learn more about Outcome 9, program staff review the 

outcome component overview (page 205), 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. 
CHAPTER 1 ► Introduction

13

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

Area 1 backward (starting at the long-term outcome) to select intermediate and 

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

intermediate outcome: Outcome 5. Reduced susceptibility to experimentation 

with tobacco products. 

This intermediate outcome (Outcome 5) serves as a funnel between the long-term 

outcome and two short-term outcomes in the logic model of NTCP Goal Area 1: 

Outcome 1. Increased knowledge of the dangers of tobacco use, attitudes 

against tobacco use, and support for policies to reduce tobacco 

use initiation 

Outcome 4. Increased policy and enforcement efforts to reduce tobacco 

industry influence 

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

short-term and intermediate outcomes should lead to achieving the selected longterm 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 workgroup members review outcome component overviews, cited 

references, and materials recommended for further reading. 

Step 3. Focus the evaluation 

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

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

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

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

its stage of development. 

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

select indicators that have a high rating for face validity to 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, 4, 5, and 9), beginning with 

Outcome 1. The staff examine the indicator rating table for Outcome 1 (page 32). 

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 33-46).

To finalize indicator selection, the program staff present the summarized 

information to the ESW for consideration and decision making. 
14

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

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 

feasibility of the evaluation plan is also an important factor the group applies to 

the decision-making process. 

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 one indicator associated with outcome component 1 can be measured 

using the state Adult Tobacco Survey that they conduct regularly: 

1.1.c Level of support for policies, and for enforcement of policies, to 

decrease availability of tobacco to young people 

The ESW also understands that short-term changes in the level of support for 

policies, and for enforcement of policies, to decrease availability of tobacco 

contribute to increased policy and enforcement efforts to reduce tobacco industry 

influence (outcome component 4). The planners and evaluators use the same 

process to select indicators for each of the outcome components they have chosen 

to focus on (4, 5, and 9):

1.4.b Proportion of jurisdictions with strong policies that regulate the extent 

and type of consumer-focused tobacco promotions 

1.5.f Proportion of young people who have never used tobacco but are 

susceptible to its use 

1.9.c Proportion of young people who report never having tried a tobacco 

product 

Step 5. Planning for conclusions 

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

objectives of the initiative as well as the strength of the core components of the 

comprehensive program infrastructure, the program planners select and design 

evidence-based interventions, such as mobilizing community support and 

involvement at the grassroots level to promote policy changes that decrease 

availability of tobacco to young people. 

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

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

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

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

ESW translate indicators into SMART program objectives. For example, for 

indicator 1.1.c (Level of support for policies, and for enforcement of policies, to 

decrease availability of tobacco to young people), they create the following 

objective: Increase the percentage of adults in the state who would support a 
CHAPTER 1 ► Introduction

15

policy to ban tobacco sales in pharmacies or drug stores from 10% in July 2013 to 

at least 40% in June 2015.

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

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

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

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

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

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

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

interpretation process needed to justify the evaluation conclusions. 

Step 6. Planning for dissemination and sharing of lessons learned

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

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

the focus on program development and improvement, information regarding 

performance and identified gaps will be shared throughout implementation with 

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

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

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

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

program’s impact on public health outcome indicators. The graphic Goal 1 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. 

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. 

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. 
16

PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control 

Programs—2014

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

and policy. Tobacco Control. 2003;12(Suppl. 1):i60–i70. 

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. 

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: clinical practice guideline. Rockville, MD: U.S. 

Department of Health and Human Services, Public Health Service; 2000. 

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: 

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

on/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. 

Kansas City, MO; August 15-17, 2012.
CHAPTER 1 ► Introduction

17

For Further Reading 

Centers for Disease Control and Prevention. Best practices for comprehensive 

tobacco control programs—2007. Atlanta, GA: U.S. Department of Health and 

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

Chronic Disease Prevention and Health Promotion, Office on Smoking and 

Health; 2007. 

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.

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. 

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. 
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CHAPTER 2 

Goal Area 1: Preventing Initiation of 

Tobacco Use
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GOAL AREA 1

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

21

Goal Area 1 

Preventing Initiation of Tobacco Use 
GOAL AREA 1

22 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Goal Area 1 

Preventing Initiation of Tobacco Use 

Short-term Outcomes 

 Outcome 1: Increased knowledge of the dangers of tobacco use, attitudes against tobacco 

use, and support for policies to reduce tobacco use initiation 

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

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

► 1.1.c Level of support for policies, and for enforcement of policies, to decrease 

availability of tobacco to young people 

► 1.1.d Level of support for creating comprehensive tobacco-free policies in schools 

and on college and university campuses 

► 1.1.e Proportion of young people who think that the tobacco companies try to get 

young people to use tobacco products 

► 1.1.f Level of perceived harm of traditional, non-traditional, and emerging tobacco 

products among young people 

 Outcome 2: Increased restriction of tobacco use and enforcement of anti-tobacco policies 

and programs in schools and on college/university campuses 

► 1.2.a Proportion of schools or colleges/universities implementing 100% tobacco-free 

policies

► 1.2.b Proportion of schools or school districts that provide tobacco-use prevention 

that meets CDC guidelines 

► 1.2.c Proportion of young people who participate in tobacco-use prevention activities 

► 1.2.d Level of reported exposure to school-based tobacco-use prevention that meets 

CDC guidelines 

► 1.2.e Perceived compliance with tobacco-free policies in schools and on college/ 

university campuses 

 Outcome 3: Increased restriction and enforcement of tobacco product sales, availability,

and use 

► 1.3.a Proportion of jurisdictions with strong policies that ban non-sale distribution or 

free sampling of all tobacco products everywhere

► 1.3.b Proportion of jurisdictions with strong policies that require retail licenses to sell 

tobacco products 

► 1.3.c Proportion of jurisdictions with strong policies that control the type, location, 

number, and/or density of tobacco retail outlets 

► 1.3.d Proportion of jurisdictions with strong policies that ban tobacco vending 

machine sales everywhere 
CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

23

► 1.3.e Number and type of enforcement actions issued for violations of restrictions on 

tobacco product availability 

► 1.3.f Proportion of jurisdictions that regulate sales of other tobacco products 

► 1.3.g Proportion of jurisdictions with strong public policies for tobacco-free 

workplaces and other public places 

► 1.3.h Proportion of states with tobacco control laws that preempt stronger local 

tobacco control and prevention laws 

 Outcome 4: Increased policy and enforcement efforts to reduce tobacco industry 

influence

► 1.4.a Proportion of jurisdictions with strong policies that regulate tobacco advertising 

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

of consumer-focused tobacco promotions 

► 1.4.c Proportion of jurisdictions with strong policies that regulate the extent and type 

of merchant-focused industry promotions 

► 1.4.d Proportion of jurisdictions with strong minimum tobacco product price laws 

► 1.4.e Proportion of jurisdictions with strong public policies to establish a fee on each 

package of tobacco product sold to cover government costs 

► 1.4.f Proportion of jurisdictions with strong policies that limit tobacco industry 

sponsorship of public and private events 

► 1.4.g Number and type of enforcement actions for violations of restrictions on 

tobacco marketing 

► 1.4.h Number and type of Master Settlement Agreement violations by tobacco 

companies 

Intermediate Outcomes 

 Outcome 5: Reduced susceptibility to experimentation with tobacco products 

► 1.5.a Proportion of young people who think that tobacco use is cool and helps them 

fit in 

► 1.5.b Proportion of young people who think that young people who use tobacco 

products have more friends 

► 1.5.c

NR Proportion of young people who overestimate the smoking rate among their 

peers 

► 1.5.dNR Proportion of young people who report that their parents would strongly 

disapprove of their use of tobacco products 

► 1.5.e Proportion of young people who have a favorite tobacco brand 

► 1.5.f Proportion of young people who have never used tobacco but are susceptible to 

its use 
GOAL AREA 1

24 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

 Outcome 6: Decreased exposure to tobacco marketing and availability of tobacco 

products

► 1.6.a Density of stores selling tobacco

► 1.6.b Proportion of young people who report receiving non-sale distribution or free 

samples of tobacco products

► 1.6.c Proportion of retailers selling tobacco products to youth

► 1.6.d Proportion of young people reporting that they have purchased tobacco products 

from a retailer

► 1.6.e Proportion of youth reporting that they have been unsuccessful in purchasing 

tobacco products from a retailer

► 1.6.f Proportion of youth reporting that they have received tobacco products from a 

social source

► 1.6.g Proportion of young people reporting that they purchased tobacco products from 

a vending machine

► 1.6.h Proportion of young people who believe that it is easy to obtain tobacco 

products

 Outcome 7: Reduced tobacco industry influence

► 1.7.a Extent and type of retail tobacco advertising

► 1.7.b Extent of tobacco industry sponsorship of public and private events

► 1.7.c Extent of tobacco advertising in media

► 1.7.d Extent of tobacco in movies

► 1.7.eNR Extent of pro-tobacco Internet presence

► 1.7.f Amount and quality of news media stories about tobacco industry practices and 

political lobbying

► 1.7.gNR Extent of industry-sponsored tobacco use prevention activities

► 1.7.h Amount of tobacco industry contributions to institutions and groups

► 1.7.i Amount of tobacco industry campaign contributions to local and state 

politicians

 Outcome 8: Increased price of tobacco products

► 1.8.a Amount of tobacco product taxes and fees

► 1.8.b Price paid for tobacco products

► 1.8.c Extent and type of consumer-focused industry promotions

► 1.8.d Extent and type of merchant-focused industry promotions
CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

25

Long-term Outcomes 

 Outcome 9: Reduced initiation of tobacco use 

► 1.9.a Average age at which young people first smoked a whole cigarette 

► 1.9.b Average age at which young people first tried a commercial tobacco product 

other than cigarettes 

► 1.9.c Proportion of young people who report never having tried a tobacco product 

 Outcome 10: Reduced tobacco-use prevalence among young people 

► 1.10.a Prevalence of tobacco use among young people 

► 1.10.b Proportion of established young tobacco users 

► 1.10.c Type and brand preferences of young tobacco users 

► 1.10.d Proportion of poly-tobacco product use among young people 

► 1.10.e Level of tobacco use among young people 

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

The table below summarizes changes made to Goal 1 indicators since KOI 2005. As shown, we 

deleted 14 KOI 2005 indicators, revised the titles of 29 KOI 2005 indicators, and added 23 new 

indicators. Indicator deletions were based on changes in policy and the evidence base that made a 

subset of the previous indicators obsolete or unwarranted. For example, indicator 1.6.3 

“Proportion of students who would ever wear or use something with a tobacco company name or 

picture” was deleted because provisions of the 2009 Tobacco Control Act banned all nontobacco promotional items with tobacco company names or pictures. 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 control programs.

2014 Revised and 2005 KOI Goal 1 Indicators Crosswalk 

Revised Indicator Number Original KOI Number Revised Title

Outcome 1 

1.1.a 1.6.1

1.1.b 1.6.2

Deleted 1.6.3

1.1.c 1.6.4 

Deleted 1.6.5

Deleted 1.6.6

1.1.d 1.6.7 

1.1.e 1.6.8 

1.1.f New
GOAL AREA 1

26 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Revised Indicator Number Original KOI Number Revised Title

Outcome 2 

1.2.a 1.7.1 

1.2.b 1.7.2 

Deleted 1.7.3

Deleted 1.7.4

Deleted 1.7.5

Deleted 1.7.6

Deleted 1.7.7

1.2.c 1.7.8 

1.2.d 1.7.9 

1.2.e 1.7.10 

Deleted 1.7.11

Outcome 3 

1.3.a New

1.3.b 1.8.2 

1.3.c 1.8.3 

1.3.d 1.8.1 

Deleted 1.8.4

Deleted 1.8.5

1.3.e 1.8.6 

1.3.f New

1.3.g 2.4.1 

1.3.h 1.8.7 

Outcome 4 

1.4.a 1.9.2 

Deleted 1.9.3

1.4.b New

Deleted 1.9.4

1.4.c New

1.4.d New

1.4.e New

1.4.f 1.9.6 

1.4.g New

1.4.h 1.9.10
CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

27

Revised Indicator Number Original KOI Number Revised Title

Deleted 1.9.7

Outcome 5 

1.5.a 1.10.1 

1.5.b 1.10.2 

Deleted 1.10.4

1.5.cNR New

1.5.dNR New

1.5.e New

1.5.f 1.10.5 

Outcome 6 

1.6.a New

1.6.b New

1.6.c 1.11.1

1.6.d 1.11.2 

1.6.e 1.11.3

1.6.f 1.11.4 

1.6.g 1.11.5 

1.6.h 1.11.6

Outcome 7 

1.7.a 1.9.1 

1.7.b 1.9.5

1.7.cNR 1.9.8 

1.7.d New

1.7.eNR New

1.7.f 1.9.9

1.7.gNR New

1.7.h 1.9.11

1.7.i 1.9.12

Outcome 8 

1.8.a 1.12.1 

1.8.b New

1.8.c New

1.8.d New
GOAL AREA 1

28 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Revised Indicator Number Original KOI Number Revised Title

Outcome 9

1.9.a 1.13.1

1.9.b New

1.9.c 1.13.2 

Outcome 10

1.10.a 1.14.1

1.10.b 1.14.2 

1.10.c New

1.10.d New

1.10.e New

NR Denotes an indicator that is not rated (see Appendix C for an explanation). 
GOAL AREA 1

► Outcome 1 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

29

Outcome 1 

Increased Knowledge of the Dangers of Tobacco Use, Attitudes Against 

Tobacco Use, and Support for Policies to Reduce Tobacco Use Initiation

The theory of change (rationale for expected linkages between outcomes) associated with 

preventing people from starting to use tobacco has been shown to begin with increasing 

knowledge of the dangers of tobacco use, changing attitudes toward tobacco use, changing 

attitudes about tobacco industry practices, and increasing public support for effective policies 

and practices that reduce the likelihood that people will use tobacco. The tobacco industry 

spends almost $8.8 billion per year on marketing smokeless tobacco and cigarettes.1,2

Adolescents are bombarded with pro-tobacco messages in and around retail stores, in magazines, 

in movies, and by having people smoke in their presence. Evidence shows that anti-tobacco 

media campaigns, either in combination with other interventions or by themselves, are effective 

in reducing smoking by adolescents.3 For example, the “truth” anti-tobacco media campaign in 

Florida achieved nearly 93% confirmed awareness of the message among young people and was 

associated with improved anti-tobacco attitudes.4 After 1 year, both susceptibility to smoking and 

cigarette use declined more among Florida’s young people than among young people in the rest 

of the nation. Furthermore, the national truth® campaign was responsible for approximately 22% 

of the decline in youth smoking from 2000 to 2002.5-7 

In addition to changing people’s attitudes toward tobacco use, evidence demonstrates that 

increasing public support for implementing and enforcing tobacco control policies reduces the 

likelihood that people will begin smoking. Such policies include passing and enforcing strong 

laws that decrease access to tobacco products and exposure to advertising, and implementing 

comprehensive tobacco-free school and college campus policies. Policies such as these create an 

environment that supports tobacco-free communities. 

The following indicators are associated with this outcome: 

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

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

► 1.1.c Level of support for policies, and for enforcement of policies, to decrease 

availability of tobacco to young people 

► 1.1.d Level of support for creating comprehensive tobacco-free policies in schools and on 

college and university campuses 

► 1.1.e Proportion of young people who think that the tobacco companies try to get young 

people to use tobacco products 

► 1.1.f Level of perceived harm of traditional, non-traditional, and emerging tobacco 

products among young people 

References

1. Federal Trade Commission. Smokeless tobacco report for 2011. Washington, DC: Federal 

Trade Commission; 2013.
GOAL AREA 1

► Outcome 1

30 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

2. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade 

Commission; 2013.

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

year results, and implications for planning future state media evaluations. Tobacco Control. 

2001;10(1):9–15.

5. Farrelly MC, Davis KC, Haviland ML, Messeri P, Healton CG. Evidence of a dose–response 

relationship between “truth” antismoking ads and youth smoking prevalence. American 

Journal of Public Health. 2005;95(3):425–31.

6. Davis KC, Nonnemaker JM, Farrelly MC. Association between national smoking prevention 

campaigns and perceived smoking prevalence among youth in the United States. Journal of 

Adolescent Health. 2007 Nov;41(5):430–6.

7. Farrelly MC, Davis KC, Duke J, Messeri P. Sustaining ‘truth’: changes in youth tobacco 

attitudes and smoking intentions after 3 years of a national antismoking campaign. Health 

Education Research. 2009 Feb;24(1):42–8.

For Further Reading

American Nonsmokers’ Rights Foundation. U.S. Colleges and Universities with Smokefree Air 

Policies, 2012. Available at: http://www.no-smoke.org/pdf/ smokefreecollegesuniversities.pdf. 

Accessed March 23, 2012.

Barnett TA, Gauvin L, Lambert M, O’Loughlin J, Paradis G, McGrath JJ. The influence of 

school smoking policies on student tobacco use. Archives of Pediatrics & Adolescent Medicine. 

2007;161(9):842–8.

Centers for Disease Control and Prevention. Effectiveness of school-based programs as a 

component of a statewide tobacco control initiative. Morbidity and Mortality Weekly Report. 

2001;50(31):663–6.

Czart C, Pacula RL, Chaloupka FJ, Wechsler H. The impact of prices and control policies on 

cigarette smoking among college students. Contemporary Economic Policy. 2001;119(2):135–

49.

DiFranza JR. Which interventions against the sale of tobacco for minors can be expected to 

reduce smoking? Tobacco Control. 2012;21(4):436–42. doi:10.1136/tobaccocontrol-2011-

050145

DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor of 

daily smoking among adolescents: a national study. BMC Public Health. 2009;9:107.

Jones SE, Alexrad R, Wattigney WA. Healthy and safe school environment, part II, physical 

school environment: results from the School Health Policies and Programs Study 2006. Journal 

of School Health. 2007;77(8):544–56.
GOAL AREA 1

► Outcome 1

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

31

National Cancer Institute. Changing adolescent smoking prevalence: where it is and why.

Smoking and Tobacco Control Monograph No. 14. NIH Publication No. 02-5086. Bethesda, 

MD: U.S. Department of Health and Human Services, National Institutes of Health, National 

Cancer Institute; 2001.

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.

Thomas RE, Baker PRA, Lorenzetti D. Family-based programmes for preventing smoking by 

children and adolescents. Cochrane Database of Systematic Reviews. 2007 Jan 

24;(1):CD004493. doi:10.1002/14651858.CD004493.pub2

Thomas RE, Perera R. School-based programmes for preventing smoking. Cochrane Database 

of Systematic Reviews. 2006 Jul 19;(3):CD001293. doi:10.1002/14651858.CD001293.pub2
GOAL AREA 1

► Outcome 1 

32 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Outcome 1 

Increased Knowledge of the Dangers of Tobacco Use, Attitudes Against 

Tobacco Use, and Support for Policies to Reduce Tobacco Use Initiation 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.1.a Level of awareness of anti-tobacco 

media messages

$$

1.1.b Level of receptivity to anti-tobacco 

media messages

$$

1.1.c Level of support for policies, and 

for enforcement of policies, to 

decrease availability of tobacco to 

young people

†† $$

1.1.d Level of support for creating 

comprehensive tobacco-free 

policies in schools and on college 

and university campuses

$$

1.1.e Proportion of young people who 

think that the tobacco companies 

try to get young people to use 

tobacco products

$$

1.1.f Level of perceived harm of 

traditional, non-traditional, and 

emerging tobacco products among 

young people

$$

$ 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 fewer than 75% of valid ratings within ±2 points of the 

median for overall quality of the indicator. 
GOAL AREA 1

► Outcome 1 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

33

Indicator 1.1.a

Level of Awareness of Anti-tobacco Media Messages 

KOI 2005 1.6.1

Goal area Preventing initiation of tobacco use

Outcome box Increased knowledge of the dangers of tobacco use, attitudes against tobacco use, and 

support for policies to reduce tobacco use initiation

What to measure Proportion of the target population that can accurately recall a media message

Why this indicator is 

useful

Evaluating recall of messages is critical to understanding the behavioral effects of antitobacco advertising on target populations and should be used to guide health 

communication planning.

1

Example data 

source(s)

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

Campaign, Follow-up Questionnaire

New York State Adult Tobacco Survey, 2011 and 2013

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

Unaided Awareness:

From New York State Adult Tobacco Survey, 2013 “Are you aware of any 

advertising or campaigns against smoking that is are now taking place?” Follow up: 

“What is the theme or slogan of this advertising or campaign?”

Aided Awareness:

From CDC 2012 Tips From Former Smokers Campaign, Follow-up Questionnaire

(Online survey)

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

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

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

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

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

1. Yes

2. No?

If yes:

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

Sometimes, Often, Very Often)

Confirmed Awareness:

From New York State Adult Tobacco Survey, 2011 (telephone survey)2

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

here]?”

“What happens in this ad?”
GOAL AREA 1

► Outcome 1 

34 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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

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

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

research literature. Unaided recall items provide little or no cues about the content of an 

ad and require the respondent to recall the details of an ad from memory. Aided recall 

items consist of an interviewer providing respondents with a verbal description of an 

advertisement’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 if they recognize the advertisement. Confirmed awareness items include a brief 

description of an advertisement with a request of the respondent to provide additional 

details about the ad.

Aided recall helps determine specific campaign and ad awareness or exposure, 2 whereas 

unaided recall allows for tracking which campaign messages are most prominent in the 

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

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

utility of confirmed awareness items compared to aided recall measures, and given the 

extra respondent and interviewer burden in asking open-ended confirmed awareness 

items, aided awareness measures may be preferable.3 The mode of survey administration 

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

surveys allows advertisements and other materials (Web site banner ads, TV ads, etc.) to 

be shown directly to survey participants, rather than relying on crude interviewer 

descriptions of advertisements as in telephone interviews. Examples of each type of 

measure are included in “Example Survey Question(s)” above.

Programs may want to evaluate recall of an advertisement by respondents’ smoking 

status (current, former, or never), demographics, and tobacco use characteristics.

Additionally, frequency of exposure should be measured to allow greater variation and 

provide for dose-response analyses.

Evaluators should work closely with countermarketing 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.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

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

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

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

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

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

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

national campaign. Journal of Health Communication. 2002;7:445–53.

4. Niederdeppe JD. Assessing the validity of confirmed AD recall measures for public health communication 

campaign evaluation. Journal of Health Communication. 2005;10(7):635–50. doi:W077210046987366 [pii]; 

10.1080/10810730500267662 
GOAL AREA 1

► Outcome 1

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

35

For Further Reading

Baker TB, Breslau N, Covey L, Shiffman S. DSM criteria for tobacco use disorder and tobacco withdrawal: a 

critique and proposed revisions for DSM-5. Addiction. 2012:107(2):263–75.

Davis KC, Nonnemaker JM, Farrelly MC. Association between national smoking prevention campaigns and 

perceived smoking prevalence among youth in the United States. Journal of Adolescent Health. 2007;41(5):430–6.

Farrelly MC, Davis KC, Duke J, Messeri P. Sustaining ‘truth’: changes in youth tobacco attitudes and smoking 

intentions after 3 years of a national antismoking campaign. Health Education Research. 2009;24(1):42–8.

Richardson AK, Green M, Xiao H, Sokol N, Vallone D. Evidence for truth®: the young adult response to a youthfocused anti-smoking media campaign. American Journal of Preventive Medicine. 2010 Dec;39(6):500–6.

Terry-McElrath YM, Wakefield MA, Emery S, Saffer H, Szczypka G, O’Malley PM, et al. State anti-tobacco 

advertising and smoking outcomes by gender and race/ethnicity. Ethnicity and Health. 2007;12(4):339–62.

Thrasher JF, Niederdeppe JD, Jackson C, Farrelly MC. Using anti-tobacco industry messages to prevent smoking 

among high-risk adolescents. Health Education Research. 2006;21(3):325–33.

Southwell BG, Langteau R. Age, memory changes, and the varying utility of recognition as a media effects 

pathway. Communication Methods and Measures. 2008;2(1–2), 100–114.
GOAL AREA 1

► Outcome 1 

36 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.1.b

Level of Receptivity to Anti-tobacco Media Messages 

KOI 2005 1.6.2

Goal area Preventing initiation of tobacco use

Outcome box Increased knowledge of the dangers of tobacco use, attitudes against tobacco use, and 

support for policies to reduce tobacco use initiation

What to measure Level of receptivity to media messages by the intended audience. In tobacco control, 

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

them think about their behavior, and stimulated discussion with others.1

Why this indicator is 

useful

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

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

intended audience.

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

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

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

growing literature has established that measures of media message receptivity predict 

changes in attitudes about the topic.

8 One study has found that receptivity to antitobacco messages was a significant predictor of lower rates of intention to smoke.9

Example data 

source(s)

Legacy Media Tracking Survey (LMTS), 2004

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From LMTS

Tell me how much you agree or disagree with the following statement: This ad is 

convincing. Would you say you:

Strongly agree Agree Disagree

Strongly disagree Have no opinion Don’t know

“On a scale from 1 to 5, where 1 means you don’t like this ad at all and 5 means you like 

the young adult ad very much, how much do you like this ad?”

One Two Three Four Five

Would you say the ad gave you good reasons not to smoke?

Yes No Don’t know

Did you talk to your friends about this ad?

Yes No Don’t know

From evaluation of national truth® campaign10

Perceived Evaluative Effectiveness Scale (reliability = 0.94)

• These ads are worth remembering.

• These ads grabbed my attention.

• These ads are powerful.

• These ads are informative.

• These ads are meaningful to me.

• These ads are convincing.
GOAL AREA 1

► Outcome 1 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

37

Comments Evaluators may want to assess receptivity to messages transmitted through various 

channels (e.g., social media, television, print, radio, or retail warning signs). See Davis 

et al. (2011) in “Further Reading” for guidance on measuring perceived effectiveness of 

media messages.

Evaluators should work closely with countermarketing 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.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

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

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

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

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

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

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

National Academies Press; 2007. 

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

Medicine. 1984;13(3):299–319. 

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

6. Maibach E, Parrott RL, editors. Designing health messages: approaches from communication theory and public 

health practice. Thousand Oaks, CA: Sage; 1995. 

7 Terry-McElrath Y, Wakefield M, Ruel E, Balch GI, Emery S, Szczypka G, et al. The effect of antismoking 

advertisement executional characteristics on youth comprehension, appraisal, recall, and engagement. Journal 

of Health Communication. 2005; 10(2):127–43.

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

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

2007;57(4):613–31. 

9. Straub DM, Hills NK, Thompson PJ, Moscicki AB. Effects of pro- and anti-tobacco advertising on nonsmoking 

adolescents’ intentions to smoke. Journal of Adolescent Health. 2003;32(1):36–43. 

10. Farrelly MC, Nonnemaker JM, Davis KC. The influence of the national truth® campaign on smoking initiation. 

American Journal of Preventive Medicine. 2009;36(5):379–84.

For Further Reading 

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

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

► Outcome 1 

38 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.1.c

Level of Support for Policies, and for Enforcement of Policies, to Decrease 

Availability of Tobacco to Young People 

KOI 2005 1.6.4 Revised Title (Previously: “Level of support for policies, and enforcement of 

policies, to decrease young people’s access to tobacco”)

Goal area Preventing initiation of tobacco use

Outcome box Increased knowledge of the dangers of tobacco use, attitudes against tobacco use, and 

support for policies to reduce tobacco use initiation

What to measure Proportion of adults who support policies and enforcement of policies to decrease the 

availability of tobacco products to young people

Why this indicator is 

useful

Tobacco-free policies are unlikely to be adopted without support from policy makers 

and the general public.1-4 Prematurely advancing a policy without sufficient support may 

result in its initial defeat and make it more difficult to address the issue in the future.5In 

California, for example, public support for retail tobacco sales licensing policies has 

grown since 1990, and this has contributed to the passage of local tobacco licensing 

ordinances in several jurisdictions.6

Example data 

source(s)

California Adult Tobacco Survey (CATS), 2008

Information available at: 

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPCaliforniaAdultTobaccoSu

rvey2008.pdf

Mississippi 2011 Social Climate Survey of Tobacco Control

Information available at: http://surveillance.mstobaccodata.org/mississippi-tobaccocontrol-data/social-climate-of-tobacco-adult-survey/

Population group(s) Decision makers, opinion leaders, and/or the general public aged 18 years or older 

Example survey 

question(s)

From CATS

Please tell me whether you agree or disagree with the following. Store owners should 

need a license to sell cigarettes (just like alcoholic beverages).

From MS Social Climate Survey

In pharmacies and drug stores, should the sale of tobacco products be:

Allowed Allowed, but only if the products are hidden from view

Not allowed at all Don’t know/not sure Refused 

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

availability of tobacco products by respondents’ tobacco use status.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

► Outcome 1

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

39

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, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000.

2. U.S. Department of Health and Human Services. Women and smoking: a report of the Surgeon General.

Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon 

General; 2001.

3. Thomson GW, Wilson N. Public attitudes about tobacco smoke in workplaces: the importance of workers’

rights in survey questions. Tobacco Control. 2004;13(2):206–7.

4. Howard KA, Rogers T, Howard-Pitney B, Flora JA, Norman GJ, Ribisl KM. Opinion leaders’ support for 

tobacco control policies and participation in tobacco control activities. American Journal of Public Health. 

2000;90(8):1283–7.

5. National Cancer Institute. ASSIST: shaping the future of tobacco prevention and control. Tobacco Control 

Monograph No. 16. NIH Publication No. 05-5645. Bethesda, MD: U.S. Department of Health and Human 

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

6. Gilpin EA, Emery SL, Farkas AJ, Distefan JM, White MM, Pierce JP. The California Tobacco Control 

Program: a decade of progress, results from the California tobacco surveys, 1990–1998. La Jolla, CA: 

University of California, San Diego; 2001. Available at: http://repositories.cdlib.org/tc/surveys/CTS1999/. 

Accessed December 2004.
GOAL AREA 1

► Outcome 1 

40 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.1.d 

Level of Support for Creating Comprehensive Tobacco-Free Policies in 

Schools and on College and University Campuses

KOI 2005 1.6.7 Revised Title (Previously: “Level of support for creating policies in schools”)

Goal area Preventing initiation of tobacco use

Outcome box Increased knowledge of the dangers of tobacco use, attitudes against tobacco use, and 

support for policies to reduce tobacco use initiation

What to measure Proportion of the population that supports creating and actively enforcing 

comprehensive tobacco-free policies in schools and on college and university campuses. 

Comprehensive policies (a) prohibit anyone from using any type of tobacco product at 

all times on school or university grounds, at all school-sponsored functions, and in 

school vehicles; (b) ban all tobacco industry marketing, sponsorship, and recruitment 

efforts; (c) call for divestiture of all tobacco company stocks or holdings; and (d) 

provide cessation services/resources for students, faculty, and staff.

Why this indicator is 

useful

Young people’s attitudes about the acceptability of tobacco use are influenced by what 

they see their peers and adult role models doing at school. Although tobacco is 

increasingly banned in primary and secondary school settings, students are often 

exposed in post-secondary settings including technical schools and college campuses,

which may still allow for the sale, advertisement, and promotion of tobacco products in 

school owned and leased properties as well as during school-sponsored events.1 Strong 

school anti-tobacco policies require the support of parents, teachers, administrators, 

policy makers, and the general public.2

Example data 

source(s)

State Adult Tobacco Survey (ATS): Questions Recommended for Specific Purposes, 

Section F: Policy Issues, 2009

Information available at: http://apps.nccd.cdc.gov/QIT/QuickSearch.aspx

Behavioral Risk Factor Surveillance System (BRFSS), Tobacco Use Prevention Module, 

2000

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

California Tobacco Survey (CTS), 1999

Information available at: http://libraries.ucsd.edu/locations/sshl/data-gov-infogis/ssds/guides/tobacco-surveys.html

California Tobacco Survey (CTS), 2005

Information available at: http://libraries.ucsd.edu/locations/sshl/data-gov-infogis/ssds/guides/tobacco-surveys.html

Population group(s) Decision makers, opinion leaders, and/or the general public

Example survey 

question(s)

From ATS

How strongly do you agree or disagree with the following statement: Tobacco use by 

adults should not be allowed on school grounds or at any school events.

Strongly agree Agree Disagree

Strongly disagree No opinion/Don’t know Refused

From BRFSS

In schools, do you think that smoking should be allowed in all areas, some areas, or not 

allowed at all?

All areas Some areas

Not allowed Don’t know/Not sure Refused
GOAL AREA 1

► Outcome 1 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

41

From CTS

Do you think schools should prohibit students from wearing clothing or bringing gear 

with tobacco brand logos to school?

Yes No Refused Don’t know

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:

Allowed Not allowed Refused Don’t know

Comments Evaluators should determine the scope of policies before evaluating the 

presence/absence and reach of such policies. See the American College Health 

Association Position Statement on Tobacco on College and University Campuses for 

suggested policies and actions colleges and universities may take:

http://www.acha.org/Publications/docs/Position_Statement_on_Tobacco_Nov2011.pdf

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

schools based on the respondent’s tobacco use status. 

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

1. American College Health Association. Position Statement on Tobacco on College and University Campuses. 

November 2011. Available at: 

http://www.acha.org/Publications/docs/Position_Statement_on_Tobacco_Nov2011.pdf. Accessed January 26, 

2012.

2. Trinidad DR, Gilpin EA, Pierce JP. Compliance and support for smoke-free school policies. Health Education 

Research. 2005;20(4):466–75. 

For Further Reading 

Lovato CY, Zeisser C, Campbell HS, Watts AW, Halpin P, Thompson M, et al. Adolescent smoking: effect of 

school and community characteristics. American Journal of Preventive Medicine, 2010 Dec; 39(6):507–14.

Rigotti NA, Regan S, Moran SE, Wechsler H. Students’ opinion of tobacco control policies recommended for US 

colleges: a national survey. Tobacco Control. 2003 Sep;12(3):251–6.

The BACCHUS Network. Certification for Tobacco-Free Campus Policy. 2012. Available at: 

http://www.tobaccofreeu.org/policy/documents/DiamondAwardBooklet.pdf. Accessed March 22, 2012. 

Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Ruel EE. Effect of restrictions on smoking at 

home, at school, and in public places on teenage smoking: cross sectional study. British Medical Journal. 2000 Aug 

5;321(7257):333–7.
GOAL AREA 1

► Outcome 1 

42 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.1.e 

Proportion of Young People Who Think that the Tobacco Companies Try to 

Get Young People to Use Tobacco Products

KOI 2005 1.6.8 Revised Title (Previously: “Proportion of young people who think that the 

cigarette companies try to get young people to smoke”)

Goal area Preventing initiation of tobacco use

Outcome box Increased knowledge of the dangers of tobacco use, attitudes against tobacco use, and 

support for policies to reduce tobacco use initiation

What to measure Proportion of young people who believe that tobacco companies try to get young people 

to start or continue using tobacco products

Why this indicator is 

useful

If young people are aware of the tobacco industry’s attempts to persuade them to start 

smoking, they may become less susceptible to the tobacco industry’s marketing tactics.1

Additionally, focusing on the deceitful practices of the tobacco industry may also deter 

tobacco use, an effect that appears to be sustained over time and results in lowered 

intentions to start smoking.2-4

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

California Student Tobacco Survey (CSTS), 2011–2012

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years 

Example survey 

question(s)

From NYTS

Do you believe that tobacco companies try to get young people under 18 to use tobacco 

products?

Yes No

From CSTS

Tobacco companies try to get young people to start smoking by using advertisements 

that are attractive to young people.

Definitely yes Probably yes Probably not Definitely not

Comments None noted

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

1. Evans N, Farkas A, Gilpin E, Berry C, Pierce JP. Influence of tobacco marketing and exposure to smokers on 

adolescent susceptibility to smoking. Journal of the National Cancer Institute. 1995;87(20):1538–45.

2. Hersey JC, Niederdeppe J, Ng SW, Mowery P, Farrelly M, Messeri P. How state counter-industry campaigns 

help prime perceptions of tobacco industry practices to promote reductions in youth smoking. Tobacco Control. 

2005;14(6):377–83.
GOAL AREA 1

► Outcome 1

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

43

3. Thrasher JF, Jackson C. Mistrusting companies, mistrusting the tobacco industry: clarifying the context of 

tobacco prevention efforts that focus on the tobacco industry. Journal of Health and Social Behavior. 2006 

Dec;47(4):406–22.

4. Farrelly MC, Davis KC, Duke J, Messeri P. Sustaining ‘truth’: changes in youth tobacco attitudes and smoking 

intentions after 3 years of a national antismoking campaign. Health Education Research. 2009;24(1):42–8.

For Further Reading

Ling PM, Neilands TB, Glantz SA. The effect of support for action against the tobacco industry on smoking among 

young adults. American Journal of Public Health. 2007 Aug;97(8):1449–56.

Ling PM, Neilands TB, Glantz SA. Young adult smoking behavior: a national survey. American Journal of 

Preventive Medicine. 2009 May;36(5):389–94.e2.
GOAL AREA 1

► Outcome 1 

44 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.1.f 

Level of Perceived Harm of Traditional, Non-Traditional, and Emerging 

Tobacco Products Among Young People

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased knowledge of the dangers of tobacco use, attitudes against tobacco use, and 

support for policies to reduce tobacco use initiation

What to measure Young people’s perceived direct and comparative harms of traditional, non-traditional,

and emerging tobacco products. See “Comments” below for clarification of 

nontraditional and emerging tobacco products.

Why this indicator is 

useful

Evidence suggests that young people’s belief in harm from tobacco products is 

associated with lower smoking frequency.1,2 The tobacco industry is increasingly 

introducing new tobacco products, such as smokeless tobacco (e.g., snus), dissolvable 

tobacco (e.g., sticks, strips, and tablets), and electronic cigarettes,3that may in fact be 

“safer” than traditional tobacco products, but contain nicotine and tobacco and are 

therefore addictive and not without harm. Research on risk perceptions of young adult 

smokers related to use of tobacco products has found that new products are generally 

perceived as safer than cigarettes.4 Research on the safety of new and emerging products 

in relation to cigarettes is only emerging; however, it is important that the public’s 

perceptions of all tobacco products be monitored and corrected through education as 

research emerges.

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: 2000 

Information available at:

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Youth Tobacco Survey (NYTS), 2006

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

National Youth Tobacco Survey (NYTS), 2009

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

National Survey on Drug Use and Health (NSDUH), 2009

Information available at: http://www.samhsa.gov/data/NSDUH.aspx

International Tobacco Control Survey (ITC), 2009

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

Minnesota Adult Tobacco Survey (MATS), 2007

Information available at: http://www.mntobacco.nonprofitoffice.com/

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years
GOAL AREA 1

► Outcome 1 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

45

Example survey 

question(s)

From NYTS

Do you think it is safe to smoke for only a year or two, as long as you quit after that?

Definitely yes Probably yes Probably not Definitely not

Do you think people risk harming themselves if they smoke one or more packs of 

cigarettes per day?

Definitely yes Probably yes Probably not Definitely not

From NSDUH

How much do you think people risk harming themselves physically and in other ways if 

they do the following? Smoke one or more packs of cigarettes per day?

No risk Slight risk Moderate risk Great risk Don’t know/Refused

From ITC

As far as you know, are ANY smokeless tobacco products less harmful than ordinary 

cigarettes?

Yes No Not applicable Refused Don’t know

Thinking about different types of tobacco products that are smoked—that is, factorymade cigarettes, roll-your-own, pipes, and cigars—are SOME of these less harmful than 

others or are they equally harmful?

Don’t know Not applicable Refused Don’t know

All kinds are equally harmful Some kinds are more harmful than others

From MATS

In your opinion, are any of the following products less harmful, more harmful, or just as 

harmful as smoking cigarettes? Smokeless tobacco such as snuff and chewing tobacco?

More Less Don’t know Refused Just as harmful

Comments Nontraditional and emerging tobacco products include all tobacco or nicotine-containing 

products that are not nicotine replacement therapies (NRTs). These include products 

such as dissolvable tobacco products, snus, and e-cigarettes.

In order for the example survey questions above to be useful, evaluators need to analyze 

how inaccurate perceptions are compared with actual harm. The example items from 

NYTS and NSDUH measure perceived direct harm, whereas the example items from 

ITC and MATS measure perceived comparative harm.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

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

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

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

on Smoking and Health; 2012. 

2. Rodriguez D, Romer D, Audrain-McGovern J. Beliefs about the risks of smoking mediate the relationship 

between exposure to smoking and smoking. Psychosomatic Medicine. 2007;69(1):106–13. 

3. Carpenter CM, Connolly GN, Ayo-Yusuf OA, Wayne GF. Developing smokeless tobacco products for 

smokers: an examination of tobacco industry documents. Tobacco Control. 2009 Feb;18(1):54–9.

4. Richter PA, Pederson LL, O’Hegarty MM. Young adult smoker risk perceptions of traditional cigarettes and 

nontraditional tobacco products. American Journal of Health Behavior. 2006;30(3):302–12. 
GOAL AREA 1

► Outcome 1 

46 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

For Further Reading 

Mejia AB, Ling PM. Tobacco industry consumer research on smokeless tobacco users and product development. 

American Journal of Public Health. 2010;100(1):78–87.
GOAL AREA 1

► Outcome 2 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

47

Outcome 2 

Increased Restriction of Tobacco Use and Enforcement of Anti-tobacco 

Policies and Programs in Schools and on College/University Campuses 

School-based prevention programs and policies, when combined with a comprehensive approach 

to prevention efforts including family, mass media, and community programs, can be effective at 

preventing and reducing tobacco use.1 School tobacco prevention programs and policies are 

widely applied in the United States today and have been recommended as a component of 

comprehensive tobacco prevention programs. In 1994, CDC provided guidelines for school 

health programs to prevent tobacco use and addiction.2 These guidelines include 

recommendations on policies, curricula and instruction, teacher training, parental involvement, 

tobacco-use cessation, and evaluation. 

Research has shown that school tobacco-free policies need to be enforced and take a proactive 

approach to implementation, rather than a punitive one, in order to be effective.1 Smoke-free 

policies in post-secondary educational institutions have also increased rapidly over the past 

decade. As of April 2013, at least 1,159 college and university campuses were 100% smoke-free 

with no exemptions in the United States.3 The American College Health Association encourages 

its members to implement 100% indoor and outdoor campus-wide tobacco-free environments to 

reduce health risks related to tobacco use.4 Although little research has examined the 

effectiveness of policy changes to promote tobacco-free campuses in colleges and universities, 

evidence from community- and state-level comprehensive tobacco control programs that use a 

socioecological approach to address multiple factors has shown that such policies, combined 

with education and cessation programs, decrease tobacco use prevalence.5, 6 

Evidence shows that school-based prevention programs that are comprehensive, interactive, and 

sustained; begin early in the students’ school career; incorporate an appropriate number of 

lessons; and are integrated into a community-wide approach can be effective at preventing or 

reducing tobacco use among students.1 The Surgeon General’s Report on preventing tobacco use 

among youth and young adults states that “Evidence is sufficient to conclude that school-based 

programs with evidence of effectiveness, containing specific components, can produce at least 

short-term effects and reduce the prevalence of tobacco use among school-aged youth” (p. 812).1

The following indicators are associated with this outcome: 

► 1.2.a Proportion of schools or colleges/universities implementing 100% tobacco-free 

policies

► 1.2.b Proportion of schools or school districts that provide tobacco-use prevention that 

meets CDC guidelines 

► 1.2.c Proportion of young people who participate in tobacco-use prevention activities 

► 1.2.d Level of reported exposure to school-based tobacco-use prevention that meets CDC 

guidelines 

► 1.2.e Perceived compliance with tobacco-free policies in schools and on college/ 

university campuses 
GOAL AREA 1

► Outcome 2

48 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012.

2. Centers for Disease Control and Prevention. Registries of Programs Effective in Reducing 

Youth Risk Behaviors. 2009. Available at: 

http://www.cdc.gov/HealthyYouth/AdolescentHealth/registries.htm.

3. American Nonsmokers’ Rights Foundation. U.S. Colleges and Universities with Smokefree

and Tobaco-Free Air Policies, April 5 2013. 2013. Available at: http://www.nosmoke.org/pdf/smokefreecollegesuniversities.pdf.

4. American College Health Association. Position statement on tobacco on college and 

university campuses. Journal of American College Health. 2012;60(3):266–7.

5. Rodgers KC. A review of multicomponent interventions to prevent and control tobacco use 

among college students. Journal of American College Health. 2012;60(3):257–61.

6. Centers for Disease Control and Prevention. Guidelines for school health programs to 

prevent tobacco use and addiction. MMWR Recommendations and Reports. 1994 Feb 

25;43(RR-2):1–18.

For Further Reading

Adams ML, Jason LA, Pokorny S, Hunt Y. The relationship between school policies and youth 

tobacco use. Journal of School Health. 2009;79(1):17–23.

Barnett TA, Gauvin L, Lambert M, O’Loughlin J, Paradis G, McGrath JJ. The influence of 

school smoking policies on student tobacco use. Archives of Pediatrics & Adolescent Medicine. 

2007;161(9):842–8.

Border TF, Xu KT, Bacchi D, Cohne L, SoRoelle-Miner D. College campus smoking policies 

and programs and students’ smoking behaviors. BMC Public Health. 2005;5:74.

Campbell R, Starkey F, Holliday J, Audrey S, Bloor M, Parry-Langdon N, et al. An informal 

school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster 

randomised trial. Lancet. 2008;371(9624):1595–602.

Chen X, Ren Y, Lin F, MacDonell K, Jiang Y. Exposure to school and community based 

prevention programs and reductions in cigarette smoking among adolescents in the United 

States, 2000–08. Evaluation and Program Planning. 2012;35(3):321–8.

Dobbins M, DeCorby K, Manske S, Goldblatt E. Effective practices for school-based tobacco 

use prevention. Preventive Medicine. 2008;46(4):289–97.

Flay BR. School-based smoking prevention programs with the promise of long-term 

effectiveness. Tobacco Induced Diseases. 2009;5:6.

Hawkins JD, Oesterle S, Brown EC, Monahan KC, Abbott RD, Arthur MW, Catalano RF. 

Sustained decreases in risk exposure and youth problem behaviors after installation of the 

Communities That Care prevention system in a randomized trial. Archives of Pediatrics & 

Adolescent Medicine. 2012;166(2):141–8.
GOAL AREA 1

► Outcome 2

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

49

Institute of Medicine (IOM). Ending the tobacco problem: a blueprint for the nation. 

Washington, DC: The National Academies Press; 2007.

Lovato CY, Sabiston CM, Hadd V, Nykiforuk CI, Campbell HS. The impact of school smoking 

policies and student perceptions of enforcement on school smoking prevalence and location of 

smoking. Health Education Research. 2007;22(6):782–93.

Lovato CY, Zeisser C, Campbell HS, Watts AW, Halpin P, Thompson M, et al. Adolescent 

smoking: effect of school and community characteristics. American Journal of Preventive 

Medicine. 2010 Dec;39(6):507–14.

Murnaghan DA, Leatherdale ST, Sihvonen M, Kekki P. A multilevel analysis examining the 

association between school-based smoking policies, prevention programs and youth smoking 

behavior: evaluating a provincial tobacco control strategy. Health Education Research. 

2008;23(6):1016–28.

Murnaghan DA, Sihvonen M, Leatherdale ST, Kekki P. The relationship between school-based 

smoking policies and prevention programs on smoking behavior among grade 12 students in 

Prince Edward Island: a multilevel analysis. Preventive Medicine. 2007;44(4):317–22.

National Cancer Institute. Changing adolescent smoking prevalence: where it is and why. 

Smoking and Tobacco Control Monograph No. 14. NIH Publication No. 02-5086. Bethesda, 

MD: U.S. Department of Health and Human Services, National Institutes of Health, National 

Cancer Institute; 2001.

Plaspohl SS, Parrillo AV, Vogel R, Tedders S, Epstein A. An assessment of America’s tobaccofree colleges and universities. Journal of American College Health. 2012;60(2):162–7.

Prokhorov AV, Kelder SH, Shegog R, Murray N, Peters R Jr, Agurcia-Parker C, et al. Impact of 

A Smoking Prevention Interactive Experience (ASPIRE), an interactive, multimedia smoking 

prevention and cessation curriculum for culturally diverse high-school students. Nicotine & 

Tobacco Research. 2008;10(9):1477–85.

Ribisl KM, Steckler A, Linnan L, Patterson CC, Pevzner ES, Markatos E, et al. North Carolina 

Youth Empowerment Study. The North Carolina Youth Empowerment Study (NCYES): a 

participatory research study examining the impact of youth empowerment for tobacco use 

prevention. Health Education & Behavior. 2004;31(5):597–614.

Thomas RE, Perera R. School-based programmes for preventing smoking. Cochrane Database 

of Systematic Reviews. 2006 July 19;(3):CD001293. doi:10.1002/14651858.CD001293.pub2

Trinidad DR, Gilpin EA, Pierce JP. Compliance and support for smoke-free school policies. 

Health Education Research. 2005;20(4):466–75.

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.

University of Colorado at Boulder. Program Matrix, 2010. Available at: 

http://www.colorado.edu/cspv/blueprints/matrixfiles/matrix.pdf.

Winkleby MA, Feighery E, Dunn M, Kole S, Ahn D, Killen JD. Effects of an advocacy 

intervention to reduce smoking among teenagers. Archives of Pediatrics & Adolescent Medicine. 

2004;158(3):269–75.
GOAL AREA 1

► Outcome 2

50 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Outcome 2 

Increased Restriction of Tobacco Use and Enforcement of Anti-tobacco 

Policies and Programs in Schools and on College/University Campuses 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.2.a Proportion of schools or colleges/

universities implementing 100% 

tobacco-free policies

$$$

1.2.b Proportion of schools or school 

districts that provide tobacco-use 

prevention that meets CDC 

guidelines

$$

1.2.c Proportion of young people who 

participate in tobacco-use 

prevention activities

$$

1.2.d Level of reported exposure to 

school-based tobacco-use 

prevention that meets CDC 

guidelines

$$$

1.2.e Perceived compliance with 

tobacco-free policies in schools and 

on college/university campuses

†† $$

$ 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 fewer than 75% of valid ratings being within ±2 points of the 

median for overall quality of the indicator. 
GOAL AREA 1

► Outcome 2 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

51

Indicator 1.2.a

Proportion of Schools or Colleges/Universities Implementing 100% 

Tobacco-free Policies

KOI 2005 1.7.1 Revised Title (Previously: “Proportion of schools or school districts reporting the 

implementation of 100% tobacco-free policies”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction of tobacco use and enforcement of anti-tobacco policies and 

programs in schools and on college/university campuses

What to measure Proportion of schools or colleges/universities that report having a policy that 

(a) prohibits anyone from using any type of tobacco product at all times on school or 

university grounds, at all school-sponsored functions, and in school vehicles; (b) bans all 

tobacco industry marketing, sponsorship, and recruitment efforts, as well as calls for 

divestiture of all tobacco company stocks or holdings; and (c) provides cessation 

services/resources for students, faculty, and staff

Why this indicator is 

useful

Young people’s attitudes toward the acceptability of tobacco use in general are 

influenced by the actions of their peers and educators at school.1,2 Comprehensive 

policies that apply to everyone in all areas of a campus may increase student support and 

compliance and decrease tobacco use among young people.3-6 However, changes in 

tobacco initiation and prevalence are reliant on strong enforcement of school policies. 

Example data 

source(s)

CDC School Health Profiles: School Principal Questionnaire (Profiles), 2010

Information available at: http://www.cdc.gov/healthyyouth/profiles/

American College Health Association (ACHA) College Campus Tobacco Cessation and 

Prevention Survey, 2005

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

Population group(s) School principals

College Health Center Directors

Example survey 

question(s)

From Profiles

Has this school adopted a policy prohibiting tobacco use?

Yes No

Does the tobacco prevention policy specifically prohibit use of each type of tobacco 

product for each of the following groups?

Type of tobacco product Students Faculty/Staff Visitors

Yes No Yes No Yes No

• Cigarettes

• Smokeless tobacco

• Cigars

• Pipes

Does the tobacco prevention policy specifically prohibit use during each of the 

following times for each of the following groups?

Time Students Faculty/Staff Visitors

Yes No Yes No Yes No

• During school hours

• During non-school hours
GOAL AREA 1

► Outcome 2 

52 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Does the tobacco prevention policy specifically prohibit tobacco use in each of the 

following locations for each of the following groups?

Location Students Faculty/Staff Visitors

Yes No Yes No Yes No

• In school buildings

• On school grounds

• In school buses or other vehicles

used to transport students

• At off-campus, schoolsponsored events

Does your school have arrangements with any organizations or health care professionals 

not on school property to provide tobacco cessation services for each of the following 

groups?

Students Faculty/Staff Visitors

Yes No Yes No Yes No

• Faculty and staff

• Students

From ACHA Survey

Does your campus currently have smoke-free/clean indoor air policies? If yes, check all 

areas that are covered. Sample response options:

Inside residence halls—common areas Student recreational areas

Bars on campus Outdoor events

What kind of programs does your college now offer to help people who want to quit 

smoking (check all that apply)? Sample response options:

quitlines cessation groups referral to community-based program

What kind of program does your campus now offer for smoking prevention (check all 

that apply)? Sample response options:

Health clinic programs Student mobilization/organization

Social marketing campaign

Comments Evaluators should determine the level of tobacco-free policies when operationalizing 

this indicator. Some states have a statewide or community-wide (e.g., city, county) 

policy in effect that may lead program managers and evaluators to focus on policy 

implementation and compliance whereas in other jurisdictions, policies may be 

implemented at the district or individual school level. Data collection methods and 

measures should be tailored to the appropriate policy level.

Additionally, the scope of tobacco-free policies should be considered when 

operationalizing this indicator. Considering guidelines such as those contained in the 

American College Health Association (ACHA) Position Statement on Tobacco on 

College and University Campuses may help with this task: 

http://www.acha.org/Publications/docs/Position_Statement_on_Tobacco_Nov2011.pdf

This indicator can be used to measure progress toward achieving recommendations of 

CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and 

Addiction.”

1

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$
GOAL AREA 1

► Outcome 2

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

53

References

1. 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.

2. 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.

3. Barnett TA, Gauvin L, Lambert M, O’Loughlin J, Paradis G, McGrath JJ. The influence of school smoking 

policies on student tobacco use. Archives of Pediatrics & Adolescent Medicine. 2007;161(9):842–8.

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

National Academies Press; 2007.

5. Trinidad DR, Gilpin EA, Pierce JP. Compliance and support for smoke-free school policies. Health Education 

Research. 2005;20(4):466–75.

6. Adams ML, Jason LA, Pokorny S, Hunt Y. The relationship between school policies and youth tobacco use. 

Journal of School Health. 2009;79(1):17–23.

For Further Reading

American College Health Association. Position Statement on College and University Campuses.

November 2011. Available at: 

http://www.acha.org/Publications/docs/Position_Statement_on_Tobacco_Nov2011.pdf. Accessed January 26, 2012.

Halperin AC, Rigotti NA. US public universities’ compliance with recommended tobacco-control policies. Journal 

of American College Health. 2003 Mar;51(5):181–8.

Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Ruel EE. Effect of restrictions on smoking at 

home, at school, and in public places on teenage smoking: cross sectional study. British Medical Journal. 2000 Aug 

5;321(7257):333–7.
GOAL AREA 1

► Outcome 2 

54 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.2.b

Proportion of Schools or School Districts That Provide Tobacco-Use 

Prevention That Meets CDC Guidelines

KOI 2005 1.7.2 Revised title (Previously: “Proportion of schools or school districts that provide 

instruction on tobacco-use prevention that meets CDC guidelines”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction of tobacco use and enforcement of anti-tobacco policies and 

programs in schools and on college/university campuses

What to measure Proportion of schools or school districts that report implementing tobacco use 

prevention that includes (1) developing and enforcing a school policy on tobacco use; 

(2) providing instruction on the physiological and social consequences of tobacco use, 

social influences on tobacco use, peer norms, and refusal skills; (3) providing tobaccouse prevention education in kindergarten through 12th grade; (4) providing programspecific training for teachers; (5) involving parents or families in support of schoolbased programs to prevent tobacco use; (6) supporting cessation efforts among students 

and all school staff who use tobacco; and (7) assessing the tobacco-use prevention 

program at regular intervals

Why this indicator is 

useful

CDC’s publication, “Guidelines for School Health Programs to Prevent Tobacco Use 

and Addiction”

1 was designed to guide health promotion and disease prevention policy 

and programs at the federal, state, and local levels. The Guidelines recognize the 

important role that parents and families play in providing social and environmental 

support that will help young people remain tobacco-free.1,2 Additionally, evidence 

suggests that programs that include the short- and long-term physiologic and social 

consequences of tobacco use, social influences on tobacco use, peer norms, and life

skills may prevent or reduce tobacco use among students in the short-term.1,3,4

Example data 

source(s)

CDC School Health Profiles: School Principal Questionnaire (Profiles), 2010

Information available at: http://www.cdc.gov/healthyyouth/profiles/

CDC School Health Profiles: School Teacher Questionnaire (Profiles), 2010

Information available at: http://www.cdc.gov/healthyyouth/profiles/

California Tobacco Use Prevention Education Evaluation: Teacher Survey, 2003 

Information available at: 

http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/Evaluation_Resources.htm

Population group(s) Teachers and school administrators 

Example survey 

question(s)

From Principal Profiles

During the past two years, has your school done each of the following activities?

Yes No

a. Gathered and shared information with students and families

about mass-media messages or community-based tobaccouse prevention efforts

b. Worked with local agencies or organizations to plan and

implement events or programs intended to reduce tobacco use
GOAL AREA 1

► Outcome 2 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

55

From Teacher Profiles

During this school year, did your school provide parents and families with health 

information designed to increase parent and family knowledge of each of the following 

topics?

Yes No

b. Tobacco-use prevention

During this school year, did teachers in your school teach each of the following tobaccouse prevention topics in a required course for students in any of grades 6 through 12? 

(Mark yes or no for each topic.)

Yes No

a. Identifying tobacco products and the harmful substances

they contain

b. Identifying short- and long-term health consequences of

tobacco use

c. Identifying legal, social, economic, and cosmetic

consequences of tobacco use

d. Understanding the addictive nature of nicotine

e. Effects of tobacco use on athletic performance

f. Effects of secondhand smoke and benefits of a

smoke-free environment

g. Understanding the social influences on tobacco use,

including media, family, peers, and culture

h. Identifying reasons why students do and do not use tobacco

i. Making accurate assessments of how many peers use tobacco

j. Using interpersonal communication skills to avoid

tobacco use (e.g., refusal skills, assertiveness)

k. Using goal-setting and decision-making skills related to

not using tobacco

l. Finding valid information and services related to tobaccouse prevention and cessation

m. Supporting others who abstain from or want to quit using tobacco

n. Supporting school and community action to support a

tobacco-free environment

o. Identifying harmful effects of tobacco use on fetal development

From California Tobacco Use Prevention Education Evaluation: Teacher Survey

To what extent have you tried to get students’ parents involved in tobacco use 

prevention education? Type of Involvement

Included parents in homework assignments

Held meeting with parents of student smokers

Distributed parent-student handbook that included description of tobacco-free 

school policy

Distributed newsletters or educational materials to parents

Provided information on smoking cessation to parents

Had tobacco education displays or discussions at open houses, meetings, health 

fairs

Invited parents to be guest speakers on tobacco issues

Involved parents in school-related activities (e.g., as judges of poster essay 

contests)

Other (describe) __________________________________________________
GOAL AREA 1

► Outcome 2 

56 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Comments This indicator can be used to measure progress toward achieving recommendations of 

CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and 

Addiction.”

1

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

1. 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.

2. Centers for Disease Control and Prevention. Tobacco use: school health guidelines. Atlanta, GA: Centers for 

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

on Smoking and Health; 2012. Available at: 

http://www.cdc.gov/healthyyouth/tobacco/guidelines/summary.htm. Accessed August 24, 2012.

3. 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. 

4. NIH State of the Science Panel. NIH State-of-the-Science Conference Statement on Tobacco Use: Prevention, 

Cessation, and Control. Annals of Internal Medicine. 2006;145:839–44. 

For Further Reading 

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

Academies Press; 2007. 
GOAL AREA 1

► Outcome 2 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

57

Indicator 1.2.c

Proportion of Young People Who Participate in Tobacco-Use Prevention 

Activities

KOI 2005 1.7.8 Revised Title (Previously: “Proportion of students who participate in tobacco-use 

prevention activities”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction of tobacco use and enforcement of anti-tobacco policies and 

programs in schools and on college/university campuses

What to measure Proportion of young people who report participating in tobacco-use prevention activities 

including policy-related initiatives in the past 12 months

Why this indicator is 

useful

Youth engagement has evolved to become a common component of coordinated tobacco 

control efforts helping to pass local policies, expose industry tactics, and take a stand 

against the tobacco industry and other prolific pro-tobacco influences.1Involving young 

people in anti-tobacco activities has been shown to contribute to comprehensive tobacco 

control effectiveness and may help reduce young people’s susceptibility to 

experimenting with tobacco by changing the social norm regarding tobacco use.2,3

Ensuring sufficient reach and dose of school-based prevention programs and

augmenting with school-plus-community programming has been shown to enhance 

longer-term outcomes, including reduced smoking rates.4

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2002

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

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

During the past 12 months, have you been involved in any organized activities to keep 

people your age from using any form of tobacco product? Yes No

Please indicate on the list below ANY anti-smoking event or meeting that you attended 

in the past 12 months: Meeting with community officials to talk about a tobacco issue?

Comments Evaluators may choose to categorize data by grade level and type of school (elementary, 

middle, high school, technical school, college/university, private, parochial, public).

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

1. 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.
GOAL AREA 1

► Outcome 2

58 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

2. Unger JB, Rohrbach LA, Howard KA, Boley Cruz T, Johnson CA, Chen X. Attitudes toward anti-tobacco 

policy among California youth: associations with smoking status, psychosocial variables and advocacy actions. 

Health Education Resources. 1999;14(6):751–63.

3. Winkleby MA, Feighery E, Dunn M, Kole S, Ahn D, Killen JD. Effects of an advocacy intervention to reduce 

smoking among teenagers. Archives of Pediatrics & Adolescent Medicine. 2004;158(3):269–75.

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

National Academies Press; 2007.
GOAL AREA 1

► Outcome 2 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

59

Indicator 1.2.d

Level of Reported Exposure to School-based Tobacco-Use Prevention that 

Meets CDC Guidelines

KOI 2005 1.7.9 Revised Title (Previously: “Level of reported exposure to school-based tobaccouse prevention curricula that meet CDC guidelines”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction of tobacco use and enforcement of anti-tobacco policies and 

programs in schools and on college/university campuses

What to measure Proportion of students who report exposure to school-based prevention, defined as (1) 

strategies to develop and enforce a school policy on tobacco use; (2) instruction on the 

physiological and social consequences of tobacco use, social influences on tobacco use, 

peer norms, and refusal skills; (3) involvement of parents or families in support of 

school-based programs to prevent tobacco use; and (4) support of cessation efforts 

among students and all school staff who use tobacco.

Why this indicator is 

useful

Although multi-dimensional school-based tobacco-use prevention programs have shown 

promise,1,2 understanding the exposure to and reach of these programs is important for 

evaluation. Resource cuts to programming can result in significant declines in exposure 

to tobacco-use prevention and may impact longer-term outcomes.3

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

California Tobacco Use Prevention Evaluation

As part of its evaluation of the school-based Tobacco Use Prevention Education (TUPE) 

programs, the California Department of Public Health, Tobacco Control Program, uses 

data collected from a variety of sources. These sources include students, teachers, school 

administrators, school coordinators, and district coordinators. A unique data collection 

instrument, tailored for each source, captures information on program implementation 

and effectiveness. The surveys include items to quantify exposure to school tobacco use 

policies, practices and enforcement; instruction on why people smoke, smoking 

prevalence and physical harm from smoking; smoking decision-making and refusal 

skills training; as well as cessation training and classes.

For more information, see Park et al.2and 

http://www.cdph.ca.gov/programs/tobacco/Documents/Resources/Publications/TUPE%

2007-08.pdf

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

During this school year, were you taught in any of your classes about why you should 

not use tobacco products?

Yes No

From California Tobacco Use Prevention Evaluation

See Park et al.

2

for description of tobacco-use prevention exposure index.
GOAL AREA 1

► Outcome 2 

60 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Comments Evaluators may also choose to categorize data by grade level and type of school 

(elementary, middle, high school, private, parochial, public).

Exposure measures should be appropriate for the type of tobacco-use prevention 

activities being assessed.

Student perceptions of tobacco prevention should also be evaluated; students who 

perceive the prevention as helpful are less susceptible to smoking than those who do not 

perceive it as useful.4

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

1. Backinger CL, Fagan P, Matthews E, Grana R. Adolescent and young adult tobacco prevention and cessation: 

current status and future directions. Tobacco Control. Dec 2003;12(Suppl 4):IV46–53. 

2. Park HY, Dent C, Abramsohn E, Dietsch B, McCarthy WJ. Evaluation of California’s in-school tobacco use 

prevention education (TUPE) activities using a nested school-longitudinal design, 2003–2004 and 2005–2006. 

Tobacco Control. 2010;19(Suppl 1):i43–i50. 

3. 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. Jan-Feb 2011;25(3):176–85. 

4. Huang TT, Unger JB, Rohrbach LA. Exposure to, and perceived usefulness of, school-based tobacco prevention 

programs: associations with susceptibility to smoking among adolescents. Journal of Adolescent Health. 

2000;27(4):248–54. 

For Further Reading 

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.
GOAL AREA 1

► Outcome 2 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

61

Indicator 1.2.e

Perceived Compliance with Tobacco-free Policies in Schools and on 

College/University Campuses

KOI 2005 1.7.10 Revised Title (Previously: “Perceived compliance with tobacco-free policies in 

schools”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction of tobacco use and enforcement of anti-tobacco policies and 

programs in schools and on college/university campuses

What to measure Proportion of students who report that the school/college/university population is 

complying with the school’s tobacco-free policy

Why this indicator is 

useful

Perceived compliance with tobacco-free policies is one measure of actual compliance 

with these policies.1,2If tobacco-free policies are not seen to be adhered to by members 

of the school community, then these policies are unlikely to be effective in changing 

social norms or inhibiting tobacco use among young people. Consistent enforcement of 

tobacco-free policies is important to ensuring high levels of observed compliance in the 

school environment.3

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

During the past 30 days, to your knowledge, has anyone, including yourself, smoked a 

tobacco product on school property when he or she was not supposed to?

Yes No

During the past 30 days, to your knowledge, has anyone, including yourself, used some 

other type of tobacco product (that is, one that is not smoked) on school property when 

he or she was not supposed to?

Yes No

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 Evaluators should determine the scope of the tobacco-free policies before evaluating 

perceived compliance. Considering guidelines such as those contained in the American 

College Health Association (ACHA) Position Statement on Tobacco on College and 

University Campuses may help with this task: 

http://www.acha.org/Publications/docs/Position%20Statement%20on%20Tobacco_Sep2

009.pdf. 
GOAL AREA 1

► Outcome 2 

62 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$

better

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. 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.

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;12(3):269–73. 

3. Adams ML, Jason LA, Pokorny S, Hunt Y. The relationship between school policies and youth tobacco use. 

Journal of School Health. 2009;79(1):17–23.

For Further Reading 

Halperin AC, Rigotti NA. US public universities’ compliance with recommended tobacco-control policies. Journal 

of American College Health. 2003 Mar;51(5):181–8.

Trinidad DR, Gilpin EA, Pierce JP. Compliance and support for smoke-free school policies. Health Education 

Research. 2005;20(4):466–75. 

Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Ruel EE. Effect of restrictions on smoking at 

home, at school, and in public places on teenage smoking: cross sectional study. British Medical Journal. 2000 Aug 

5;321(7257):333–7.
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

63

Outcome 3 

Increased Restriction and Enforcement of Tobacco Product Sales, 

Availability, and Use 

Coordinated activities to decrease access to tobacco products are recognized components of a 

comprehensive approach to reducing the number of people who start using tobacco products.1

Studies show that aggressive enforcement of laws regulating tobacco sales to youth, when part of 

a comprehensive tobacco control program, results in significantly reduced sales to minors and 

may also result in reduced smoking prevalence among teenagers.2-4 Because youth may make 

multiple purchase attempts, especially in areas of high retailer density, and rely on social sources 

to supplement or substitute for reduced retail availability, enforcing policies that target the entire 

population may have a greater impact on reduced initiation.5 Additionally, strategies that reduce 

the availability of tobacco products, even to those of legal age to purchase them, can help to 

reduce initiation of tobacco product use. 

Experience shows that adoption and sustained enforcement of strong laws are prerequisites for 

reducing young people’s access to tobacco.6 According to the Guide to Community Preventive 

Services, the most effective approach to preventing youth from gaining access to tobacco 

products (as measured by minors’ self-reported tobacco purchase or use behaviors) consists of a 

combination of strong local and state laws, vigorous and sustained enforcement of these laws, 

retailer education, and community mobilization to generate community support for efforts to 

reduce youth access to tobacco products.7 Community mobilization plays a particularly 

important role because of its ability to change social norms regarding the social acceptability of 

selling or otherwise providing tobacco products to minors. The Family Smoking Prevention and 

Tobacco Control Act (Tobacco Control Act) of 2009 prohibits the sale of cigarettes and 

smokeless tobacco in vending machines, self-service displays, or other impersonal modes of sale, 

except in adult-only facilities. The law also prohibits free cigarette sampling but allows sampling 

of smokeless tobacco products in qualified adult-only facilities. Under the Tobacco Control Act, 

states and local jurisdictions may consider banning vending machines entirely and banning free 

or low-cost smokeless tobacco sampling. 

In addition to laws banning self-service displays and laws barring the sale and purchase of 

tobacco products to and by minors, laws that require retailers to maintain a license to sell tobacco 

products can help to reduce illegal sales to youth. Licensing can serve as an effective mechanism 

to reduce the concentration, location, and type of tobacco retailers. Licensing is also useful for 

imposing restrictions on the sale and promotion of tobacco products, including indoor and 

outdoor advertising and the display of tobacco products. Moreover, strong tobacco licensing 

policies that provide for suspension or revocation can serve as effective means to regulate retailer 

behavior. This is especially true if the licensing policy is written so that a violation of any 

tobacco-related ordinance or law at the local, state, or federal level triggers enforcement action.8

High tobacco retail density is associated with experimental smoking and greater smoking 

prevalence among youth. Evidence demonstrates that the greater the number of tobacco retailers 

surrounding schools, the more likely youth smokers are to purchase their own cigarettes.6

Limiting the number of retail tobacco outlets in a community decreases the availability of 

tobacco products and the number of pro-tobacco messages in a community.9
GOAL AREA 1

► Outcome 3

64 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Finally, marketing of new and other tobacco products could undermine effective tobacco control 

policies. Some new smokeless tobacco products, including e-cigarettes, are being marketed as 

substitution or poly-use products to supplement tobacco use when cigarette smoking is not 

permitted. Electronic or e-cigarettes are also emerging as heavily marketed cigarette 

alternatives.10,11 In addition to enacting policies that apply to cigarettes at the point of sale (e.g., 

limiting the size and placement of cigarette advertising), jurisdictions can apply similar policies 

to regulate sales of other tobacco products.

The following indicators are associated with this outcome:

► 1.3.a Proportion of jurisdictions with strong policies that ban non-sale distribution or free 

sampling of all tobacco products everywhere

► 1.3.b Proportion of jurisdictions with strong policies that require retail licenses to sell 

tobacco products

► 1.3.c Proportion of jurisdictions with strong policies that control the type, location, 

number, and/or density of tobacco retail outlets

► 1.3.d Proportion of jurisdictions with strong policies that ban tobacco vending machine 

sales everywhere

► 1.3.e Number and type of enforcement actions issued for violations of restrictions on 

tobacco product availability

► 1.3.f Proportion of jurisdictions that regulate sales of other tobacco products

► 1.3.g Proportion of jurisdictions with strong public policies for tobacco-free workplaces 

and other public places

► 1.3.h Proportion of states with tobacco control laws that preempt stronger local tobacco 

control and prevention laws

References

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

control programs—2007. Atlanta, GA: U.S. Department of Health and Human Services, 

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

and Health Promotion, Office on Smoking and Health; 2007.

2. Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing 

tobacco-sales laws on adolescents’ access to tobacco and smoking behavior. The New 

England Journal of Medicine. 1997;337(15):1044–51.

3. Howard KA, Ribisl KM, Howard-Pitney B, Norman GJ, Rohrbach LA. What factors are 

associated with local enforcement of laws banning illegal tobacco sales to minors? A study of 

182 law enforcement agencies in California. Preventive Medicine. 2001;33(2 Pt 1):63–70.

4. Chen VF, Forster JL. The long-term effect of local policies to restrict retail sale of tobacco to 

youth. Nicotine & Tobacco Research. Jun 2006;8(3):371–7.

5. Friend KB, Lipperman-Kreda S, Grube JW. The impact of local U.S. tobacco policies on 

youth tobacco use: a critical review. Open Journal of Preventive Medicine. 2011;1(2):34–43.
GOAL AREA 1

► Outcome 3

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

65

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

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012.

7. 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.

8. McLaughlin I. License to kill?: tobacco retailer licensing as an effective enforcement tool. 

2010. St. Paul, MN: Tobacco Control Legal Consortium. Available at: 

http://publichealthlawcenter.org/sites/default/files/resources/tclc-syn-retailer-2010.pdf

9. Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is 

adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette 

advertising near schools? Preventive Medicine. 2008;47(2):210–4.

10. Cobb NK, Abrams DB. E-cigarette or drug-delivery device? Regulating novel nicotine 

products. New England Journal of Medicine. 2011 Jul 21;365(3):193–5.

11. Ayers JW, Ribisl KM, Brownstein JS. Tracking the rise in popularity of electronic nicotine 

delivery systems (electronic cigarettes) using search query surveillance. American Journal of 

Preventive Medicine. 2011;40(4):448–53.

For Further Reading

Celebucki CC, Diskin K. A longitudinal study of externally visible cigarette advertising on retail 

storefronts in Massachusetts before and after the Master Settlement Agreement. Tobacco 

Control. 2002;11(Suppl 2):ii47–53.

Chuang YC, Cubbin C, Ahn D, Winkleby MA. Effects of neighbourhood socioeconomic status 

and convenience store concentration on individual level smoking. Journal of Epidemiology and 

Community Health. 2005;59(7):568–73.

DiFranza JR. Which interventions against the sale of tobacco for minors can be expected to 

reduce smoking? Tobacco Control. 2012;21(4):436–42. doi:10.1136/tobaccocontrol-2011-

050145

DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor of 

daily smoking among adolescents: a national study. BMC Public Health. 2009;9:107.

Fakunle D, Morton CM, Peterson NA. The importance of income in the link between tobacco 

outlet density and demographics at the tract level of analysis in New Jersey. Journal of Ethnicity 

in Substance Abuse. 2010;9(4):249–59.

Francis JA, Abramsohn EM, Park HY. Policy-driven tobacco control. Tobacco Control. 

2010;19(Suppl 1):i16–i20.

Institute of Medicine (IOM). Ending the tobacco problem: a blueprint for the nation. 

Washington, DC: The National Academies; 2007.

Jason LA, Pokorny SB, Adams M. A randomized trial evaluating tobacco possession-usepurchase laws in the USA. Social Science & Medicine. 2008;67(11):1700–7.
GOAL AREA 1

► Outcome 3

66 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Kandel DB, Kiros GE, Schaffran C, Hu MC. Racial/ethnic differences in cigarette smoking 

initiation and progression to daily smoking: a multilevel analysis. American Journal of Public 

Health. 2004;94(1):128–35.

Leatherdale S, Strath J. Tobacco retailer density surrounding schools and cigarette access 

behaviors among underage smoking students. Annals of Behavioral Medicine. 2007;33(1):105–

11.

Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. 

Tobacco Control. 2002;11(1):3–6.

Luke DA, Ribisl KM, Smith C, Sorg AA. Family Smoking Prevention and Tobacco Control Act: 

banning outdoor tobacco advertising near schools and playgrounds. American Journal of 

Preventive Medicine. 2011 Mar;40(3):295–302.

McCarthy WJ, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of tobacco retailers near 

schools: effects on tobacco use among students. American Journal of Public Health. 

2009;99(11):2006–13.

National Cancer Institute. ASSIST: shaping the future of tobacco prevention and control. 

Tobacco Control Monograph No. 16. NIH Publication No. 05-5645. Bethesda, MD: U.S. 

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

Institute; May 2005.

Novak SP, Reardon SF, Raudenbush SW, Buka SL. Retail tobacco outlet density and youth 

cigarette smoking: a propensity-modeling approach. American Journal of Public Health. 

2006;96(4):670–6.

Rogers T, Feighery EC, Haladjian HH. Current practices in enforcement of California laws 

regarding youth access to tobacco products and exposure to secondhand smoke. Sacramento, 

CA: California Department of Public Health; 2008.

Schneider JE, Reid RJ, Peterson NA, Lowe JB, Hughey J. Tobacco outlet density and 

demographics at the tract level of analysis in Iowa: implications for environmentally based 

prevention initiatives. Prevention Science. 2005 Dec; 6(4):319–25.

Seidenberg AB, Behm I, Rees VW, Connolly GN. Cigarette sales in pharmacies in the USA 

(2005–2009). Tobacco Control. 2012 Sep; 21(5):509-10.

Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database 

of Systematic Reviews. 2005;(1):CD001497. doi:10.1002/14651858.CD001497.pub2
GOAL AREA 1

► Outcome 3

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

67

Outcome 3 

Increased Restriction and Enforcement of Tobacco Product Sales, 

Availability, and Use 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.3.a Proportion of jurisdictions with 

strong policies that ban non-sale 

distribution or free sampling of all 

tobacco products everywhere

$$$$

1.3.b Proportion of jurisdictions with 

strong policies that require retail 

licenses to sell tobacco products

$$$

1.3.c Proportion of jurisdictions with 

strong policies that control the type, 

location, number, and/or density of 

tobacco retail outlets

$$$

1.3.d Proportion of jurisdictions with 

strong policies that ban tobacco 

vending machine sales everywhere

†† $$$

1.3.e Number and type of enforcement 

actions issued for violations of 

restrictions on tobacco product 

availability

$$†

1.3.f Proportion of jurisdictions that 

regulate sales of other tobacco 

products

†† $$$$ † 

1.3.g Proportion of jurisdictions with 

strong public policies for tobaccofree workplaces and other public 

places

$$$$

1.3.h Changes in state tobacco control 

laws that preempt stronger local 

tobacco control and prevention laws

†† $ †

$ 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 fewer than 75% of valid ratings within ±1 point of the 

median for this indicator-specific criterion. 

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings within ±2 points of the 

median for overall quality of the indicator. 
GOAL AREA 1

► Outcome 3 

68 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.3.a

Proportion of Jurisdictions with Strong Policies that Ban Non-sale 

Distribution or Free Sampling of All Tobacco Products Everywhere

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Proportion of local jurisdictions with public policies that universally ban non-sale 

distribution or free tobacco sampling in all settings, including adult-only facilities. See 

“Comments” below for applicable definitions and clarification of “strong” policies.

Why this indicator is 

useful

The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) 

prohibits free cigarette sampling but allows sampling of smokeless tobacco products in 

qualified adult-only facilities. As demonstrated in the period following the 1998 Master 

Settlement Agreement, the tobacco industry increases its marketing expenditures on

activities not explicitly banned by legal agreement/legislation.1 Closing the federal 

loopholes by banning low-cost, nominal cost, or free sampling of all tobacco products is 

one way that local jurisdictions can mitigate industry efforts to increase tobacco use 

initiation and engage individual consumers.

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

state and local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Note that under the Tobacco Control Act, state and local governments are not prohibited 

from initiating state and local bans on tobacco product sampling.

Non-sale distribution is defined as giving a tobacco product to the general public at no 

cost, or at nominal cost, including via coupons, coupon offers, gift certificates, gift 

cards, or other similar offers.

Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. See the Public Health Law and Policy, 

Technical Assistance Legal Center for an example Model Tobacco Sampling Ordinance

for example guidance and definitions: http://changelabsolutions.org/publications/modelord-tobacco-sampling. A strong policy is one that includes all of the model policy 

provisions.

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws and ordinances.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$$
GOAL AREA 1

► Outcome 3

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

69

References

1. Lewis MJ, Yulis SG, Delnevo C, Hrywna M. Tobacco industry direct marketing after the Master Settlement 

Agreement. Health Promotion Practice. 2004 Jul;5(3 Suppl):75S–83S.

For Further Reading

MacFadyen L, Hastings G, Mackintosh AM. Cross-sectional study of young people’s awareness and involvement 

with tobacco marketing. British Medical Journal. 2001 Mar;322(7285):513–7.

Mejia AB, Ling PM. Tobacco industry consumer research on smokeless tobacco users and product development. 

American Journal of Public Health. 2010;100:78–87.

Rigotti NA, Moran SE, Wechsler H. U.S. college students’ exposure to tobacco promotions: prevalence and 

association with use. American Journal of Public Health. 2005 Jan; 95(1):138–44.
GOAL AREA 1

► Outcome 3 

70 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.3.b

Proportion of Jurisdictions with Strong Policies That Require Retail 

Licenses to Sell Tobacco Products

KOI 2005 1.8.2 Revised Title (Previously: “Proportion of jurisdictions with policies that require 

retail licenses to sell tobacco products”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Proportion of local jurisdictions that have strong public policies requiring a license for 

retail sale of tobacco products. See “Comments” below for clarification of “strong” 

policies.

Why this indicator is 

useful

Laws that require retailers to maintain a license to sell tobacco products can help to 

reduce illegal sales to youth and can be used to increase compliance with other local, 

state, and federal tobacco laws. Licensing can also serve as an effective mechanism to 

reduce the concentration, location, and type of tobacco retailers and to impose 

restrictions on the sale and promotion of tobacco products at the point of sale, including 

indoor and outdoor advertising and the display of tobacco products.1 As of 2011, 40 

states and the District of Columbia required tobacco retailers to obtain a license for 

over-the-counter tobacco sales and 37 states and the District of Columbia had laws in 

place identifying circumstances in which retail licenses can be suspended or revoked.2

Example data 

source(s)

Policy tracking system

Americans for Nonsmokers’ Rights (ANR)

Information available at: http://www.no-smoke.org

CDC State Tobacco Activities Tracking and Evaluation (STATE) system—Licensure: 

over-the-counter.

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 pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” licensure includes, among other 

things, a requirement to obtain a license and renew it annually; a license fee set high 

enough to cover state costs associated with administration, implementation, and 

enforcement of the license; and provisions authorizing a penalty to the business,

including suspension or revocation of the license for any violations of local, state, or 

federal tobacco laws. See The Center for Tobacco Policy & Organizing, American Lung 

Association in California Web site as an example for policy guidelines: 

http://www.center4tobaccopolicy.org/CTPO/_files/_file/Matrix%20of%20Strong%20Lo

cal%20Tobacco%20Retailer%20Licensing%20Ordinances%20March%202011.pdf

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances. 
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

71

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

1. McLaughlin I. License to kill?: tobacco retailer licensing as an effective enforcement tool. 2010. St. Paul, MN: 

Tobacco Control Legal Consortium. Available at: 

http://publichealthlawcenter.org/sites/default/files/resources/tclc-syn-retailer-2010.pdf

2. Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) 

System. Atlanta, GA: Centers for Disease Control and Prevention. Online database. Available at: 

http://www.cdc.gov/tobacco/statesystem. Accessed August 2011.

For Further Reading 

American Lung Association. State Legislative Actions on Tobacco Issues (SLATI) Overview. 2009. Available at: 

http://slati.lungusa.org/StateLegislateAction.asp

Forster JL, Wolfson M. Youth access to tobacco: policies and politics. Annual Review of Public Health. 

1998;19:203–35. 

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

Academies Press; 2007.

National Cancer Institute. ASSIST: shaping the future of tobacco prevention and control. Tobacco Control 

Monograph No. 16. NIH Publication No. 05-5645. Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; May 2005. 
GOAL AREA 1

► Outcome 3 

72 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.3.c

Proportion of Jurisdictions with Strong Policies That Control the Type, 

Location, Number, and/or Density of Tobacco Retail Outlets

KOI 2005 1.8.3 Revised Title (Previously: “Proportion of jurisdictions with policies that control 

the location, number, and density of retail outlets”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Proportion of local jurisdictions that have public policies controlling the store type, 

location, number, and/or density of tobacco retail outlets. Example policies enacted 

through retailer licensing requirements or zoning restrictions include banning tobacco 

sales in pharmacies and restricting tobacco retailers within close proximity to schools.

See “Comments” below for clarification of “strong” policies.

Why this indicator is 

useful

Limiting the number of retail tobacco outlets decreases the availability of tobacco 

products and the number of pro-tobacco messages in a community. High tobacco retail 

density is associated with experimental smoking and greater smoking prevalence among 

youth.1,2 Evidence demonstrates that the greater the numbers of tobacco retailers 

surrounding schools, the more likely youth smokers are to purchase their own 

cigarettes.3 Furthermore, the density of tobacco retail outlets has been shown to be 

higher in low-income neighborhoods with greater health disparities.4,5 Therefore, 

regulating the density of tobacco retailers may improve the health of susceptible 

populations.6

Example data 

source(s)

Policy tracking system

Americans for Nonsmokers’ Rights (ANR)

Information available at: http://www.no-smoke.org

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Operationalizing the indicator will require identifying discrete policies of interest and 

determining the scope of the policy standards prior to evaluating the presence/absence 

and reach of such policies. Example policies may include restricting the type of business 

that can sell tobacco and related products, such as pharmacy bans, and/or regulating 

where tobacco retail outlets can be physically located, for example, banning retail 

outlets near schools. More information on pharmacy bans, including model ordinance 

language, can be found at http://changelabsolutions.org/publications/tobacco-freepharmacies.

“Strong” policies that control the type, location, number, and/or density of tobacco retail 

outlets are able to withstand legal challenge, provide meaningful enforcement provisions 

that require compliance with all relevant laws, limit loopholes such as transferability 

clauses, and are actively enforced. See the Public Health Law Center Web site for 

additional information: http://publichealthlawcenter.org/sites/default/files/resources/tclcguide-regulating-retailer-locations-2012.pdf.

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances.
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

73

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

1. McCarthy W, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of tobacco retailers near schools: effects 

on tobacco use among students. American Journal of Public Health. 2009;99(11):2006–13. 

2. Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is adolescent smoking 

related to the density and proximity of tobacco outlets and retail cigarette advertising near schools? Preventive 

Medicine. 2008; 47(2):210–4.

3. Leatherdale S, Strath J. Tobacco retailer density surrounding schools and cigarette access behaviors among 

underage smoking students. Annals of Behavioral Medicine. 2007;33(1):105–11. 

4. Schneider JE, Reid RJ, Peterson NA, Lowe JB, Hughey J. Tobacco outlet density and demographics at the tract 

level of analysis in Iowa: implications for environmentally based prevention initiatives. Prevention Science. 

2005 Dec;6(4):319–25.

5. Fakunle D, Morton CM, Peterson NA. The importance of income in the link between tobacco outlet density and 

demographics at the tract level of analysis in New Jersey. Journal of Ethnicity in Substance Abuse. 

2010;9(4):249–59.

6. Novak SP, Reardon SF, Raudenbush SW, Buka SL. Retail tobacco outlet density and youth cigarette smoking: a 

propensity-modeling approach. American Journal of Public Health. 2006;96(4):670–6.

For Further Reading 

Chuang YC, Cubbin C, Ahn D, Winkleby MA. Effects of neighbourhood socioeconomic status and convenience 

store concentration on individual level smoking. Journal of Epidemiology and Community Health. 2005;59(7):568–

73.

Hyland A, Travers MJ, Cummings KM, Bauer J, Alford T, Wieczorek WF. Tobacco outlet density and 

demographics in Erie County, New York. American Journal of Public Health. 2003;93(7):1075–6.

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

Academies Press; 2007. 

Luke DA, Ribisl KM, Smith C, Sorg AA. Family Smoking Prevention and Tobacco Control Act: banning outdoor 

tobacco advertising near schools and playgrounds. American Journal of Preventive Medicine. 2011 Mar;40(3):295–

302. 

Seidenberg AB, Behm I, Rees VW, Connolly GN. Cigarette sales in pharmacies in the USA (2005–2009). Tobacco 

Control. 2012 Sep;21(5):509–10.
GOAL AREA 1

► Outcome 3 

74 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.3.d

Proportion of Jurisdictions with Strong Policies That Ban Tobacco 

Vending Machine Sales Everywhere

KOI 2005 1.8.1 Revised Title (Previously: “Proportion of jurisdictions with policies that ban 

tobacco vending machine sales in places accessible to young people”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Proportion of local jurisdictions that have enforceable policies banning tobacco vending 

machine sales in all locations, whether an adult-only facility or a location accessible to 

youth younger than age 18. See “Comments” below for clarification of “strong” 

policies.

Why this indicator is 

useful

Banning vending machines has been shown to reduce smoking onset.1 The 2009 Family 

Smoking Prevention and Tobacco Control Act (Tobacco Control Act) prohibits

nationally the sale of cigarettes and smokeless tobacco in vending machines, self-service 

displays, or other impersonal modes of sales, except in adult-only facilities. Given the 

increasing rate of smoking initiation among young adults,2states and local jurisdictions 

may consider banning the sale of all tobacco products in vending machines entirely, an 

action allowable under the Tobacco Control Act. As of 2011, no states ban tobacco 

vending machines in all locations.3

Example data 

source(s)

Policy tracking system

Americans for Nonsmokers’ Rights (ANR)

Information available at: http://www.no-smoke.org

American Lung Association’s State Legislated Actions on Tobacco Issues (SLATI) 

Information available at: http://slati.lungusa.org

CDC State Tobacco Activities Tracking and Evaluation (STATE) system—Youth 

access: cigarette vending machines

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 pertinent 

state and local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” policies are those that ban 

tobacco vending machine sales in all locations, whether an adult-only facility or a 

location accessible to youth younger than age 18, and are able to withstand legal 

challenge, provide meaningful enforcement provisions that require compliance with all 

relevant laws, limit loopholes such as transferability clauses, and are actively enforced.

See the Tobacco Control Legal Consortium document Location, Location, Location: 

Regulating Tobacco Retailer Locations for Public Health for more information: 

http://publichealthlawcenter.org/sites/default/files/resources/tclc-guide-regulatingretailer-locations-2012.pdf.

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances.
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

75

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$$

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. Kandel DB, Kiros GE, Schaffran C, Hu MC. Racial/ethnic differences in cigarette smoking initiation and 

progression to daily smoking: a multilevel analysis. American Journal of Public Health. 2004 Jan;94(1):128–

35.

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. Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) 

system. Atlanta, GA: Centers for Disease Control and Prevention. Online database. Available at: 

http://www.cdc.gov/tobacco/statesystem. Accessed August 2011. 

For Further Reading 

Johnston LD, O’Malley PM, Terry-McElrath YM. Methods, locations, and ease of cigarette access for American 

youth, 1997–2002. American Journal of Preventive Medicine. 2004 Nov;27(4):267–76. 
GOAL AREA 1

► Outcome 3 

76 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.3.e

Number and Type of Enforcement Actions for Violations of Restrictions on 

Tobacco Product Availability

KOI 2005 1.8.6 Revised Title (Previously: “Number of warnings, citations, and fines issued for 

infractions of public policies against young people’s access to tobacco products”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Number and type of enforcement actions, including warnings, citations, and fines issued 

to retailers for infractions of public policies restricting tobacco product availability. 

Penalties may include civil and/or criminal penalties, including citations, graduated 

fines, and suspension or loss of license to sell tobacco. Examples of public policies 

restricting tobacco product availability include illegal sales to minors, restricting retailer 

outlet density, restricting tobacco sampling, and banning vending machines and selfservice displays of all tobacco products.

Why this indicator is 

useful

Studies show that aggressive enforcement of laws regulating tobacco sales to youth 

results in significantly reduced sales to minors and may also result in reduced smoking 

prevalence among teenagers.1-4 However, because youth may make multiple purchase 

attempts, especially in areas of high retailer density, and rely on social sources to 

supplement or substitute for reduced retail availability, enforcing policies that target the 

entire population may have a greater impact on reduced initiation.5

Example data 

source(s)

FDA, Compliance Check Inspection of Tobacco Product Retailers

Information available at: 

http://www.accessdata.fda.gov/scripts/oce/inspections/oce_insp_searching.cfm

California Tobacco Control Program: Enforcement Survey (2008)

Information available at: 

http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/Evaluation_Resources.htm

Population group(s) Agency representatives responsible for enforcement

Example survey 

question(s)

From FDA, Compliance Check Inspection of Tobacco Product Retailers:

FDA conducts compliance check inspections of tobacco product retailers to determine a 

retailer’s compliance with federal laws and regulations. Results from compliance check 

inspections covering cigarettes and smokeless tobacco products are available in a 

searchable inspection database that includes the following variables:

Retailer Name, City, State, Zip, Decision Type: No violations observed, Warning letters 

issued

From California Tobacco Control Program: Enforcement Survey

Information available at: 

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPEnforcementReport08-

05.pdf

In the past year, how often has your agency conducted any of the following types of 

enforcement activities related to Penal Code §308?

Never Rarely Very often Don’t know

• Responded to complaints about merchants

selling tobacco products to minors

• Issued warnings to merchants selling

tobacco products to minors

• Issued citations to merchants for illegal

sales of tobacco products to minors
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

77

Comments Evaluators may want to assess the effects that different penalties (e.g., graduated fines, 

loss of license to sell tobacco) have on violations of public policies. Data must be 

interpreted in context. For example, a low number of citations may indicate either high 

levels of compliance or low levels of enforcement.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$†

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.

References 

1. Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco-sales laws 

on adolescents’ access to tobacco and smoking behavior. New England Journal of Medicine. 

1997;337(15):1044–51. 

2. Jason LA, Berk M, Schnopp-Wyatt DL, Talbot B. Effects of enforcement of youth access laws on smoking 

prevalence. American Journal of Community Psychology. 1999;27(2):143–61. 

3. Howard KA, Ribisl KM, Howard-Pitney B, Norman GJ, Rohrbach LA. What factors are associated with local 

enforcement of laws banning illegal tobacco sales to minors? A study of 182 law enforcement agencies in 

California. Preventive Medicine. 2001;33(2 Pt 1):63–70.

4. Chen V, Forster JL. The long-term effect of local policies to restrict retail sale of tobacco to youth. Nicotine & 

Tobacco Research. 2006;8(3):371–7.

5. Friend KB, Lipperman-Kreda S, Grube JW. The impact of local U.S. tobacco policies on youth tobacco use: a 

critical review. Open Journal of Preventive Medicine. 2011;1(2):34–43. 

For Further Reading 

DiFranza JR. Best practices for enforcing state laws prohibiting the sale of tobacco to minors. Journal of Public 

Health Management and Practice. 2005;11(6):559–65. 

Francis JA, Abramsohn EM, Park HY. Policy-driven tobacco control. Tobacco Control. 2010 Apr;19(Suppl 1):i16–

20.

National Cancer Institute. ASSIST: shaping the future of tobacco prevention and control. Tobacco Control 

Monograph No. 16. NIH Publication No. 05-5645. Bethesda, MD: U.S. Department of Health and Human Services, 

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

Rogers T, Feighery EC, Haladjian HH. Current practices in enforcement of California laws regarding youth access 

to tobacco products and exposure to secondhand smoke. Sacramento, CA: California Department of Public Health; 

2008.

Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic 

Reviews. 2005;(1):CD001497. doi:10.1002/14651858.CD001497.pub2. 
GOAL AREA 1

► Outcome 3 

78 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.3.f

Proportion of Jurisdictions that Regulate Sales of Other Tobacco Products

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Proportion of local jurisdictions with public policies that regulate the sales and 

distribution of other tobacco products in addition to cigarettes

Why this indicator is 

useful

Marketing of new and other, non-cigarette, tobacco products is being used to undermine 

effective tobacco control policies. Internal industry documents outline the increasing 

importance of the development of smokeless tobacco products to offset smoking 

reductions due to clean indoor air policy restrictions.1 These new products are marketed 

as substitution or poly-use products to supplement tobacco use when cigarette smoking 

is not permitted. New and alternative tobacco products are being developed by the 

tobacco industry as a method for increasing tobacco use among targeted subpopulations 

and are frequently used in combination with aggressive consumer marketing 

campaigns.2

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments None noted

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$$$ †

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. Carpenter C, Connolly G, Ayo-Yusuf O, Wayne G. Developing smokeless tobacco products for smokers: an 

examination of tobacco industry documents. Tobacco Control. 2009 Feb 18;18(1):54–9.

2. Biener L, Bogen K. Receptivity to Taboka and Camel Snus in a U.S. test market. Nicotine & Tobacco Research. 

2009 Oct;11(10):1154–9.

For Further Reading 

Rogers J, Biener L, Clark P. Test marketing of new smokeless tobacco products in four U.S. cities. Nicotine & 

Tobacco Research. 2010 Jan;12(1):69–72. 
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

79

Indicator 1.3.g 

Proportion of Jurisdictions with Strong Public Policies for Tobacco-Free 

Workplaces and Other Public Places 

KOI 2005 2.4.1 Revised Title (Previously: “Proportion of jurisdictions with public policies for 

tobacco-free workplaces and other indoor and outdoor public places”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Proportion of local jurisdictions that have public policies requiring tobacco-free 

workplaces, including restaurants, bars, and other indoor and outdoor places. See 

“Comments” below for clarification of “strong” policies.

Why this indicator is 

useful

Tobacco-free policies help establish nonsmoking environments as a social norm while 

also protecting nonsmoking community members from exposure to secondhand 

smoke.1,2 Youth living in communities with strong smoke-free policies are more likely 

to perceive a lower prevalence of adult smoking and are less likely to progress to 

established smoking.3,4 By changing the perception that smoking is a normal adult 

behavior, “these policies can change the attitudes and behaviors of adolescents, resulting 

in a reduction in tobacco use initiation” (Task Force on Community Preventive 

Services,5 p. 48). Young people who work in smoke-free workplaces have been shown 

to be 32% less likely to be smokers than peers who work in locations with only partial 

smoke-free bans.3

Example data 

source(s)

Policy tracking system

Americans for Nonsmokers’ Rights (ANR)

Information available at: http://www.no-smoke.org

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” tobacco-free policies include 

those that apply to all public and private workplaces, restaurants, and bars at all times 

and do not include preemptions, opt-out provisions, or exemptions. See the Americans 

for Nonsmokers’ Rights Web site for additional information: http://www.no-smoke.org/

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances. 

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$$
GOAL AREA 1

► Outcome 3 

80 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References 

1. Hamilton WL, Biener L, Brennan RT. Do local tobacco regulations influence perceived smoking norms? 

Evidence from adult and youth surveys in Massachusetts. Health Education Research. 2008 Aug;23(4):709–22. 

2. Francis JA, Abramsohn EM, Park HY. Policy-driven tobacco control. Tobacco Control. 2010 Apr;19(Suppl 

1):i16–20.

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

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

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. 

4. Siegel M, Albers AB, Cheng DM, Hamilton WL, Biener L. Local restaurant smoking regulations and the 

adolescent smoking initiation process: results of a multilevel contextual analysis among Massachusetts youth. 

Archives of Pediatrics & Adolescent Medicine. 2008;162(5):477–83.

5. Task Force on Community Preventive Services. The guide to community preventive services: what works to 

promote health? New York, NY: Oxford University Press; 2005. 

For Further Reading 

Forster JL, Widome R, Bernat DH. Policy interventions and surveillance as strategies to prevent tobacco use in 

adolescents and young adults. American Journal of Preventive Medicine. 2007 Dec;33(6 Suppl):S335–9.

McMullen KM, Brownson RC, Luke D, Chriqui J. Strength of clean indoor air laws and smoking related outcomes 

in the USA. Tobacco Control. 2005;14(1):43–8.

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. 

Voorhees CC, Ye C, Carter-Pokras O, MacPherson L, Kanamori M, Zhang G, et al. Peers, tobacco advertising, and 

secondhand smoke exposure influences smoking initiation in diverse adolescents. American Journal of Health 

Promotion. Jan-Feb 2011;25(3):e1–11. 
GOAL AREA 1

► Outcome 3 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

81

Indicator 1.3.h 

Proportion of States with Tobacco Control Laws That Preempt Stronger 

Local Tobacco Control and Prevention Laws

KOI 2005 1.8.7 Revised Title (Previously: “Changes in state tobacco control laws that preempt 

stronger local tobacco control laws”)

Goal area Preventing initiation of tobacco use

Outcome box Increased restriction and enforcement of tobacco product sales, availability, and use

What to measure Any change in legislation that prevents local jurisdictions from enacting restrictions that 

are more stringent than the state’s tobacco control statutes and/or regulations (e.g., 

restrictions on youth access to tobacco, smoke-free indoor air, or tobacco-related 

advertising)

Why this indicator is 

useful

Preemptive legislation is the tobacco industry’s chief strategy for eradicating local 

tobacco control ordinances. The industry aggressively pushes for states to pass 

legislation that preempts local regulation of tobacco in various areas, including youth 

access, smoke-free indoor air, and tobacco advertising.1 Preemptive laws prevent 

communities from engaging in the process of public education, mobilization, and debate 

that occurs when a local ordinance is under consideration. Suppressing public education, 

mobilization, and debate undermines changes in awareness and social norms. As of 

December 31, 2010, 27 states had some type of preemption related to youth access, 

smoke-free indoor air, or tobacco advertising.2 Although progress has been made in 

repealing preemptive provisions related to smoke-free indoor air, more work is needed 

under youth access and tobacco advertising.3

Example data 

source(s)

CDC State Tobacco Activities Tracking and Evaluation (STATE) System

Information available at: http://www.cdc.gov/tobacco/STATEsystem

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 None

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $ †

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. 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 1

► Outcome 3 

82 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

2. Centers for Disease Control and Prevention. State preemption of local tobacco control policies restricting 

smoking, advertising, and youth access—United States, 2000–2010. Morbidity and Mortality Weekly Report. 

2011;60(33):1124–7. 

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(04):105–8. 

For Further Reading 

American Lung Association. State Legislative Actions on Tobacco Issues (SLATI) Overview. 2009. Available at: 

http://slati.lungusa.org/StateLegislateAction.asp

Chen V, Forster JL. The long-term effect of local policies to restrict retail sale of tobacco to youth. Nicotine & 

Tobacco Research. 2006;8(3):371–7.

National Cancer Institute. ASSIST: shaping the future of tobacco prevention and control. Tobacco Control 

Monograph No. 16. NIH Publication No. 05-5645. Bethesda, MD: U.S. Department of Health and Human Services, 

National Institutes of Health, National Cancer Institute; May 2005. 
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

83

Outcome 4 

Increased Policy and Enforcement Efforts to Reduce Tobacco Industry 

Influence 

According to the most recent Federal Trade Commission tobacco reports, the U.S. tobacco 

industry spends almost $8.8 billion per year to advertise and promote its products.1,2 It is not 

surprising, therefore, that studies show that a high percentage of young people are exposed to, 

aware of, and able to recall tobacco advertising.3,4 Moreover, numerous studies have found a 

causal relationship between the advertising and promotional activities of the tobacco industry 

and initiation and progression of tobacco use among youth and young adults.3-5 In addition, 

tobacco advertising can distort young people’s perceptions of tobacco use.2, 6-8

In 2011, the tobacco companies spent 87% of their marketing dollars in the retail environment, 

including point-of-sale advertising, price discounts, retail promotional allowances, and retailvalue-added items.1,2 The tobacco industry offers retailers volume discounts, price promotions, 

in-store branded displays, and payment for prime shelf space, exposing all consumers, including 

youth, to pro-smoking messages in the retail environment. In return for financial incentives, 

retailers enter into contractual agreements with tobacco companies to ensure high visibility and 

accessibility of their products to stimulate impulse purchases.6,7 Studies have shown that pointof-sale tobacco advertising is more prevalent in stores near schools and in minority and lowincome neighborhoods.8-11 Research has also identified a relationship between exposure to 

tobacco marketing in the retail environment and use of tobacco by youth, including 

experimentation and uptake of smoking.12-14 Signage visible outside the stores exposes entire 

communities to tobacco marketing. The result is that many U.S. children grow up surrounded by 

pro-tobacco messages.10

Exposure to cigarette advertising at the point of sale is a risk factor for smoking initiation,14

suggesting that countermarketing messages delivered in tobacco retail outlets could contribute to 

prevention of tobacco use initiation among youth and young people. Posting health warnings at 

the point of sale provides potential users with factual information about the health risks of 

tobacco use, as well as information on how to access effective cessation services. 

Advertising bans have been shown to reduce per capita tobacco consumption.15 Following the 

ban on television and radio tobacco advertising in 1971, the United States instated additional 

restrictions on advertising as part of the 1998 Master Settlement Agreement, which banned any 

advertising targeting youth, as well as billboard and transit ads. Furthermore, the Family 

Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 2009 set forth 

additional rules banning promotional activities, such as the sale and distribution of tobaccobranded nontobacco products, and sponsorship of music and sporting events. States and localities 

can restrict or regulate the time, place, and manner (but not the content) of tobacco advertising 

under the Tobacco Control Act. It is important to note, however, that noncomprehensive 

restrictions can result in increased advertising in “non-banned” media and increased expenditures 

in other promotion and marketing activities.3
GOAL AREA 1

► Outcome 4

84 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

The following indicators are associated with this outcome:

► 1.4.a Proportion of jurisdictions with strong policies that regulate tobacco advertising

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

consumer-focused tobacco promotions

► 1.4.c Proportion of jurisdictions with strong policies that regulate the extent and type of 

merchant-focused industry promotions

► 1.4.d Proportion of jurisdictions with strong minimum tobacco product price laws

► 1.4.e Proportion of jurisdictions with strong public policies to establish a fee on each 

package of tobacco product sold to cover government costs

► 1.4.f Proportion of jurisdictions with strong policies that limit tobacco industry 

sponsorship of public and private events

► 1.4.g Number and type of enforcement actions issued for violations of restrictions on 

tobacco marketing

► 1.4.h Number and type of Master Settlement Agreement violations by tobacco companies

References

1. Federal Trade Commission. Smokeless tobacco report for 2011. Washington, DC: Federal 

Trade Commission; 2013.

2. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade 

Commission; 2013.

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

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

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

Institute; June 2008.

4. 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. Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing 

adolescent smoking behaviours. Cochrane Database of Systematic Reviews. 

2011(10):CD003439.

6. Dewhirst T. POP goes the power wall? Taking aim at tobacco promotional strategies utilised 

at retail. Tobacco Control. 2004;13(3):209–10.

7. Pollay RW. More than meets the eye: on the importance of retail cigarette merchandising. 

Tobacco Control. 2007;16(4):270–4.

8. Pucci LG, Joseph HM, Jr., Siegel M. Outdoor tobacco advertising in six Boston 

neighborhoods. Evaluating youth exposure. American Journal of Preventive Medicine. 

1998;15(2):155–9.
GOAL AREA 1

► Outcome 4

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

85

9. John R, Cheney MK, Azad MR. Point-of-sale marketing of tobacco products: taking 

advantage of the socially disadvantaged? Journal of Health Care for the Poor and 

Underserved. 2009;20(2):489–506.

10. Barbeau EM, Wolin KY, Naumova EN, Balbach E. Tobacco advertising in communities: 

associations with race and class. Preventive Medicine. 2005;40(1):16–22.

11. Cohen JE, Planinac LC, Griffin K, Robinson DJ, O’Connor SC, Lavack A, et al. Tobacco 

promotions at point-of-sale: the last hurrah. Canadian Journal of Public Health Revue 

Canadienne De Santé Publique. 2008;99(3):166–71.

12. Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail 

cigarette marketing practices on youth smoking uptake. Archives of Pediatrics & Adolescent 

Medicine. 2007;161(5):440–5.

13. Paynter J, Edwards R, Schluter PJ, McDuff I. Point of sale tobacco displays and smoking 

among 14–15 year olds in New Zealand: a cross-sectional study. Tobacco Control. 

2009;18(4):268–74.

14. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal study of exposure to 

retail cigarette advertising and smoking initiation. Pediatrics. 2010;126(2):232–8.

15. Henriksen L. Comprehensive tobacco marketing: promotion, packaging, price and place. 

Tobacco Control. 2012;21(2):147–53.

For Further Reading

Carpenter C, Cook PJ. Cigarette taxes and youth smoking: new evidence from national, state, 

and local Youth Risk Behavior Surveys. Journal of Health Economics. 2008;27(2):287–99.

Celebucki CC, Diskin K. A longitudinal study of externally visible cigarette advertising on retail 

storefronts in Massachusetts before and after the Master Settlement Agreement. Tobacco 

Control. 2002;11(Suppl 2):ii47–ii53.

DeCicca P, Kenkel D, Mathios A. Cigarette taxes and the transition from youth to adult smoking: 

smoking initiation, cessation, and participation. Journal of Health Economics. 2008;27(4):904–

17.

DeCicca P, Kenkel D, Mathios A, Shin YJ, Lim JY. Youth smoking, cigarette prices, and antismoking sentiment. Health Economics. 2008;17(6):733–49.

DiFranza JR, Wellman RJ, Sargent JD, Weitzman M, Hipple BJ, Winickoff JP, Tobacco 

Consortium, Center for Child Health Research of the American Academy of Pediatrics. Tobacco 

promotion and the initiation of tobacco use: assessing the evidence for causality. Pediatrics. 

2006;117(6):e1237–e1248.

Dinno A, Glantz S. Tobacco control policies are egalitarian: a vulnerabilities perspective on 

clean indoor air laws, cigarette prices, and tobacco use disparities. Social Science & Medicine. 

2009;68(8):1439–47.

Institute of Medicine (IOM). Ending the tobacco problem: a blueprint for the nation. 

Washington, DC: The National Academies Press; 2007.

Katzman B, Markowitz S, McGeary KA. An empirical investigation of the social market for 

cigarettes. Health Economics. 2007;16(10):1025–39.
GOAL AREA 1

► Outcome 4

86 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Morley CP, Cummings KM, Hyland A, Giovino GA, Horan JK. Tobacco Institute lobbying at 

the state and local levels of government in the 1990s. Tobacco Control. 2002;11(Suppl 1):I102–

I109.

Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. 

Nicotine & Tobacco Research. 2009;11(1):25–35.

Powell LM, Tauras JA, Ross H. The importance of peer effects, cigarette prices and tobacco 

control policies for youth smoking behavior. Journal of Health Economics. 2005;24(5):950–68.

Roeseler A, Feighery EC, Cruz TB. Tobacco marketing in California and implications for the 

future. Tobacco Control. 2010;19(Suppl 1):i21–i29.

Sloan FA, Trogdon JG. The impact of the Master Settlement Agreement on cigarette 

consumption. Journal of Policy Analysis and Management. 2004;23(4):843–55.

Tauras JA. Can public policy deter smoking escalation among young adults? Journal of Policy 

Analysis and Management. 2005;24(4):771–84.

Tauras JA, Markowitz S, Cawley J. Tobacco control policies and youth smoking: evidence from 

a new era. Advances in Health Economics and Health Services Research. 2005;16:277–91.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

87

Outcome 4 

Increased Policy and Enforcement Efforts to Reduce Tobacco Industry 

Influence 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.4.a Proportion of jurisdictions with 

strong policies that regulate 

tobacco advertising

$$$

1.4.b Proportion of jurisdictions with 

strong policies that regulate the 

extent and type of consumerfocused tobacco promotions

$$$$

1.4.c Proportion of jurisdictions with 

strong policies that regulate the 

extent and type of merchantfocused industry promotions

$$$$

1.4.d Proportion of jurisdictions with 

strong minimum tobacco product 

price laws

$$$$

1.4.e Proportion of jurisdictions with 

strong public policies to establish a 

fee on each package of tobacco 

product sold to cover government 

costs

†† $$$$

1.4.f Proportion of jurisdictions with 

strong policies that limit tobacco 

industry sponsorship of public and 

private events

†† $$$$

1.4.g Number and type of enforcement 

actions issued for violations of 

restrictions on tobacco marketing

$$†

1.4.h Number and type of Master 

Settlement Agreement violations 

by tobacco companies

$$$

$ 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. 
GOAL AREA 1

► Outcome 4

88 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±1 point of the median for 

this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±2 points of the 

median for overall quality of the indicator.

 Denotes no data.

NR Denotes an indicator that is not rated (see Appendix C for an explanation).
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

89

Indicator 1.4.a

Proportion of Jurisdictions with Strong Policies That Regulate Tobacco 

Advertising 

KOI 2005 1.9.2 Revised Title (Previously: “Proportion of jurisdictions with policies that regulate 

the extent and type of retail tobacco advertising and promotions”)

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Proportion of local jurisdictions with public policies that regulate time, place, and/or 

manner of retail tobacco advertising (either inside or outside stores), such as product 

displays and printed or electronic tobacco advertisements. See “Comments” below for 

clarification of “strong” policies.

Why this indicator is 

useful

There is a causal relationship between exposure to tobacco advertising and tobacco 

initiation and increased tobacco use.1 Studies have shown that the volume of in-store 

advertisements and the proportion of stores with sales promotions have increased more 

rapidly in neighborhoods with a higher proportion of African Americans than in other 

communities.2 Regulating retail advertising and promotions may significantly reduce 

young people’s exposure to tobacco advertising.3,4 As of 2011, 20 states had some type 

of tobacco advertising restriction in place. These restrictions varied by state but included 

provisions such as bans on tobacco advertising in certain locations, restrictions on size 

or placement of advertisements, bans on certain manner of advertising such as in video 

games, and requirements for warning labels on tobacco advertisements.5

Example data 

source(s)

Policy tracking system

Americans for Nonsmokers’ Rights (ANR)

Information available at: http://www.no-smoke.org

CDC State Tobacco Activities Tracking and Evaluation (STATE) system—LegislationAdvertising

Data 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 pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments The Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 

2009 gave the U.S. Food and Drug Administration the authority to regulate the 

manufacturing, marketing, and sale of tobacco products and allows states and localities 

to restrict or regulate the time, place, and manner (but not the content) of cigarette 

advertising (Pub. L. No. 111-31, § 203 (2009).

Evaluators should determine the scope of the policy standards before evaluating the 

presence/absence and reach of such policies. See the Center for Public Health Law and 

Tobacco Policy for an example Model Tobacco Product Display Ban Ordinance:

http://publichealthlawcenter.org/sites/default/files/resources/nycenter-syntobproductdisplaybans-2010.pdf

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances. It may also be useful to gather 

details regarding any time, location, and medium restrictions included in the policies.
GOAL AREA 1

► Outcome 4 

90 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

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

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

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

2. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8.

3. Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their 

advertising and products in stores: interviews with retailers about tobacco company incentive programmes. 

Tobacco Control. 2003;12(2):184–8.

4. Henriksen L, Schleicher NC, Feighery E, Fortmann SP. A longitudinal study of exposure to retail cigarette 

advertising and smoking initiation. Pediatrics. 2010;126:232–8.

5. Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) 

system. Atlanta, GA: Centers for Disease Control and Prevention. Online database. Available at: 

http://www.cdc.gov/tobacco/statesystem. Accessed August 2011. 

For Further Reading 

Chuang YC, Cubbin C, Ahn D, Winkleby MA. Effects of neighbourhood socioeconomic status and convenience 

store concentration on individual level smoking. Journal of Epidemiology and Community Health. 2005;59(7):568–

73.

Duke JC, Appleyard Allen J, Pederson LL, Mowery PD, Xiao H, Sargent JD. Reported exposure to pro-tobacco 

messages in the media: Trends among youth in the United States, 2000–2004. American Journal of Health 

Promotion. 2009;23(3):195–202.

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

Academies Press; 2007. 

Ribisl KM. Research gaps related to product marketing and sales in the 2009 Family Smoking Prevention and 

Tobacco Control Act. Nicotine & Tobacco Research. 2012;14(2012):43–53.

Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail cigarette marketing 

practices on youth smoking uptake. Archives of Pediatrics & Adolescent Medicine. 2007;161(5):440–5.

Weiss JW, Cen S, Schuster DV, Unger JB, Johnson CA, Mouttapa M, et al. Longitudinal effects of pro-tobacco and 

anti-tobacco messages on adolescent smoking susceptibility. Nicotine & Tobacco Research. 2006;8(3):455–65. 
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

91

Indicator 1.4.b

Proportion of Jurisdictions with Strong Policies that Regulate the Extent 

and Type of Consumer-Focused Tobacco Promotions

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence 

What to measure Proportion of local jurisdictions with public policies that regulate consumer-focused 

promotions, such as cents off, rebates, coupons, and buy-one-get-one-free offers. See 

“Comments” below for clarification of “strong” policies.

Why this indicator is 

useful

There is a causal relationship between tobacco promotion and increased tobacco use.1,2

In 2011, almost $8.4 billion was spent on cigarette advertising and promotion 

expenditures, with approximately 84% of these expenditures directed at price 

promotions in the retail setting.3 A substantial increase in the percentage of stores 

offering price promotions for cigarettes has been documented over the past decade.4

Recent studies show that price-related promotions are accelerating disproportionately 

among retailers in neighborhoods with lower socioeconomic status and higher 

proportions of racial and ethnic populations experiencing health disparities.5,6 Greater 

availability of cigarette promotions and lower cigarette prices are associated with 

increased initiation and uptake among youth and decreased quit attempts among current 

smokers.2,7-9

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Evaluators should determine the scope of policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” policies that regulate the extent 

and type of consumer-focused tobacco promotions may include those that restrict the 

distribution or redemption of discount coupons for tobacco products, that limit discounts 

and incentive programs offered by tobacco manufacturers to retailers, and that prohibit 

“buy-one-get-one-free” and other value-added promotional discounts. See the Center for 

Public Health and Tobacco Policy’s report, Tobacco Price Promotion: Policy Responses 

to Industry Price Manipulation, for more information: 

http://www.tobaccopolicycenter.org/documents/Final%20Report%20with%20covers%2

010.28.11.pdf.

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$$
GOAL AREA 1

► Outcome 4

92 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

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

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

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

2. Pierce JP. Tobacco industry marketing, population-based tobacco control, and smoking behavior. American 

Journal of Preventive Medicine. 2007;33(6 Suppl):S327–34.

3. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade Commission; 2013.

4. Roeseler A, Feighery E, Cruz T. Tobacco marketing in California and implications for the future. Tobacco 

Control. 2010 Apr;19(Suppl 1):i21–i29.

5. Chuang Y, Cubbin C, Ahn D, Winkleby M. Effects of neighbourhood socioeconomic status and convenience 

store concentration on individual level smoking. Journal of Epidemiology and Community Health. 

2005;59(7):568–73.

6. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8.

7. Slater S, Chaloupka F, Wakefield M, Johnston L, O’Malley P. The impact of retail cigarette marketing practices 

on youth smoking uptake. Archives of Pediatrics & Adolescent Medicine. 2007;161(5):440–5.

8. Henriksen L, Feighery E, Schleicher N, Cowling D, Kline R, Fortmann S. Is adolescent smoking related to the 

density and proximity of tobacco outlets and retail cigarette advertising near schools? Preventive Medicine. 

2008;47(2):210–4.

9. Feighery E, Rogers T, Ribisl KM. Tobacco retail price manipulation policy strategy summit proceedings. 

Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2009.

For Further Reading

Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their 

advertising and products in stores: interviews with retailers about tobacco company incentive programmes. Tobacco 

Control. 2003;12(2):184–8.

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

Academies Press; 2007.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

93

Indicator 1.4.c

Proportion of Jurisdictions with Strong Policies that Regulate the Extent 

and Type of Merchant-Focused Industry Promotions

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Proportion of local jurisdictions with public policies that regulate merchant-focused 

industry promotions. These promotions include those where tobacco manufacturers 

provide retail and/or wholesale discounts on tobacco products or payments in return for 

prime advertising space. See “Comments” below for clarification of “strong” policies.

Why this indicator is 

useful

Tobacco manufacturers have increasingly focused marketing resources on price 

promotions in the years since the 1998 Master Settlement Agreement.1,2In 2011, almost 

$8.4 billion was spent on cigarette advertising and promotion expenditures, with 

approximately $6.99 billion (84%) of these expenditures directed at price discounts.3

The industry’s increased use of slotting fees and trade promotions has kept prices lower 

and increased youth exposure to tobacco products and pro-tobacco messaging in the 

retail setting.

4,5 Price-sensitive groups, including young and low-income people, are 

especially vulnerable to industry price promotions, and thus these incentives may place a 

higher burden on these populations.6,7 For a discussion of policy options, see 

http://www.tobaccopolicycenter.org/documents/Final%20Report%20with%20covers%2

010.28.11.pdf.

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Evaluators should determine the scope of policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” policies that regulate the extent 

and type of merchant-focused industry promotions include those that limit allowances 

paid to retailers, slotting fees, price discounts, and buy-downs. See the Center for Public 

Health and Tobacco Policy’s report, Tobacco Price Promotion: Policy Responses to 

Industry Price Manipulation, for more information: 

http://www.tobaccopolicycenter.org/documents/Final%20Report%20with%20covers%2

010.28.11.pdf.

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$$ *

* Denotes low reviewer response, defined as fewer than 75% of valid ratings on a 

criterion for an indicator.
GOAL AREA 1

► Outcome 4

94 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. Loomis BR, Farrelly MC, Nonnemaker JM, Mann NH. Point of purchase cigarette promotions before and after 

the Master Settlement Agreement: exploring retail scanner data. Tobacco Control. 2006;15(2):140–2.

2. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8.

3. Federal Trade Commission. Federal Trade Commission cigarette report for 2011 Washington, DC: Federal 

Trade Commission; 2013.

4. Bloom PN. Role of slotting fees and trade promotions in shaping how tobacco is marketed in retail stores. 

Tobacco Control. 2001 Dec;10(4):340–4.

5. Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their

advertising and products in stores: interviews with retailers about tobacco company incentive programmes. 

Tobacco Control. 2003 Jun;12(2):184–8.

6. Pierce JP, Gilmer TP, Lee L, Gilpin EA, de Beyer J, Messer K. Tobacco industry price-subsidizing promotions

may overcome the downward pressures of higher prices on initiation of regular smoking. Health Economics.

2005;14(10):1061–71.

7. White VM, White MM, Freeman K, Gilpin EA, Pierce JP. Cigarette promotional offers: who takes advantage? 

American Journal of Preventive Medicine. 2006;30(3):225–31.

For Further Reading

Feighery EC, Ribisl KM, Achabal DD, Tyebjee T. Retail trade incentives: how tobacco industry practices compare 

with those of other industries. American Journal of Public Health. 1999;89(10):1564–6.

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

Academies Press; 2007.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

95

Indicator 1.4.d

Proportion of Jurisdictions with Strong Minimum Tobacco Product Price 

Laws

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Proportion of local jurisdictions with strong public policies that regulate the minimum 

price of tobacco products. See “Comments” below for clarification of “strong” policies.

Why this indicator is 

useful

Increasing the price of tobacco products reduces tobacco consumption and prevalence, 

especially among price-sensitive populations (e.g., youth).1,2 The tobacco industry uses 

price promotions, including discounts and coupons, to undermine government efforts to 

raise the price of tobacco products.3,4 Minimum price laws are one way for states to 

counteract the tobacco companies’ efforts by prohibiting cigarettes from being sold for 

less than a specific, formulated price. Minimum price laws are a means to prevent or 

mitigate tobacco industry efforts to keep effective prices low.5 As of December 31, 

2009, 24 states and the District of Columbia had minimum price laws in place.6

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s) Not applicable

Comments “Strong” laws may include those that prohibit trade discounts from the minimum price 

calculation, set a minimum price by mandating a high percentage markup for tobacco 

wholesalers and retailers, and are applied to a breadth of tobacco products. Evaluators 

should determine the scope of the policy standards, and set an operational definition of 

strong minimum tobacco product price laws before evaluating the presence/absence and 

reach of such policies. See the Tobacco Control Legal Consortium for policy 

considerations relevant to minimum tobacco price laws and possible elements of a 

strong law:

http://publichealthlawcenter.org/sites/default/files/resources/tclc-guidecigminimumpricelaws-2011.pdf

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$$
GOAL AREA 1

► Outcome 4

96 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the 

Surgeon General. 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. 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.

3. Chaloupka FJ, Cummings KM, Morley CP, Horan JK. Tax, price and cigarette smoking: evidence from the 

tobacco documents and implications for tobacco company marketing strategies. Tobacco Control. 

2002;11(Suppl 1):i62–72.

4. Feighery E, Rogers T, Ribisl KM. Tobacco retail price manipulation policy strategy summit proceedings. 

Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2009. 

Available at: http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPPriceStrategySummit2009.pdf

5. Feighery EC, Ribisl KM, Schleicher NC, Zellers L, Wellington N. How do minimum cigarette price laws affect 

cigarette prices at the retail level? Tobacco Control. 2005;14:80–5.

6. Ribisl KM, Patrick, R, Eidson S, Tynan M, Francis J. Centers for Disease Control and Prevention. State 

cigarette minimum price laws—United States, 2009. Morbidity and Mortality Weekly Report. 2010 Apr 

9;59(13):389–92.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

97

Indicator 1.4.e

Proportion of Jurisdictions with Strong Public Policies to Establish a Fee 

on Each Package of Tobacco Product Sold to Cover Government Costs

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Proportion of local jurisdictions with public policies that establish a fee on each package 

of tobacco product sold to cover government costs related to improperly discarded 

tobacco products. The fee might be used to cover the cost of tobacco-related health care, 

litter mitigation, wildfire management, or other types of social and environmental 

protection programs. See “Comments” below for clarification of “strong” policies.

Why this indicator is 

useful

Increasing price is one of the most effective methods to decrease tobacco use and 

prevent initiation.1 Although limited studies have assessed the impact of mitigation fees 

on tobacco price, a fee that is consistently applied to every tobacco product sold may 

have effects similar to an excise tax.2 Additionally, policies to recover costs of tobacco 

product litter would have secondary environmental, health, and economic benefits.3-5

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments These types of fees may not be able to be imposed at the local level in some states.

Evaluators should determine the scope of policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” policies are those that are actively 

enforced and include a fee on each package of tobacco product sold to cover 

governmental costs. Applicable costs may include, but are not limited to, tobaccorelated health care, litter mitigation, wildfire management, or other types of social and 

environmental protection programs.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$$$ †

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

► Outcome 4 

98 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References 

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

National Academies Press; 2007. 

2. Feighery E, Rogers T, Ribisl KM. Tobacco retail price manipulation policy strategy summit proceedings. 

Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2009. 

Available at: http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPPriceStrategySummit2009.pdf

3. Schneider JE, Decker CS, Doyle A, Meinders K, Kiss N. Estimates of the costs of tobacco litter in San 

Francisco and calculations of maximum permissible per-pack fees. Morristown, NJ: Health Economics 

Consulting Group; 2009. Available at: http://www.sfenvironment.org/downloads/library/ 

tobacco_litter_study_hecg_062209.pdf

4. Novotny TE, Lum K, Smith E, Wang V, Barnes R. Cigarette butts and the case for an environmental policy on 

hazardous cigarette waste. International Journal of Research in Public Health. 2009;6(5):1691–705. 

5. Novotny TE, Zhao F. Consumption and production waste: another externality of tobacco use. Tobacco Control. 

1999;8(1):75–80.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

99

Indicator 1.4.f 

Proportion of Jurisdictions with Strong Policies That Limit Tobacco 

Industry Sponsorship of Public and Private Events

KOI 2005 1.9.6 Revised Title (Previously: “Proportion of jurisdictions with policies that regulate 

tobacco industry sponsorship of public events”)

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Proportion of local jurisdictions with policies that limit tobacco industry sponsorship. 

The Master Settlement Agreement and the Family Smoking Prevention and Tobacco 

Control Act (Tobacco Control Act) placed limitations on cigarette brand sponsorship. 

However, local jurisdictions may seek to expand sponsorship policies relevant to other 

tobacco products and in other venues. See “Comments” below for clarification of 

“strong” policies.

Why this indicator is 

useful

The tobacco industry sponsors highly publicized community, cultural, and sporting 

events to build brand recognition and increase exposure to pro-tobacco messaging.1-6

These efforts serve to buy legitimacy for the tobacco industry while increasing public 

opinion of tobacco companies and their products.1-3 These efforts may also make 

community members and key opinion leaders resistant to anti-tobacco messaging and 

weaken support for tobacco control policies.3

Example data 

source(s)

Policy tracking system

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey 

question(s)

Not applicable

Comments Evaluators are encouraged to document existing policies impacting sponsorship such as 

marketing exceptions in the Master Settlement Agreement and the Family Smoking and 

Tobacco Control Act of 2009.

Evaluators should determine the scope of policy standards before evaluating the 

presence/absence and reach of such policies. “Strong” policies that limit tobacco 

industry sponsorship include actively enforced provisions banning all types of industry 

sponsorship in all venues including adult only facilities and venues. See Change Lab 

Solutions Web site for additional information: http://changelabsolutions.org/tobaccocontrol/question/what-is-tobacco-sponsorship.

Evaluators may also choose to gather data on the size and demographics of the 

population protected by the relevant laws or ordinances.

Rating

Resources 

needed

Strength of

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$$$

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

► Outcome 4

100 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. Rosenberg NJ, Siegel M. Use of corporate sponsorship as a tobacco marketing tool: a review of tobacco 

industry sponsorship in the USA, 1995–99. Tobacco Control. 2001;10(3):239–46.

2. Federal Trade Commission. Cigarette report for 2002. Washington, DC: Federal Trade Commission; 2004.

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

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

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

4. Cruz TB. Monitoring the tobacco use epidemic IV. The vector: tobacco industry data sources and 

recommendations for research and evaluation. Preventive Medicine. 2009;48(1 Suppl):S24–S34.

5. Bogen K, Biener L, Nyman A. Consequences of marketing exceptions in the Master Settlement Agreement: 

exposure of youth to adult-only tobacco promotions. Nicotine & Tobacco Research. 2006;8(3):467–71.

6. Siegel M. Counteracting tobacco motor sports sponsorship as a promotional tool: is the tobacco settlement 

enough? American Journal of Public Health. 2001;91(7):1100–6.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

101

Indicator 1.4.g 

Number and Type of Enforcement Actions Issued for Violations of 

Restrictions on Tobacco Marketing

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Number and type of enforcement actions, including warnings, citations, and fines issued 

to manufacturers, wholesalers, and/or retailers for infractions of public policies 

restricting tobacco marketing. Penalties may include civil and/or criminal penalties,

including citations, graduated fines, and suspension or loss of license to sell tobacco for 

retailers. 

Why this indicator is 

useful

An effective means of enforcing tobacco control public policies is to conduct regular 

compliance checks.1 Such checks convey the message that policy makers and the public 

care about tobacco policies and are serious about enforcing them.

2-4

Example data 

source(s)

FDA, Compliance Check Inspection of Tobacco Product Retailers

Information available at: 

http://www.accessdata.fda.gov/scripts/oce/inspections/oce_insp_searching.cfm

California Tobacco Control Program: Enforcement Survey

Information available at: 

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPEnforcementReport08-

05.pdf

Population group(s) Agency representatives responsible for enforcement

Example survey 

question(s)

From FDA, Compliance Check Inspection of Tobacco Product Retailers: Retailer 

Name, City, State, Zip, Decision Type: No violations observed, Warning letters issued

From California Tobacco Control Program: Enforcement Survey

In the past year, how often has your agency conducted any of the following types of 

enforcement activities?

• Compliance checks of tobacco advertisement restrictions ___________________

• Compliance checks of tobacco promotions ______________________________

• Issued warnings for marketing violations ________________________________

• Issued penalties for marketing violations ________________________________

Proportion of retailers who have received a compliance check in the past 12 months.

____________________________________________________________________

Comments Example survey questions are adapted from existing youth access enforcement surveys:

http://www.cdph.ca.gov/programs/tobacco/Documents/CTCPEnforcementReport08-

05.pdf

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$†

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.
GOAL AREA 1

► Outcome 4

102 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. Roeseler A, Feighery E, Cruz TB. Tobacco marketing in California and implications for the future. Tobacco 

Control. 2010;19(Suppl 1):i22–i29.

2. Weber MD, Bugwell 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.

3. Rogers T, Feighery EC, Haladjian HH. Current practices in enforcement of California laws regarding youth 

access to tobacco products and exposure to secondhand smoke. Sacramento, CA: California Department of 

Public Health; 2008.

4. Rogers T, Feighery EC, Tencati EM, Butler JL, Weiner L. Community mobilization to reduce point of purchase 

advertising of tobacco products. Health Education Quarterly. 1995;22(4):427–42.
GOAL AREA 1

► Outcome 4 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

103

Indicator 1.4.h 

Number and Type of Master Settlement Agreement Violations by Tobacco 

Companies

KOI 2005 1.9.10 

Goal area Preventing initiation of tobacco use among young people

Outcome box Increased policy and enforcement efforts to reduce tobacco industry influence

What to measure Number and type of Master Settlement Agreement (MSA) violations by tobacco 

companies

Why this indicator is 

useful

The 1998 MSA prohibits tobacco advertising to youth and limits the extent and 

distribution of marketing to “adult-only” venues. However, the MSA contains numerous 

loopholes related to sponsorship, advertising, and promotions that provide ongoing 

exposure to youth.1 Although tobacco companies have shifted their marketing policies to 

exploit these loopholes, the industry also continues to violate existing provisions.2

Tracking MSA violations will aid in enforcement3and may decrease exposure to 

tobacco industry marketing.4,5

Example data 

source(s)

Tobacco industry monitoring system

Information available at: http://tobaccocontrol.bmj.com/content/19/Suppl_1/i21.full

California Tobacco Industry Monitoring Evaluation: Project SMART Money 

Information available in Roeseler et al.6

Population group(s) Not applicable. This indicator is best measured by monitoring and tracking tobacco 

industry practices.

Example survey 

question(s)

Not applicable

Comments None noted

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

1. Bogen K, Biener L, Nyman A. Consequences of marketing exceptions in the Master Settlement Agreement: 

exposure of youth to adult-only tobacco promotions. Nicotine & Tobacco Research. 2006;8(3):467–71.

2. Chung PJ, Garfield CF, Rathouz PJ, Lauderdale DS, Best D, Lantos J. Youth targeting by tobacco 

manufacturers since the Master Settlement Agreement: the first study to document violations of the youthtargeting ban in magazine ads by the three top U.S. tobacco companies. Health Affairs. 2002;21(2):254–63. 

3. Roeseler A, Burns D. The quarter that changed the world. Tobacco Control. 2010;19(Suppl 1):i3–15.

4. Hamilton WL, Turner-Bowker DM, Celebucki CC, Connolly GN. Cigarette advertising in magazines: the 

tobacco industry response to the Master Settlement Agreement and to public pressure. Tobacco Control. 

2002;11(Suppl 2):ii54–8.

5. Celebucki CC, Diskin K. A longitudinal study of externally visible cigarette advertising on retail storefronts in 

Massachusetts before and after the Master Settlement Agreement. Tobacco Control. 2002;11(Suppl 2):ii47–53.
GOAL AREA 1

► Outcome 4 

104 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

6. Roeseler A, Feighery EC, Cruz TB. Tobacco marketing in California and implications for the future. Tobacco 

Control. 2010 Apr;19(Supp 1):21–7.

For Further Reading 

Cruz TB. Monitoring the tobacco use epidemic IV. The vector: Tobacco industry data sources and recommendations 

for research and evaluation. Preventive Medicine. 2009;48(1 Suppl):S24–S34.

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.

Scott MM, Cohen DA, Schonlau M, Farley TA, Bluthenthal RN. Alcohol and tobacco marketing: evaluating 

compliance with outdoor advertising guidelines. American Journal of Preventive Medicine. 2008;35(3):203–9.
GOAL AREA 1

► Outcome 5 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

105

Outcome 5 

Reduced Susceptibility to Experimentation with Tobacco Products 

The combination of de-normalization of tobacco use, decreased perception of ease of retail 

access among youth, increased price, and reduced tobacco industry influence would be expected 

to lead to reduced susceptibility to experiment with tobacco products. Youth and young adults 

are uniquely vulnerable to influences to use tobacco due to their developmental stage.1

The original model of susceptibility to smoking was defined as the intention to smoke or the 

absence of a strong intention not to smoke.2 Other classifications have since added intermediate 

stages to this model; the development of smoking is heterogeneous, and several trajectories exist 

in the uptake and progression of smoking.1 Studies show that susceptibility to experimentation is 

a valid and reliable predictor of future smoking behavior.2 Studies also show that susceptible 

youth (those who have not made a firm decision not to smoke) are more likely than other youth 

to experiment with smoking.2 Moreover, recent evidence suggests that even low levels of 

smoking experimentation (two to four cigarettes smoked by age 10) substantially increase the 

likelihood of daily smoking in late adolescence.3 To reduce the percentage of youth who take up 

smoking, it is therefore necessary to prevent youth from becoming susceptible to experimenting 

with tobacco. 

A number of biological, environmental, and psychosocial factors contribute to smoking uptake 

and progression, with each having different levels of influence at different stages of smoking 

progression. In addition to tobacco industry influences, tobacco use by peers and perceptions that 

peers smoke are strongly associated with initiation and maintenance of smoking among 

adolescents.1 Beyond parental smoking and smoking by older siblings, parenting practices and 

quality of family relationships also predict smoking among youth.1 Finally, both explicit (e.g., 

beliefs about the health consequences of smoking) and implicit (e.g., memory associations 

related to tobacco use) cognitive processes also influence smoking experimentation and use.2

Specifically, given the relationship between exposure to tobacco marketing and initiation of 

tobacco use by youth, having a favorite tobacco advertisement indicates receptivity to 

advertising, which predicts smoking among youth.1

The following indicators are associated with this outcome: 

► 1.5.a Proportion of young people who think that tobacco use is cool and helps them fit in 

► 1.5.b Proportion of young people who think that young people who use tobacco products 

have more friends 

► 1.5.c

NR Proportion of young people who overestimate the smoking rate among their peers 

► 1.5.dNR Proportion of young people who report that their parents would strongly disapprove 

of their use of tobacco products 

► 1.5.e Proportion of young people who have a favorite tobacco brand 

► 1.5.f Proportion of young people who have never used tobacco but are susceptible to its 

use 
GOAL AREA 1

► Outcome 5

106 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a 

predictor of which adolescents take up smoking in the United States. Health Psychology. 

1996;15(5):355–61.

3. Jackson C, Dickinson D. Cigarette consumption during childhood and persistence of 

smoking through adolescence. Archives of Pediatrics & Adolescent Medicine. 2004

Nov;158(11):1050–6.

For Further Reading

Freedman KS, Nelson NM, Feldman LL. Smoking initiation among young adults in the United 

States and Canada, 1998–2010: a systematic review. Preventing Chronic Disease. 2012;9:E05.

Howard KA, Ribisl KM, Howard-Pitney B, Norman GJ, Rohrbach LA. What factors are 

associated with local enforcement of laws banning illegal tobacco sales to minors? A study of 

182 law enforcement agencies in California. Preventive Medicine. 2001 Aug;33(2 Pt 1):63–70.

Jason LA, Pokorny SB, Schoeny ME. Evaluating the effects of enforcements and fines on youth 

smoking. Critical Public Health. 2003;13(1):33–45.

Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing 

tobacco-sales laws on adolescents’ access to tobacco and smoking behavior. New England 

Journal of Medicine. 1997;337(15):1044–51.

Siegel M, Biener L, Rigotti NA. The effect of local tobacco sales laws on adolescent smoking 

initiation. Preventive Medicine. 1999;29(5):334–42.
GOAL AREA 1

► Outcome 5 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

107

Outcome 5 

Reduced Susceptibility to Experimentation with Tobacco Products 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.5.a Proportion of young people who 

think that tobacco use is cool and 

helps them fit in

$$

1.5.b Proportion of young people who 

think that young people who use 

tobacco products have more friends

$

1.5.cNR Proportion of young people who 

overestimate the smoking rate 

among their peers

     

1.5.dNR Proportion of young people who 

report that their parents would 

strongly disapprove of their use of 

tobacco products

     

1.5.e Proportion of young people who 

have a favorite tobacco brand

†† $

1.5.f Proportion of young people who 

have never used tobacco but are 

susceptible to its 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 low agreement among reviewers, defined as fewer than 75% of valid ratings within ±2 points of the 

median for overall quality of the indicator. 

 Denotes no data. 

NR Denotes an indicator that is not rated (see Appendix C for an explanation). 
GOAL AREA 1

► Outcome 5 

108 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.5.a

Proportion of Young People Who Think That Tobacco Use Is Cool and 

Helps Them Fit In

KOI 2005 1.10.1 Revised Title (Previously: “Proportion of young people who think that smoking 

is cool and helps them fit in”)

Goal area Preventing initiation of tobacco use

Outcome box Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who believe that tobacco use will improve their social 

standing

Why this indicator is 

useful

Tobacco advertising has been shown to target young people’s psychological needs, 

including the desire to be popular and accepted by their peers, and creates the perception 

that using tobacco products will satisfy these desires. Young people who believe that 

tobacco use will meet their social needs are more likely to use tobacco.1 Additionally, 

studies demonstrate that adolescent cigarette smokers are significantly more likely to 

believe that smokers are more socially adept than nonsmokers.2-4 These data can be used

to estimate norms regarding the social desirability of smoking, which in turn affect 

tobacco use initiation and cessation.5

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

Legacy Media Tracking Survey (LMTS), 2003 

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

Do you think smoking cigarettes makes young people look cool or fit in?

Definitely yes Probably yes Probably not Definitely not

From LMTS

Smoking cigarettes makes people your age look cool or fit in?

Strongly agree Agree Disagree Strongly Disagree No opinion

Comments These items can be modified to address other tobacco products.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

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

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

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

2. 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.
GOAL AREA 1

► Outcome 5

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

109

3. Unger JB, Rohrbach LA, Howard-Pitney B, Ritt-Olson A, Mouttapa M. Peer influences and susceptibility to 

smoking among California adolescents. Substance Use and Misuse. 2001;36(5):551–71.

4. Wang MQ. Social environmental influences on adolescents’ smoking progression. American Journal of Health 

Behavior. 2001;25(4):418–25.

5. Alamar B, Glantz SA. Effect of increased social unacceptability of cigarette smoking on reduction in cigarette 

consumption. American Journal of Public Health. 2006;96(8):1359–63.

For Further Reading

Centers for Disease Control and Prevention. Tobacco use among middle and high school students—United States, 

2000–2009. Morbidity and Mortality Weekly Report. 2010;59(33):1063–8.

Centers for Disease Control and Prevention. Youth tobacco surveillance—United States, 2001–2002. Morbidity and 

Mortality Weekly Report Surveillance Summaries. 2006;55(SS03):1–56.
GOAL AREA 1

► Outcome 5 

110 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.5.b

Proportion of Young People Who Think That Young People Who Use 

Tobacco Products Have More Friends

KOI 2005 1.10.2 Revised Title (Previously: “Proportion of young people who think that young 

people who smoke have more friends”)

Goal area Preventing initiation of tobacco use

Outcome box Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who believe that those who use tobacco products have more 

friends than those who do not use tobacco products

Why this indicator is 

useful

Data indicate that both daily and nondaily cigarette smokers are significantly more 

likely to believe that those who smoke have more friends than those who do not 

smoke.1-4 Additionally, youth who perceive smoking to be more prevalent were 

significantly more likely to smoke.5 These data can be used as an estimate of norms 

concerning the social desirability of smoking. 

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

Do you think young people who smoke cigarettes have more friends?

Definitely yes Probably yes Probably not Definitely not

Comments These items can be modified to address other tobacco products.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

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. Unger JB, Rohrbach LA, Howard-Pitney B, Ritt-Olson A, Mouttapa M. Peer influences and susceptibility to 

smoking among California adolescents. Substance Use and Misuse. 2001;36(5):551–71. 

3. Wang MQ. Social environmental influences on adolescents’ smoking progression. American Journal of Health 

Behavior. 2001;25(4):418–25.

4. Carpenter MJ, Garrett-Mayer E, Vitoc C, Cartmell K, Biggers S, Alberg AJ. Adolescent nondaily smokers: 

favorable views of tobacco yet receptive to cessation. Nicotine & Tobacco Research. Apr 2009;11(4):348–55. 

5. Ling PM, Neilands TB, Glantz SA. Young adult smoking behavior: a national survey. American Journal of 

Preventive Medicine. 2009;36(5):389–94. 
GOAL AREA 1

► Outcome 5

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

111

For Further Reading

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.
GOAL AREA 1

► Outcome 5 

112 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.5.cNR

Proportion of Young People Who Overestimate the Smoking Rate Among 

Their Peers

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of youth and young adults who perceive smoking rates to be higher than they 

actually are

Why this indicator is 

useful

Adolescents and young adults tend to overestimate actual smoking prevalence among 

their peers and adults.1-3 Such false normative expectations have been shown to predict 

initiation, experimentation, and progression in smoking in youth.3In one study of 7th 

graders, perceived smoking prevalence among peers, but not actual smoking prevalence, 

predicted future smoking.4 Youth prevention mass media campaigns often target 

perceived prevalence as a factor for intervention in order to increase realistic perceptions 

of smoking prevalence, given its influence on youth smoking behavior. Because youth 

perceptions of peer smoking levels can matter more than actual smoking levels,5

adolescent perception of peer smoking is important to monitor as a salient risk factor 

upon which to intervene. 

Example data 

source(s)

Legacy Media Tracking Survey (LMTS), 2003

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years 

Example survey 

question(s)

From LMTS: Perceived peers’ smoking

Out of every 10 people your age, how many do you think smoke?

____________________________________________________________________

Similar measure used by other researchers (e.g., Sussman et al.6):

Out of every 100 students, how many do you think smoke?

____________________________________________________________________

Botvin et al.

1

:

How many people your own age smoke cigarettes?

None Only a few Less than half

About half More than half Almost all

Cunningham and Selby2:

What percentage of people your age and sex do you think smoke cigarettes?

____________________________________________________________________

Perceived adults’ smoking

Botvin et al.1:

How many adults smoke cigarettes?

None Only a few Less than half

About half More than half Almost all

Comments These items can be modified to address other tobacco products.
GOAL AREA 1

► Outcome 5 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

113

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

 Denotes no data.

References 

1. Botvin JG, Botvin EM, Baker E, Dusenbury L, Goldberg CJ. The false consensus effect: predicting adolescents’

tobacco use from normative expectations. Psychological Reports. 1992;70:171–8.

2. Cunningham JA, Selby PL. Implications of the normative fallacy in young adult smokers aged 19–24 years. 

American Journal of Public Health. 2007;97(8):1399–400. 

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. Ellickson PL, Bird CE, Orlando M, Klein DJ, McCaffrey DF. Social context and adolescent health behavior: 

does school-level smoking prevalence affect students’ subsequent smoking behavior? Journal of Health and 

Social Behavior. 2003;44(4):525–35. 

5. Davis KC, Nonnemaker JM, Farrelly MC. Association between national smoking prevention campaigns and 

perceived smoking prevalence among youth in the United States. Journal of Adolescent Health. 

2007;41(5):430–6.

6. Sussman S, Dent CW, Mestel-Rauch J, Johnson CA, Hansen WB, Flay BR. Adolescent nonsmokers, triers, and 

regular smokers’ estimates of cigarette smoking prevalence: when do overestimations occur and by whom? 

Journal of Applied Social Psychology. 1988;18(7):537–51.

For Further Reading 

Choi K, Forster J, Erickson D, Lazovich D, Southwell BG. The reciprocal relationships between changes in 

adolescent perceived prevalence of smoking in movies and progression of smoking status. Tobacco Control. 2012 

Sep;21(5):492–6.

Davis KC, Nonnemaker JM, Asfaw HA, Vallone DM. Racial/ethnic differences in perceived smoking prevalence: 

evidence from a national survey of teens. International Journal of Environmental Research and Public Health. 2010 

Dec; 7(12):4152–68. 

Farrelly MC, Davis KC, Duke J, Messeri P. Sustaining “truth”: changes in youth tobacco attitudes and smoking 

intentions after 3 years of a national antismoking campaign. Health Education Research. 2009;24(1):42–8.

Sherman SJ, Presson CC, Chassin L, Corty E, Olshavsky R. The false consensus effect in estimates of smoking 

prevalence: Underlying mechanisms. Personality & Social Psychology Bulletin. 1983;9(2):197–207.

Thrasher JF, Jackson C, Arillo-Santillán E, Sargent JD. Exposure to smoking imagery in popular films and 

adolescent smoking in Mexico. American Journal of Preventive Medicine. 2008;35(2):95–102.
GOAL AREA 1

► Outcome 5 

114 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.5.dNR

Proportion of Young People Who Report That Their Parents Would 

Strongly Disapprove of Their Use of Tobacco Products

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who report that their parents would strongly disapprove of 

their tobacco use 

Why this indicator is 

useful

Youth in families with parents who discuss the harms of tobacco use are less likely to 

smoke.1,2 Conversely, youth who report that their parents are unconcerned about 

smoking or do not talk to them about it are more likely than their peers to take up 

smoking.3-5Irrespective of parental smoking, youth who perceive strong parental 

disapproval of their smoking are significantly less likely to become established smokers 

than those who do not perceive strong disapproval.

Example data 

source(s)

No commonly used data sources were found.

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

Modified from Sargent and Dalton6to address tobacco use, not just smoking:

How do you think your mother (father) would react if you were using tobacco products

and she (he) knew about it?"

S/he would tell me to stop and be very upset

S/he would tell me to stop, but not be too upset

S/he would not tell me to stop, but would disapprove

S/he would have no reaction

Don’t know how s/he would react

Don’t have a stepmother/father

Question is repeated to ask about each parent

Comments Strong disapproval is defined as youth reporting that both parents (if applicable) or one 

parent (if applicable) “would tell me to stop and be very upset.”

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

 Denotes no data.

References 

1. Chassin L, Presson CC, Rose J, Sherman SJ, Davis MJ, Gonzalez JL. Parenting style and smoking-specific 

parenting practices as predictors of adolescent smoking onset. Journal of Pediatric Psychology. 

2005;30(4):333–44. 

2. Jackson C, Dickinson D. Enabling parents who smoke to prevent their children from initiating smoking. 

Archives of Pediatrics & Adolescent Medicine. 2006;160(1):56–62. 
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

115

3. Distefan JM, Gilpin EA, Choi WS, Pierce JP. Parental influences predict adolescent smoking in the United 

States, 1989–1993. Journal of Adolescent Health. 1998;22(6):466–74.

4. Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, and smoking onset among 

children. Addictive Behaviors. 1997;22(1):107–14. 

5. Pierce JP, Distefan JM, Jackson C, White MM, Gilpin EA. Does tobacco marketing undermine the influence of 

recommended parenting in discouraging adolescents from smoking? American Journal of Preventive Medicine. 

2002;23(2):73–81.

6. Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established 

smokers? Pediatrics. 2001;108(6):1256–62.

For Further Reading 

O’Byrne K, Haddock CK, Poston WS. Parenting style and adolescent smoking. Journal of Adolescent Health. 

2002;30(6):418–25. 
GOAL AREA 1

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116 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.5.e 

Proportion of Young People Who Have a Favorite Tobacco Brand

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who identify that they have a favorite tobacco brand. Given 

the extensive tobacco industry use of integrated marketing communication strategies, 

brand advertising may include many types of marketing, including print advertising 

(e.g., in magazines, newspapers, signage at point-of-sale), electronic advertising (e.g., 

company Web sites, industry-sponsored online social media), direct-to-consumer 

advertising (e.g., direct mail, coupons), product packaging, paid product placement, and 

sponsorship.

Why this indicator is 

useful

Marketing by the tobacco industry raises awareness of smoking and increases brand 

recognition.1 Having a favorite brand is an indicator of receptivity to marketing.

Receptivity to tobacco industry marketing is associated with susceptibility toward 

tobacco use among youth.2 Having a favorite tobacco brand advertisement has been 

shown to be a predictor of future experimentation and initiation of tobacco.1-5 The 2000 

Surgeon General’s report stated that most adolescents can recall certain brands, and such 

recall is correlated with smoking intentions and behavior.6 One study found that 

adolescents who had never smoked but reported having a favorite cigarette 

advertisement had a 50% increase in probability of future experimentation with 

smoking.7 Favorite brand is a measure of receptivity to advertising that predicts smoking 

behavior among youth.1

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2011

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years 

Example survey 

question(s)

From NYTS

What is the name of your favorite tobacco brand?

American Spirit Camel GPC, Basic, or Doral Kool Marlboro

Newport Some other brand not listed here I don’t know/I’m not sure

Created verification question

If you have a favorite cigarette brand, where was the most recent place you saw this 

brand advertised?

Billboard Print advertisement in a magazine Television Radio

Inside a store that sells tobacco products Internet Movie

Created question

Tell me how much you agree or disagree with the following statement: I tell other kids 

my age to check out my favorite tobacco brand. Would you say you:

Strongly agree Agree Disagree

Strongly disagree I don’t have a favorite tobacco brand

Comments The authors created the second example question. It is not in any commonly used data 

source. The intent is to provide a check to eliminate potential respondents who may have 

noted a favorite brand in the first example question simply because of the demand 

characteristics of the question. Respondents with a favorite tobacco brand who note that 

they saw the brand advertised most recently in a banned mode, such as television, would 

be omitted from analyses for this indicator.
GOAL AREA 1

► Outcome 5 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

117

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

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. Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing adolescent smoking 

behaviours. Cochrane Database of Systematic Reviews. 2011(5):CD003439. 

3. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Berry CC. Tobacco industry promotion of cigarettes and adolescent 

smoking. Journal of the American Medical Association. 1998; 279(7):511–5.

4. Gilpin EA, White MM, Messer K, Pierce JP. Receptivity to tobacco advertising and promotions among young 

adolescents as a predictor of established smoking in young adulthood. American Journal of Public Health. 

2007;97(8):1489–95. 

5. Mowery PD, Farrelly MC, Lyndon Haviland M, Gable JM, Wells HE. Progression to established smoking 

among US youths. American Journal of Public Health. 2004;94(2):331–7.

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

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

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000.

7. Pierce JP, Messer K, James LE, White MM, Kealey S, Vallone DM, Healton CG. Camel No. 9 cigarettemarketing campaign targeted young teenage girls. Pediatrics. 2010;125(4):619–26. 
GOAL AREA 1

► Outcome 5 

118 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.5.f 

Proportion of Young People Who Have Never Used Tobacco but are 

Susceptible to its Use

KOI 2005 1.10.5 Revised Title (Previously: “Proportion of young people who are susceptible 

never-smokers”)

Goal area Preventing initiation of tobacco use

Outcome box Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who have never used a tobacco product but have not made a 

firm decision not to use a tobacco product

Why this indicator is 

useful

Studies show that susceptible young people (those who have not made a firm decision 

not to smoke) are more likely than other young people to experiment with smoking.1.2

Additionally, these young people tend to be more receptive to pro-tobacco advertising, 

an additional risk factor for smoking initiation.2-4

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/QuickSearch.aspx

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

Have you ever tried cigarette smoking, even one or two puffs?

Yes No

Do you think that you will try a cigarette soon?

I have already tried smoking cigarettes Yes No

Do you think you will smoke a cigarette at any time during the next year?

Definitely yes Probably yes Probably not Definitely not

If one of your best friends offered you a cigarette, would you smoke it?

Definitely yes Probably yes Probably not Definitely not

From NATS

How likely are you to smoke a cigarette in the next year ...?

Very likely Somewhat likely Refused

Not at all likely Don’t know/Not sure

Comments Evaluators should ask all four example questions from the NYTS to create a 

susceptibility index. 1

These items can be modified to address other tobacco products.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$
GOAL AREA 1

► Outcome 5 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

119

References 

1. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a predictor of which 

adolescents take up smoking in the United States. Health Psychology. 1996;15(5):355–61.

2. Gilpin EA, White MM, Messer K, Pierce JP. Receptivity to tobacco advertising and promotions among young 

adolescents as a predictor of established smoking in young adulthood. American Journal of Public Health. 

2007;97(8):1489–95.

3. Weiss JW, Cen S, Schuster DV, Unger JB, Johnson CA, Mouttapa M, et al. Longitudinal effects of pro-tobacco 

and anti-tobacco messages on adolescent smoking susceptibility. Nicotine & Tobacco Research. 2006;8(3):455–

65.

4. Straub DM, Hills NK, Thompson PJ, Moscicki AB. Effects of pro- and anti-tobacco advertising on nonsmoking 

adolescents’ intentions to smoke. Journal of Adolescent Health. 2003;32(1):36–43.

For Further Reading 

Centers for Disease Control and Prevention. Tobacco use among middle and high school students—United States, 

2000–2009. Morbidity and Mortality Weekly Report. 2010;59(33):1063–8.
GOAL AREA 1

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120 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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GOAL AREA 1

► Outcome 6 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

121

Outcome 6 

Decreased Exposure to Tobacco Marketing and Availability of Tobacco 

Products 

Exposure to tobacco retail advertising is associated with experimental smoking and greater 

smoking prevalence among youth.1,2 Evidence demonstrates that the greater the number of 

tobacco retailers surrounding schools, the more likely youth smokers are to purchase their own 

cigarettes.3 Local jurisdictions may use local zoning laws to limit the number of retail tobacco 

outlets in a community, thereby decreasing the availability of tobacco products and the number 

of pro-tobacco messages in a community.2

The Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 2009 

establishes 18 as the nationwide minimum age to purchase cigarettes and smokeless tobacco 

legally and requires all retailers to verify the age of purchasers younger than age 27 by checking 

photographic identification that includes date of birth.4 The 1992 Synar Amendment requires all 

states to enact and enforce laws that prohibit the sale of tobacco to those younger than 18 years 

of age. Currently, all states have enacted youth tobacco access laws. Federal and state-level 

regulations are enforced using compliance checks that monitor retailers’ compliance with youth 

tobacco access laws. A recent study on youth access to tobacco reported that after controlling for 

price changes, media campaigns, and smoking restrictions, merchant compliance was associated 

with a 20.8% reduction from 1997 to 2003 in the odds of daily smoking among 10th graders.5

Additionally, the Task Force on Community Preventive Services recommends interventions such 

as stronger local laws directed at retailers and enforcement of retailer sales laws in combination 

with community mobilization, “on the basis of sufficient evidence of effectiveness in reducing 

youth tobacco use and access to tobacco products from commercial sources” (p. 19).6

Efforts by the U.S. Food and Drug Administration (FDA) and state and local agencies to educate 

retailers and conduct compliance checks may make tobacco retailers less likely to sell tobacco 

products to youth. However, the 2012 Surgeon General Report, Preventing Tobacco Use Among 

Youth and Young Adults, concluded that “[d]ata on whether interventions to restrict access can 

lead to a reduction in the number of retailers selling tobacco to minors are mixed”2(p. 712). 

Additionally, youth who purchase tobacco products from commercial sources may begin to rely 

more heavily on social sources. Because of this, it will continue to be important to monitor 

exposure to tobacco marketing and availability of tobacco products. 

The following indicators are associated with this outcome: 

► 1.6.a Density of stores selling tobacco 

► 1.6.b Proportion of young people who report receiving non-sale distribution or free 

samples of tobacco products 

► 1.6.c Proportion of retailers selling tobacco products to youth 

► 1.6.d Proportion of young people reporting that they have purchased tobacco products 

from a retailer 
GOAL AREA 1

► Outcome 6

122 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

► 1.6.e Proportion of youth reporting that they have been unsuccessful in purchasing 

tobacco products from a retailer

► 1.6.f Proportion of youth reporting that they have received tobacco products from a 

social source

► 1.6.g Proportion of young people reporting that they purchased tobacco products from a 

vending machine

► 1.6.h Proportion of young people who believe that it is easy to obtain tobacco products

References

1. Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail 

cigarette marketing practices on youth smoking uptake. Archives of Pediatrics & Adolescent 

Medicine. 2007;161(5):440–5.

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. Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is 

adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette 

advertising near schools? Preventive Medicine. 2008 Aug;47(2):210–4.

4. Family Smoking Prevention and Tobacco Control Act, Public Law 111-13, 123 Stat. 1776;

2009.

5. DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor 

of daily smoking among adolescents—a national study. BMC Public Health. 2009;9(1):107.

6. Task Force on Community Preventive Services. The guide to community preventive services: 

what works to promote health? New York, NY: Oxford University Press; 2005.

For Further Reading

Alexander C, Piazza M, Mekos D, Valente T. Peers, schools, and adolescent cigarette smoking. 

Journal of Adolescent Health. 2001;29(1):22–30.

Biener L, Siegel M. Tobacco marketing and adolescent smoking: more support for a causal 

inference. American Journal of Public Health. 2000;90(3):407–11.

Castrucci BC, Gerlach KK, Kaufman NJ, Orleans CT. The association among adolescents’

tobacco use, their beliefs and attitudes, and friends’ and parents’ opinions of smoking. Maternal 

and Child Health Journal. 2002;6(3):159–67.

Centers for Disease Control and Prevention. Youth tobacco surveillance: United States, 2000. 

MMWR Surveillance Summaries. 2001;50(SS4):1–84.

Jason LA, Pokorny SB, Schoeny ME. Evaluating the effects of enforcements and fines on youth 

smoking. Critical Public Health. 2003;13(1):33–45.

Luke DA, Stamatakis KA, Brownson RC. State youth-access tobacco control policies and youth 

smoking behavior in the United States. American Journal of Preventive Medicine. 

2000;19(3):180–7.
GOAL AREA 1

► Outcome 6

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

123

Pierce JP, Distefan JM, Jackson C, White MM, Gilpin EA. Does tobacco marketing undermine 

the influence of recommended parenting in discouraging adolescents from smoking? American 

Journal of Preventive Medicine. 2002;23(2):73–81.

Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming 

established smokers? Pediatrics. 2001;108(6):1256–62.

Sargent JD, Dalton M, Beach M, Bernhardt A, Heatherton T, Stevens M. Effect of cigarette 

promotions on smoking uptake among adolescents. Preventive Medicine. 2000;30(4):320–7.

Simons-Morton B, Haynie DL, Crump AD, Eitel SP, Saylor KE. Peer and parent influences on 

smoking and drinking among early adolescents. Health Education & Behavior. 2001;28(1):95–

107.

Unger JB, Chen X. The role of social networks and media receptivity in predicting age of 

smoking initiation: a proportional hazards model of risk and protective factors. Addictive 

Behaviors. 1999;24(3):371–81.

Wang MQ. Social environmental influences on adolescents’ smoking progression. American 

Journal of Health Behavior. 2001;25(4):418–25.
GOAL AREA 1

► Outcome 6 

124 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Outcome 6 

Decreased Exposure to Tobacco Marketing and Availability of Tobacco 

Products 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.6.a Density of stores selling tobacco $$

1.6.b Proportion of young people who 

report receiving non-sale 

distribution or free samples of

tobacco products

†† $$ †

1.6.c Proportion of retailers selling 

tobacco products to youth

†† $

1.6.d Proportion of young people 

reporting that they have purchased 

tobacco products from a retailer

†† $ †

1.6.e Proportion of youth reporting that 

they have been unsuccessful in 

purchasing tobacco products from a 

retailer

†† $

1.6.f Proportion of youth reporting that 

they have received tobacco products 

from a social source

†† $

1.6.g Proportion of young people

reporting that they purchased 

tobacco products from a vending 

machine

†† $ †

1.6.h Proportion of young people who 

believe that it is easy to obtain 

tobacco products

$

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

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

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

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

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±1 point of the 

median for this indicator-specific criterion. 

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±2 points of the 

median for overall quality of the indicator. 
GOAL AREA 1

► Outcome 6 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

125

Indicator 1.6.a

Density of Stores Selling Tobacco 

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure The number of stores selling tobacco products within a given geographic area or 

population size. Density may be determined by calculating the number of tobacco 

retailers per population or the number of retailers per land area/street segment. The most 

appropriate method should be determined based on the specific geographic 

circumstances. 

Why this indicator is 

useful

State and local governments may reduce tobacco retailer density using tobacco retailer 

licensing and/or local zoning code restrictions to limit the number and location of 

tobacco sales outlets.1 Research shows that the density of tobacco retailers influences 

smoking behaviors for youth and adults.2-5 A recent study using cross-sectional survey 

data from California found that density of tobacco retailers is associated with 

experimental smoking among high school students in urban areas.4 This finding supports 

previous work showing that retailer density is also associated with student-reported 

tobacco use,5as well as a higher proportion of students purchasing cigarettes rather than 

obtaining them from social sources.6 Local jurisdictions can use policy options to reduce 

the density of tobacco retailers; for example, in November 2010, the Santa Clara County 

(California) Board of Supervisors adopted a strong tobacco retail licensing ordinance 

that requires retailers in the unincorporated areas of the county to obtain an annual 

license to sell tobacco and that limits new tobacco retail licenses and tobacco sales near 

schools (see

http://www.sccgov.org/SCC/docs%2FEnvironmental%20Health,%20Department%20of

%20(DEP)%2Fattachments%2FTMPKeyboard203261357.pdf).

Example data 

source(s)

No commonly used data sources were found.

Population group(s) Not applicable. This indicator is best measured by reviewing tobacco retailer 

information. 

Example survey 

question(s)

Not applicable

Comments Evaluators may want to consider using licensing information to begin assessing retailer 

density. Note that licensing lists often contain omissions or dated information.

Evaluators may also choose to utilize geographic information system (GIS) information 

when examining tobacco retailer density to identify differences that may be associated 

with demographics of populations in different geographic areas. 

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$
GOAL AREA 1

► Outcome 6

126 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. Banthin C, Tobacco Control Legal Consortium. Regulating Tobacco Retailers: Options for State and Local 

Governments. 2010. Available at: http://publichealthlawcenter.org/sites/default/files/resources/tclc-fs-retailers2010_0.pdf. Accessed February 9, 2012.

2. Henriksen L, Feighery E, Schleicher N, Cowling D, Kline R, Fortmann S. Is adolescent smoking related to the 

density and proximity of tobacco outlets and retail cigarette advertising near schools? Preventive Medicine. 

2008;47(2):210–4.

3. Chuang Y, Cubbin C, Ahn D, Winkleby M. Effects of neighbourhood socioeconomic status and convenience 

store concentration on individual level smoking. Journal of Epidemiology and Community Health. 

2005;59(7):568–73.

4. McCarthy W, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. Density of tobacco retailers near schools: effects 

on tobacco use among students. American Journal of Public Health. 2009;99(11):2006–13.

5. Novak S, Reardon S, Raudenbush S, Buka S. Retail tobacco outlet density and youth cigarette smoking: a 

propensity-modeling approach. American Journal of Public Health 2006;96(4):670–6.

6. Leatherdale S, Strath J. Tobacco retailer density surrounding schools and cigarette access behaviors among 

underage smoking students. Annals of Behavioral Medicine. 2007;33(1):105–11.

For Further Reading

Eule B, Sullivan MK, Schroeder SA, Hudmon KS. Merchandising of cigarettes in San Francisco pharmacies. 

Tobacco Control. 2004;13(4):429–32.

Hyland A, Travers MJ, Cummings KM, Bauer J, Alford T, Wieczorek WF. Tobacco outlet density and 

demographics in Erie County, New York. American Journal of Public Health. 2003;93(7):1075–6.

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

Academies Press; 2007.

Luke DA, Ribisl KM, Smith C, Sorg AA. Family Smoking Prevention and Tobacco Control Act: banning outdoor 

tobacco advertising near schools and playgrounds. American Journal of Preventive Medicine. 2011 Mar;40(3):295–

302.
GOAL AREA 1

► Outcome 6 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

127

Indicator 1.6.b

Proportion of Young People Who Report Receiving Non-sale Distribution 

or Free Samples of Tobacco Products

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Proportion of young people who report having been given free, nominal cost, or low cost

samples of tobacco products in the past 30 days

Why this indicator is 

useful

The tobacco industry has encouraged sampling of tobacco products as a marketing 

activity to target subgroups of the population, appeal to new users, and teach current 

users how to use their products.1,2 The 2009 Family Smoking Prevention and Tobacco 

Control Act (Tobacco Control Act), which gives the U.S. Food and Drug Administration 

(FDA) regulatory authority over tobacco, prohibits free cigarette sampling but allows 

sampling of smokeless tobacco products in qualified adult-only facilities, including 

marketing tents at concerts, rodeos, and other sporting events often attended by young 

people. In 2008, the tobacco industry spent $29.9 million on smokeless tobacco samples 

or coupons for free smokeless tobacco products with no additional purchase required.3

Example data 

source(s)

Monitoring the Future (MTF), 2010

Information available at: http://monitoringthefuture.org/

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From MTF

Has anyone from a tobacco company ever given you, or mailed you a free sample of their 

cigarettes?

Never Yes, in the past 12 months Yes, but not in the past 12 months

Has anyone from a tobacco company ever given you, or mailed you a free sample of their 

smokeless tobacco?

Never Yes, in the past 12 months Yes, but not in the past 12 months

In the last 6 months, have YOU received free samples of smokeless tobacco?

Yes No Not applicable Refused Don’t know

Comments Under the FDA law, state and local governments are not prohibited from initiating state 

and local bans on tobacco product sampling.

Monitoring tobacco company sampling can be time and resource intensive.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$ †

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

► Outcome 6

128 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. Mejia AB, Ling PM. Tobacco industry consumer research on smokeless tobacco users and product 

development. American Journal of Public Health. 2010;100(1):78–87.

2. Ling PM, Haber LA, Wedl S. Branding the rodeo: a case study of tobacco sports sponsorship. American 

Journal of Public Health. 2010;100(1):32–41.

3. Federal Trade Commission (FTC). Smokeless tobacco report for 2007 and 2008. Washington, DC: Federal 

Trade Commission; 2011. Available at: http://ftc.gov/os/2011/07/110729smokelesstobaccoreport.pdf. Accessed 

October 31, 2011.

For Further Reading

Hyland A, Bauer JE, Li Q, Abrams SM, Higbee C, Peppone L, Cummings KM. Higher cigarette prices influence 

cigarette purchase patterns. Tobacco Control. 2005;14(2):86–92.

White VM, Gilpin EA, White MM, Pierce JP. How do smokers control their cigarette expenditures? Nicotine & 

Tobacco Research. 2005;7(4):625–35.

White VM, White MM, Freeman K, Gilpin EA, Pierce JP. Cigarette promotional offers: who takes advantage? 

American Journal of Preventive Medicine. 2006;30(3):225–31.
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

129

Indicator 1.6.c

Proportion of Retailers Selling Tobacco Products to Youth

KOI 2005 1.11.1 Revised Title (Previously: “Proportion of successful attempts to purchase tobacco 

products by young people”)

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Proportion of retailers not in compliance with policies prohibiting the sale of tobacco 

products to minors

Why this indicator is 

useful

Youth who live in states with more stringent laws preventing youth access to tobacco 

products are less likely to be daily smokers or experiment with smoking than youth who 

live in states with less strict tobacco access laws.1 Decreasing the rate at which youth are 

successful in purchasing tobacco may contribute to reductions in their tobacco use.2

However, youth access initiatives require sustained compliance along with stringent 

enforcement and penalization of lawbreakers to be effective.3-5

Example data 

source(s)

FDA, Compliance Check Inspection of Tobacco Product Retailers

Information available at: 

http://www.accessdata.fda.gov/scripts/oce/inspections/oce_insp_searching.cfm

Substance Abuse and Mental Health Services Administration (SAMHSA) Compliance 

Checks

Information available at: http://prevention.samhsa.gov/tobacco/guidance.asp

Population group(s) Tobacco retailers

Example survey 

question(s)

FDA, Compliance Check Inspection of Tobacco Product Retailers: Retailer Name, City, 

State, Zip, Decision Type: No violations observed, Warning letters issued

Comments Evaluators must consider a number of factors when determining the proportion of 

successful purchase attempts, including (1) variations in the sampling frame (e.g., 

number, type, and location of stores), (2) number of successful and unsuccessful purchase 

attempts per store, and (3) real and apparent ages of minors attempting to purchase 

tobacco.6

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. Botello-Harbaum MT, Haynie DL, Iannotti RJ, Wang J, Gase L, Simons-Morton B. Tobacco control policy and 

adolescent cigarette smoking status in the United States. Nicotine & Tobacco Research. 2009;11(7):875–85. 

2. Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco-sales laws 

on adolescents’ access to tobacco and smoking behavior. New England Journal of Medicine. 

1997;337(15):1044–51. 

3. DiFranza JR. Best practices for enforcing state laws prohibiting the sale of tobacco to minors. Journal of Public 

Health Management and Practice. 2005 Nov-Dec;11(6):559–65.
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130 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

4. DiFranza JR, Dussault GF. The federal initiative to halt the sale of tobacco to children—the Synar Amendment, 

1992–2000: lessons learned. Tobacco Control. 2005 Apr;14(2):93–8.

5. Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic 

Reviews. 2005;(1):CD001497. doi:10.1002/14651858.CD001497.pub2

6. DiFranza JR. Are the federal and state governments complying with the Synar Amendment? Archives of 

Pediatrics & Adolescent Medicine. 1999;153(10):1089–97.

For Further Reading

DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor of daily smoking among 

adolescents: a national study. BMC Public Health. Apr 2009 17;9:107.

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

Academies Press; 2007.
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

131

Indicator 1.6.d

Proportion of Young People Reporting That They Have Purchased 

Tobacco Products from a Retailer

KOI 2005 1.11.2 Revised Title (Previously: “Proportion of young people reporting that they have 

been sold tobacco products by a retailer”)

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Proportion of young people who report having purchased a tobacco product from a 

retailer in the previous 30 days

Why this indicator is 

useful

Young people who buy their own tobacco products from commercial sources are more 

likely to be established smokers and to become heavy smokers than those who acquire 

cigarettes through social sources alone.1,2 Retailers who illegally sell to minors increase 

availability to tobacco throughout an entire community.3 Additionally, retailers who fail 

to demand identification when selling tobacco products have been shown to sell 

significantly more to minority youth.4

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years 

Example survey 

question(s)

From NYTS

During the past 30 days, how did you get your own cigarettes? (You can CHOOSE ONE 

ANSWER or MORE THAN ONE ANSWER)

I did not smoke cigarettes during the past 30 days I bought them myself

I had someone else buy them for me I borrowed or bummed them

Someone gave them to me without my asking I took them from a store

I got them some other way or another person

During the past 30 days, how did you get your own cigars, cigarillos, or little cigars? 

(You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

I did not smoke cigars, cigarillos, or little cigars I bought them myself

 during the past 30 days I borrowed or bummed them

I had someone else buy them for me Someone gave them to me

I took them from a store or another person without my asking

I got them some other way

From NATS (2012–2013)

(Asked of respondents who bought cigarettes for themselves in the past 30 days)

The last time you bought cigarettes for yourself, did you buy them...

At a convenience store or gas station On an Indian reservation

At a supermarket From a vending machine

At a liquor store On the Internet

At a drug store From another person

At a tobacco discount store Other (specify)

At another discount store, such as

 Wal-Mart or Costco

Comments None noted
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132 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $ †

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

being within ±1 point of the median for this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. Emery S, Gilpin EA, White MM, Pierce JP. How adolescents get their cigarettes: implications for policies on 

access and price. Journal of the National Cancer Institute. 1999;91(2):184–6.

2. Forster J, Chen V, Blaine T, Perry C, Toomey T. Social exchange of cigarettes by youth. Tobacco Control. 

2003;12(2):148–54. 

3. Jones SE, Sharp DJ, Husten CG, Crossett LS. Cigarette acquisition and proof of age among US high school 

students who smoke. Tobacco Control. 2002;11(1):20–5.

4. Landrine H, Corral I, Klonoff EA, Jensen J, Kashima K, Hickman N, Martinez J. Ethnic disparities in youth 

access to tobacco: California statewide results, 1999–2003. Health Promotion Practice. 2010 Jan;11(1):132–9.

For Further Reading 

DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor of daily smoking among 

adolescents: a national study. BMC Public Health. 2009 Apr 17;9:107

Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris WA, et al. Youth risk behavior surveillance—United 

States, 2005. MMWR Surveillance Summaries. 2006 Jun 9;55(5):1–108. 

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

Academies Press; 2007. 
GOAL AREA 1

► Outcome 6 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

133

Indicator 1.6.e

Proportion of Youth Reporting That They Have Been Unsuccessful in 

Purchasing Tobacco Products from a Retailer

KOI 2005 1.11.3 Revised Title (Previously: “Proportion of young people reporting that they have 

been unsuccessful in purchasing tobacco products from a retailer”)

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Proportion of youth who report that they were refused sale of tobacco products because 

of their age during the previous 30 days

Why this indicator is 

useful

Restricting youth access increases the opportunity cost for youth attempting to purchase 

tobacco products.1 Measuring the proportion of youth who have been refused sale of a 

tobacco product helps determine the extent to which local and state policies and 

enforcement activities are reducing young people’s access to tobacco.2

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2004 

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

Population group(s) Youth aged younger than 18 years

Example survey 

question(s)

From NYTS

During the past 30 days, did anyone ever refuse to sell you cigarettes because of your 

age?

I did not try to buy cigarettes in a store during the past 30 days

Yes

No

Comments Evaluators may also want to assess the type of retailer (e.g., gas station, convenience 

store, grocery store) that sold tobacco to a minor.

The item can be modified to address other tobacco products.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor of daily smoking 

among adolescents: a national study. BMC Public Health. 2009;9:107. 

2. Jones SE, Sharp DJ, Husten CG, Crossett LS. Cigarette acquisition and proof of age among US high school 

students who smoke. Tobacco Control. 2002;11(1):20–5.
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134 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

For Further Reading 

Centers for Disease Control and Prevention. Youth tobacco surveillance—United States, 2001–2002. MMWR 

Surveillance Summaries. 2006;55(SS03):1–56.

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

Academies Press; 2007. 
GOAL AREA 1

► Outcome 6 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

135

Indicator 1.6.f

Proportion of Youth Reporting That They Have Received Tobacco 

Products from a Social Source

KOI 2005 1.11.4 Revised Title (Previously: “Proportion of young people reporting that they have 

received tobacco products from a social source”)

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Proportion of youth who report getting their cigarettes or other tobacco products from a 

social source such as a friend, family member, or schoolmate during the previous 30 days

Why this indicator is 

useful

There has been a shift in cigarette acquisition among teen smokers, from retail and 

commercial to social sources; this suggests that the barriers to youth tobacco access in the 

retail setting are strengthening and thus social sources are an even greater concern.1,2

Although increasing enforcement of laws prohibiting the sale of tobacco to minors 

reduces illegal sales, studies also suggest that more than half of high school–aged 

smokers report obtaining cigarettes from social sources.3 An inverse relationship has been 

found between obtaining cigarettes from a social source and the likelihood of 

transitioning to heavy smoking.2

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

Population group(s) Youth aged younger than 18 years

Example survey 

question(s)

From NYTS

During the past 30 days, how did you get your own cigarettes? (You can CHOOSE ONE 

ANSWER or MORE THAN ONE ANSWER)

I did not smoke cigarettes during the past 30 days

I bought them myself

I had someone else buy them for me

I borrowed or bummed them

Someone gave them to me without my asking

I took them from a store or another person

I got them some other way

During the past 30 days, how did you get your own cigars, cigarillos, or little cigars? 

(You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

I did not smoke cigars, cigarillos, or little cigars during the past 30 days

I bought them myself

I had someone else buy them for me

I borrowed or bummed them

Someone gave them to me without my asking

I took them from a store or another person

I got them some other way

Comments None
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136 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. Jason LA, Pokorny SB, Adams M, Hunt Y, Gadiraju P, Morello T, et al. Youth caught in violation of tobacco 

purchase, use, and possession laws. Behavior Modification. 2007;31(6):713–31.

2. Widome R, Forster JL, Hannan PJ, Perry CL. Longitudinal patterns of youth access to cigarettes and smoking 

progression: Minnesota Adolescent Community Cohort (MACC) study (2000–2003). Preventive Medicine. 

2007;45(6):442–6.

3. Jones SE, Sharp DJ, Husten CG, Crossett LS. Cigarette acquisition and proof of age among US high school 

students who smoke. Tobacco Control. 2002;11(1):20–5.

For Further Reading 

Centers for Disease Control and Prevention. Usual sources of cigarettes for middle and high school students—

Texas, 1998–1999. Morbidity and Mortality Weekly Report. 2002 Oct 11;51(40):900–1.

DiFranza JR, Coleman M. Sources of tobacco for youths in communities with strong enforcement of youth access 

laws. Tobacco Control. 2001 Dec;10(4):323–8.

Forster J, Chen V, Blaine T, Perry C, Toomey T. Social exchange of cigarettes by youth. Tobacco Control. 

2003;12(2):148–54. 

Jones SE, Sharp DJ, Husten CG, Crossett LS. Cigarette acquisition and proof of age among US high school students 

who smoke. Tobacco Control. 2002;11(1):20–5.

Widome R, Forster JL, Hannan PJ, Perry CL. Longitudinal patterns of youth access to cigarettes and smoking 

progression: Minnesota Adolescent Community Cohort (MACC) study (2000–2003). Preventive Medicine. 

2007;45(6):442–6.
GOAL AREA 1

► Outcome 6 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

137

Indicator 1.6.g

Proportion of Young People Reporting That They Purchased Tobacco 

Products from a Vending Machine

KOI 2005 1.11.5 Revised Title (Previously: “Proportion of young people reporting that they 

purchased cigarettes from a vending machine”)

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Proportion of young people who usually purchased their tobacco products from a vending 

machine during the previous 30 days

Why this indicator is 

useful

Banning vending machines has been shown to reduce smoking onset.1 Although the 2009 

Family Smoking Prevention and Tobacco Control Act included provisions to prohibit the 

sale of cigarettes and smokeless tobacco in vending machines except in adult-only 

facilities, these machines are still available to young adults and to youth in areas with 

poor enforcement. As of 2011, no states ban vending machines in all locations.2

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

National Adult Tobacco Survey (NATS), 2012–2013 

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

During the past 30 days, where did you buy your own cigarettes? (You can CHOOSE 

ONE ANSWER or MORE THAN ONE ANSWER)

I did not buy cigarettes during the past 30 days A vending machine

A gas station Over the Internet

A convenience store Through the mail

A grocery store Some other place not listed here

A drugstore

During the past 30 days, where did you buy your own cigars, cigarillos, or little cigars? 

(You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER) __________

I did not buy cigars, cigarillos, or little A grocery store

 cigars during the past 30 days A drugstore

A gas station A vending machine

A convenience store Over the Internet

From NATS

(Asked of respondents who bought cigarettes for themselves in the past 30 days)

The last time you bought cigarettes for yourself, did you buy them...

At a convenience store or gas station On an Indian reservation

At a supermarket From a vending machine

At a liquor store On the Internet

At a drug store From another person

At a tobacco discount store Other (specify)

At another discount store, such as

 Wal-Mart or Costco

Comments None noted
GOAL AREA 1

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138 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $ †

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±1 point of the median for this indicator-specific criterion.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

References 

1. Kandel DB, Kiros GE, Schaffran C, Hu MC. Racial/ethnic differences in cigarette smoking initiation and 

progression to daily smoking: a multilevel analysis. American Journal of Public Health. 2004 Jan;94(1):128–

35.

2. Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) 

system. Atlanta, GA: Centers for Disease Control and Prevention; 2011. Online database. Available from: 

http://www.cdc.gov/tobacco/statesystem. Accessed October 2011. 

For Further Reading 

Botello-Harbaum MT, Haynie DL, Iannotti RJ, Wang J, Gase L, Simons-Morton B. Tobacco control policy and 

adolescent cigarette smoking status in the United States. Nicotine & Tobacco Research. 2009;11(7):875–85. 

Johnston LD, O’Malley PM, Terry-McElrath YM. Methods, locations, and ease of cigarette access for American 

youth, 1997–2002. American Journal of Preventive Medicine. 2004 Nov;27(4):267–76. 
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

139

Indicator 1.6.h

Proportion of Young People Who Believe That It Is Easy to Obtain Tobacco 

Products

KOI 2005 1.11.6 

Goal area Preventing initiation of tobacco use

Outcome box Decreased exposure to tobacco marketing and availability of tobacco products

What to measure Degree to which young people believe that it is easy or difficult to obtain tobacco 

products

Why this indicator is 

useful

Believing that cigarettes are easy to obtain increases young people’s risk for both 

smoking initiation and continued use.1

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

How easy would it be for you to get tobacco products if you wanted some?

Very easy Somewhat easy Not easy at all

Comments None noted

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

References 

1. Doubeni CA, Li W, Fouayzi H, DiFranza JR. Perceived accessibility as a predictor of youth smoking. Annals of 

Family Medicine. 2008 Jul-Aug;6(4):323–30.

For Further Reading 

Doubeni CA, Li W, Fouayzi H, DiFranza JR. Perceived accessibility of cigarettes among youth: a prospective 

cohort study. American Journal of Preventive Medicine. 2009 Mar;36(3):239–42.

Gilpin EA, Lee L, Pierce JP. Does adolescent perception of difficulty in getting cigarettes deter experimentation? 

Preventive Medicine. 2004;38(4):485–91. 

Speizer IS, Bean MK, Obando CP, Fries E. Middle school students’ perceived access to cigarettes in Virginia. 

American Journal of Health Behavior. 2008;32(4):399–410. 
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GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

141

Outcome 7 

Reduced Tobacco Industry Influence 

In 2011, the tobacco companies spent 87% of their marketing dollars in the retail environment, 

including point-of-sale advertising, price discounts, retail promotional allowances, and retailvalue-added items.1,2 The tobacco industry offers retailers volume discounts, price promotions, 

in-store branded displays, and payment for prime shelf space, exposing all consumers, including 

youth, to pro-smoking messages in the retail environment. In return for financial incentives, 

retailers enter into contractual agreements with tobacco companies to ensure high visibility and 

accessibility of their products to stimulate impulse purchases.3,4 Studies have shown that pointof-sale tobacco advertising is more prevalent in stores near schools and in minority and lowincome neighborhoods.5-8 Research has also identified a relationship between exposure to 

tobacco marketing in the retail environment and use of tobacco by youth, including 

experimentation and uptake of smoking.9-11 Signage visible outside the stores exposes entire 

communities to tobacco marketing. The result is that many U.S. children grow up surrounded by 

pro-tobacco messages.10

The Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 2009 set 

forth rules banning promotional activities, such as the sale and distribution of tobacco-branded 

non-tobacco products, and sponsorship of music and sporting events. In addition, cities and 

counties can limit the free or low-cost distribution of tobacco products known as “sampling” 

under the Tobacco Control Act.12

Comprehensive advertising bans can reduce tobacco consumption.13 Following the ban on 

television and radio tobacco advertising in 1971, the U.S. federal government established 

additional restrictions on advertising as part of the 1998 Master Settlement Agreement, which 

banned any advertising targeting youth, as well as billboard and transit ads. Under the Tobacco 

Control Act, states and localities can restrict or regulate the time, place, and manner (but not the 

content) of tobacco advertising. It is important to note, however, that noncomprehensive 

restrictions can result in increased advertising in “non-banned” media and increased expenditures 

in other promotional and marketing activities.14

Many tobacco companies host Web sites for particular brands, where consumers are encouraged 

to register to receive exclusive promotions and watch videos, play games, enter contests, and 

converse with other consumers on message boards. Most of these Web sites require age 

verification for entry. In addition to brand-specific Web sites, some companies sponsor smokers’

rights Web sites, such as R.J. Reynolds’ “My Smokers’ Rights” Web site of 2010 and, more 

recently, Philip Morris’ “Citizens for Tobacco Rights” Web site,15 which encourages consumers 

to engage by contacting their legislative representative to oppose tobacco control policies. These 

attempts to foster individual political activism are consistent with the tobacco industry’s long 

history of political influence through contributions and lobbying at the corporate level.16,17

Movies deliver billions of onscreen images of smoking to youth audiences. Both the Surgeon 

General and the National Cancer Institute have concluded that exposure to depictions of smoking 

in the movies causes tobacco use among youth.13,14 Giving movies with tobacco an R rating 

might reduce the number of exposures of youth to tobacco onscreen.18 Showing an antismoking 
GOAL AREA 1

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142 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

advertisement before a movie containing smoking has also been shown to affect how audiences 

view smoking and react to its depiction.19

Even though news media coverage can help frame the discussion of tobacco-related issues 

among the public, organized media advocacy on behalf of tobacco control is underutilized. 

Studies on news coverage of tobacco-related issues show that secondhand smoke, policies, and 

health effects of smoking are most frequently covered.14 Less frequently covered are issues 

related to tobacco industry practices and political lobbying.

To improve its public image, the tobacco industry sponsors events and causes such as the arts 

and minority organizations.14 Additionally, the industry has sponsored youth smoking prevention 

campaigns with little to no success—the efforts have been largely ineffective at reducing youth 

smoking and may have increased smoking in some subgroups of youth.20-22 The tobacco 

industry’s activities and corporate sponsorships should be monitored.14

The following indicators are associated with this outcome:

► 1.7.a Extent and type of retail tobacco advertising

► 1.7.b Extent of tobacco industry sponsorship of public and private events

► 1.7.cNR Extent of tobacco advertising in media

► 1.7.d Extent of tobacco in movies

► 1.7.eNR Extent of pro-tobacco internet presence

► 1.7.f Amount and quality of news media stories about tobacco industry practices and 

political lobbying

► 1.7.gNR Extent of industry-sponsored tobacco use prevention activities

► 1.7.h Amount of tobacco industry contributions to institutions and groups

► 1.7.i Amount of tobacco industry campaign contributions to local and state politicians

References

1. Federal Trade Commission. Smokeless tobacco report for 2011. Washington, DC: Federal 

Trade Commission; 2013.

2. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade 

Commission; 2013.

3. Dewhirst T. POP goes the power wall? Taking aim at tobacco promotional strategies utilised 

at retail. Tobacco Control. 2004;13(3):209–10.

4. Pollay RW. More than meets the eye: on the importance of retail cigarette merchandising. 

Tobacco Control. 2007;16(4):270–4.

5. Pucci LG, Joseph HM Jr, Siegel M. Outdoor tobacco advertising in six Boston 

neighborhoods. Evaluating youth exposure. American Journal of Preventive Medicine. 

1998;15(2):155–9.

6. John R, Cheney MK, Azad MR. Point-of-sale marketing of tobacco products: taking 

advantage of the socially disadvantaged? Journal of Health Care for the Poor and 

Underserved. 2009;20(2):489–506.
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

143

7. Barbeau EM, Wolin KY, Naumova EN, Balbach E. Tobacco advertising in communities: 

associations with race and class. Preventive Medicine. 2005;40(1):16–22.

8. Cohen JE, Planinac LC, Griffin K, Robinson DJ, O’Connor SC, Lavack A, et al. Tobacco 

promotions at point-of-sale: the last hurrah. Canadian Journal of Public Health Revue 

Canadienne De Santé Publique. 2008;99(3):166–71.

9. Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail 

cigarette marketing practices on youth smoking uptake. Archives of Pediatrics & Adolescent 

Medicine. 2007;161(5):440–5.

10. Paynter J, Edwards R, Schluter PJ, McDuff I. Point of sale tobacco displays and smoking 

among 14–15 year olds in New Zealand: a cross-sectional study. Tobacco Control. 

2009;18(4):268–74.

11. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal study of exposure to 

retail cigarette advertising and smoking initiation. Pediatrics. 2010;126(2):232–8.

12. Public Health Law & Policy Technical Assistance Legal Center. Model California Ordinance 

Regulating Tobacco Product Sampling. 2009. Available at: http://www.phlpnet.org/tobaccocontrol/products/sampling-ordinance.

13. 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.

14. 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.

15. Philip Morris USA. Citizens for Tobacco Rights. 2012. Available at: 

http://www.tobaccorights.com/ctr/advocacy/default.aspx. Accessed April 4, 2012.

16. Luke DA, Krauss M. Where there’s smoke there’s money: tobacco industry campaign 

contributions and U.S. Congressional voting. American Journal of Preventive Medicine. 

2004;27(5):363–72.

17. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state 

legislative behavior? American Journal of Public Health. 1998;88(6):918–23.

18. Centers for Disease Control and Prevention. Smoking in top-grossing movies—United 

States, 2010. Morbidity and Mortality Weekly Report. 2011 Jul 15;60(27):910–13.

19. U.S. Department of Health and Human Services. Ending the Tobacco Epidemic: A Tobacco 

Control Strategic Action Plan for the U.S. Department of Health and Human Services

Washington, DC: Office of the Assistant Secretary for Health; 2010.

20. Donovan RJ, Jalleh G, Carter OBJ. Tobacco industry smoking prevention advertisements’

impact on youth motivation for smoking in the future. Social Marketing Quarterly. 

2006;12(2):3–13.
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144 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

21. Henriksen L, Dauphinee AL, Wang Y, Fortmann SP. Industry sponsored anti-smoking ads 

and adolescent reactance: test of a boomerang effect. Tobacco Control. 2006;15(1):13–8.

22. Wakefield M, Terry-McElrath Y, Emery S, Saffer H, Chaloupka FJ, Szczypka G, et al. Effect 

of televised, tobacco company-funded smoking prevention advertising on youth smokingrelated beliefs, intentions, and behavior. American Journal of Public Health. 

2006;96(12):2154–60.

For Further Reading

Dal Cin S, Stoolmiller M, Sargent JD. When movies matter: exposure to smoking in movies and 

changes in smoking behavior. Journal of Health Communication. 2012;17(1):76–89.

Freeman B, Chapman S. Open source marketing: Camel cigarette brand marketing in the “Web 

2.0” world. Tobacco Control. 2009;18(3):212–7.

Golmier I, Chebat JC, Gélinas-Chebat C. Can cigarette warnings counterbalance effects of 

smoking scenes in movies? Psychological Reports. 2007;100(1):3–18.

Hafez N, Ling PM. Finding the Kool Mixx: how Brown & Williamson used music marketing to 

sell cigarettes. Tobacco Control. 2006;15(5):359–66.

Hanewinkel R, Isensee B, Sargent JD, Morgenstern M. Effect of an antismoking advertisement 

on cinema patrons’ perception of smoking and intention to smoke: a quasi-experimental study. 

Addiction. 2010;105(7):1269–77.

Lewis MJ, Yulis SG, Delnevo C, Hrywna M. Tobacco industry direct marketing after the Master 

Settlement Agreement. Health Promotion Practice. 2004;5(3 Suppl):75S–83S.

Lochbuehler K, Engels RC, Scholte RH. Influence of smoking cues in movies on craving among 

smokers. Addiction. 2009;104(12):2102–9.

Lochbuehler K, Peters M, Scholte RH, Engels RC. Effects of smoking cues in movies on 

immediate smoking behavior. Nicotine & Tobacco Research. 2010;12(9):913–8.

Lochbuehler K, Voogd H, Scholte RH, Engels RC. Attentional bias in smokers: exposure to 

dynamic smoking cues in contemporary movies. Journal of Psychopharmacology. 

2011;25(4):514–9.

Moreland-Russell S, Harris JK, Israel K, Schell S, Mohr A. “Anti-smoking data are exaggerated” 

versus “The data are clear and indisputable”: examining letters to the editor about tobacco.

Journal of Health Communication. 2012;17(4):443–59.

Paek HJ, Reid LN, Jeong HJ, Choi H, Krugman D. Five decades of promotion techniques in 

cigarette advertising: a longitudinal content analysis. Health Marketing Quarterly. 2012 

Jan;29(1):1–17.

Primack BA, Longacre MR, Beach ML, Adachi-Mejia AM, Titus LJ, Dalton MA. Association of 

established smoking among adolescents with timing of exposure to smoking depicted in movies. 

Journal of the National Cancer Institute. 2012;104(7):549–55.

Sargent JD, Maruska K, Morgenstern M, Isensee B, Hanewinkel R. Movie smoking, movie 

horror, and urge to smoke. Przegla̧d Lekarski. 2009;66(10):545–7.
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

145

Shadel WG, Martino SC, Setodji C, Scharf D. Momentary effects of exposure to prosmoking 

media on college students’ future smoking risk. Health Psychology. 2012 Jul;31(4):460–6.

Shmueli D, Prochaska JJ, Glantz SA. Effect of smoking scenes in films on immediate smoking: a 

randomized controlled study. American Journal of Preventive Medicine. 2010;38(4):351–8.

Wagner DD, Dal Cin S, Sargent JD, Kelley WM, Heatherton TF. Spontaneous action 

representation in smokers when watching movie characters smoke. Journal of Neuroscience. 

2011;31(3):894–8.
GOAL AREA 1

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146 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Outcome 7 

Reduced Tobacco Industry Influence 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.7.a Extent and type of retail tobacco 

advertising

$$$

1.7.b Extent of tobacco industry 

sponsorship of public and private 

events

†† $$$

1.7.cNR Extent of tobacco advertising in 

media

     

1.7.d Extent of tobacco in movies †† $$

1.7.eNR Extent of pro-tobacco Internet 

presence

     

1.7.f Amount and quality of news media 

stories about tobacco industry 

practices and political lobbying

$$$

1.7.gNR Extent of industry sponsored 

tobacco use prevention activities

     

1.7.h Amount of tobacco industry 

contributions to institutions and 

groups

$$$*

1.7.i Amount of tobacco industry 

campaign contributions to local 

and state politicians

†† $$$*

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

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±2 points of the 

median for overall quality of the indicator. 

 Denotes no data. 

NR Denotes an indicator that is not rated (see Appendix C for an explanation). 
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

147

Indicator 1.7.a

Extent and Type of Retail Tobacco Advertising

KOI 2005 1.9.1 Revised Title (Previously: “Extent and type of retail tobacco advertising and 

promotions”)

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Amount and type of tobacco advertising in and around retail outlets, including strategic 

product placement

Why this indicator is 

useful

There is a causal relationship between exposure to retail tobacco advertising and 

promotion and tobacco initiation and use.1-4 Studies have shown that the volume of instore advertisements and the proportion of retail outlets with sales promotions have

increased more rapidly in neighborhoods with a higher proportion of African Americans 

than in other communities.5 Additionally, evidence demonstrates that the tobacco 

industry targets youth through increased advertising and promotions in stores located 

near schools.6-9 Contradicting tobacco manufacturer claims that advertising is not 

targeted on race/ethnicity, recent studies have shown that advertising for menthol 

cigarettes is significantly higher in neighborhoods around high schools with a high 

proportion of African American students than in neighborhoods around schools with 

lower proportions of African Americans.

8

Example data 

source(s)

Environmental scan of tobacco advertising in retail outlets

Operation Storefront: Youth Against Tobacco Advertising and Promotion Initiative 

Information available at: 

http://www.dhs.ca.gov/tobacco/html/Evaluation_Resources.htm

New York State’s Retail Advertising Tobacco Survey (RATS)

Information available at: http://www.health.ny.gov/prevention/tobacco_control/ 

docs/tobacco_marketing_exposure_rpt.pdf

Population group(s) Not applicable. This indicator is best measured by observation.

Example survey 

question(s)

Not applicable

Comments The Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 

2009 gave the U.S. Food and Drug Administration the authority to regulate the 

manufacturing, marketing, and sale of tobacco products and allow states and localities to 

restrict or regulate the time, place, and manner (but not the content) of cigarette 

advertising or promotions.

Findings from this work have utility for monitoring compliance with existing laws or 

informing new policy; therefore, evaluators may choose to measure local-level 

geographic variables to inform policy initiatives. Evaluators may also choose to gather 

and report their findings by type of retailer (e.g., grocery store, convenience store, gas 

station); by proximity to schools, parks, and other areas where young people congregate; 

by neighborhood characteristics; and by affected population size, density, and 

demographics.

State-specific lists of tobacco retailers will inform sampling strategies.
GOAL AREA 1

► Outcome 7 

148 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

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

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

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

on Smoking and Health; 2012. 

2. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal study of exposure to retail cigarette 

advertising and smoking initiation. Pediatrics. 2010 Aug;126(2):232–8.

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

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

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

4. Pierce JP. Tobacco industry marketing, population-based tobacco control and smoking behavior. American 

Journal of Preventive Medicine. 2007;33(6 Suppl):S327–34.

5. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8.

6. Roeseler A, Rogers T, Feighery E, Gehrman J. Operation storefront: youth against tobacco advertising and 

promotion. Sacramento, CA: California Department of Health Services; 2003. 

7. Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is adolescent smoking 

related to the density and proximity of tobacco outlets and retail cigarette advertising near schools? Preventive 

Medicine. 2008;47(2):210–4.

8. Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted advertising, promotion, and price for 

menthol cigarettes in California high school neighborhoods. Nicotine & Tobacco Research. 2012 

Jan;14(1):116–21.

9. Widome R, Brock B, Klein EG, Forster JL. Smokeless tobacco advertising at the point of sale: prevalence, 

placement, and demographic correlates. Nicotine & Tobacco Research. 2012 Feb;14(2):217–23.

For Further Reading 

Centers for Disease Control and Prevention. Point-of-purchase tobacco environments and variation by store type—

United States, 1999. Morbidity and Mortality Weekly Report. 2002;51(9):184–7.

Feighery E, Henriksen L, Schleicher N, Wang Y, Fortmann S. An evaluation of four measures of adolescents’

exposure to cigarette marketing in stores. Nicotine & Tobacco Research. 2006;8(6):751–9.

Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their 

advertising and products in stores: interviews with retailers about tobacco company incentive programmes. Tobacco 

Control. 2003;12(2):184–8.

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

Academies Press; 2007. 

Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine & 

Tobacco Research. 2009;11(1):25–35. 

Roeseler A, Feighery E, Cruz TB. Tobacco marketing in California and implications for the future. Tobacco 

Control. 2010;19(Supp 1):21e30. 

Wakefield M, Germain D, Henriksen L. The effect of retail cigarette pack displays on impulse purchase. Addiction. 

2007;103(2):322–8.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

149

Indicator 1.7.b

Extent of Tobacco Industry Sponsorship of Public and Private Events

KOI 2005 1.9.5 “Extent of tobacco industry sponsorship of public and private events”

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Extent of tobacco industry sponsorship of public and private events (e.g., sports, 

recreation, music, family, or work-related events)

Why this indicator is 

useful

Tobacco companies use sponsorship as a key public relations strategy to buy legitimacy 

for the industry.1,2 Sponsorship of sporting events, such as rodeos, is strategically used by 

the tobacco industry to reach young people, enhance the brand image of tobacco 

products, and conduct market research.3 Attendance at industry-sponsored events at bars, 

clubs, and fraternities has been associated with higher smoking prevalence among young 

adults.4

Example data 

source(s)

Event sponsorship tracking system

California Tobacco Industry Monitoring Evaluation: Project SMART Money Information 

available in Roeseler et al.5

Population group(s) Not applicable. This indicator is best measured by observation.

Example survey 

question(s)

Not applicable

Comments Evaluators may want to assess the number and types of events that are being sponsored 

and the numbers of attendees as well as predominant population groups at these events.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$$

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.

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. Rosenberg NJ, Siegel M. Use of corporate sponsorship as a tobacco marketing tool: a review of tobacco 

industry sponsorship in the USA, 1995–99. Tobacco Control. 2001;10(3):239–46.

3. Ling PM, Haber LA, Wedl S. Branding the rodeo: a case study of tobacco sports sponsorship. American 

Journal of Public Health. 2010 Jan;100(1):32–41.

4. Rigotti NA, Moran SE, Wechsler H. US college students’ exposure to tobacco promotions: prevalence and 

association with tobacco use. American Journal of Public Health. 2005 Jan;95(1):138–44.

5. Roeseler A, Feighery E, Cruz TB. Tobacco marketing in California and implications for the future. Tobacco 

Control. 2010;19(Suppl 1):i22–i29. 
GOAL AREA 1

► Outcome 7

150 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

For Further Reading

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

Academies Press; 2007.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

151

Indicator 1.7.cNR

Extent of Tobacco Advertising in Media

KOI 2005 1.9.8 Revised Title (Previously: “Extent of tobacco advertising in print media”)

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Extent of tobacco advertisement in print advertising (e.g., in magazines, newspapers, 

signage at point of sale), electronic advertising (e.g., company Web sites, industrysponsored online social media), direct-to-consumer advertising (e.g., direct mail, 

coupons), product packaging, and paid product placement

Why this indicator is 

useful

The Master Settlement Agreement (MSA) regulated aspects of tobacco advertising in 

print media; one study, however, found that after the MSA, the combined advertising 

expenditures of the four major tobacco companies increased in 19 magazines that have a 

youth focus, and more than half (54%) of magazines preferred by teens contained 

cigarette advertisements.1 Additionally, the tobacco industry is using “new media” and 

other advertising modes to create intense engagement of target audiences with 

entertaining and participatory events, using new technologies to collect data and target 

behaviors, and implementing a “360-degree” strategy that encompasses multiple forms 

of media.3 Understanding the extent of tobacco advertising will help to monitor the 

impact of regulations and provide additional information regarding the ways the tobacco 

industry targets youth.

Example data 

source(s)

Print, Internet Media Monitoring: Kantar Media Intelligence’s StradegyTM database 

Information available at:: http://kantarmediana.com/intelligence

Self-reported exposure: National Youth Tobacco Survey (NYTS), 2011

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

Population group(s) This indicator is best measured by directly tracking tobacco advertisements in media; 

however, currently tested methodologies for monitoring media channels are often 

expensive. Therefore, capturing information on reported exposure by youth younger 

than 18 years and young adults aged 18 to 25 years may provide additional useful 

information.

Example survey 

question(s)

From NYTS

When you read newspapers or magazines, how often do you see ads or promotions for 

cigarettes and other tobacco products?

I do not read newspapers or magazines Sometimes

Never Most of the time

Rarely Always

When you are using the Internet, how often do you see ads or promotions for cigarettes 

or other tobacco products?

I do not use the Internet Sometimes

Never Most of the time

Rarely Always

During the past 30 days, did you receive ads from a tobacco company through... (You 

can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

The mail Facebook

E-mail Myspace

The Internet A text message
GOAL AREA 1

► Outcome 7 

152 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Comments Evaluators may want to assess tobacco advertising by type or channel of media, by 

content theme, and/or by target audience.

The distinction between commercial and personal tobacco promotion online is often 

hard to discern. See indicator 1.7.e for additional data sources and information on 

surveillance of pro-tobacco content on the Internet.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

 Denotes no data.

References 

1. Hamilton WL, Turner-Bowker DM, Celebucki CC, Connolly GN. Cigarette advertising in magazines: the 

tobacco industry response to the Master Settlement Agreement and to public pressure. Tobacco Control. 

2002;11(Suppl 2):ii54–8.

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. 

For Further Reading 

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

Academies Press; 2007. 

Jenssen B, Klein J, Salazar L, Daluga N, DiClemente R. Exposure to tobacco on the internet: content analysis of 

adolescents’ internet use. Pediatrics. 2009 Aug 12;124(2):180–6.

Ribisl KM, Kim AE, Williams RS. Sales and marketing of cigarettes on the Internet: emerging threats to tobacco 

control and promising policy solutions. In: Institute of Medicine (IOM). Ending the tobacco problem: a blueprint 

for the nation. Washington, DC: The National Academies Press; 2007:653–78.

Stillman F, Cronin K, Evans W, Ulasevich A. Can media advocacy influence newspaper coverage of tobacco: 

measuring the effectiveness of the American Stop Smoking Intervention Study’s (ASSIST) media advocacy 

strategies. Tobacco Control. 2001;10(2):137–44.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

153

Indicator 1.7.d

Extent of Tobacco in Movies

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Proportion of movies that show tobacco use and/or tobacco products

Why this indicator is 

useful

Extensive evidence indicates a causal relationship between exposure to movie smoking 

depictions and youth smoking initiation.1-3 Additional evidence is needed to determine 

whether this also holds true for young adults or for specific racial and ethnic groups.1

Smoking in movies serves as an important form of indirect marketing that normalizes 

tobacco use. Although the Master Settlement Agreement (MSA) in 1998 prohibited paid 

placement of tobacco products in movies, the number of tobacco incidents in films 

reached a peak in 2005.4 By 2009, the number of incidents had been reduced by 

approximately half, the first time a decline of that magnitude and duration has been 

observed.4

Example data 

source(s)

Scene Smoking, “Thumbs Up! Thumbs Down!” sponsored by Breathe California of 

Sacramento-Emigrant Trails

Information available at: http://www.scenesmoking.org/frame.htm

Population group(s) Not applicable

Example survey 

question(s)

Not applicable

Comments The extent of tobacco in movies can be measured using a number of methods. The 2012 

Surgeon General’s Report1 describes using content analysis to capture the prevalence of 

smoking in movies. Multiple variables may be measured, including type of movie in 

which tobacco appears (i.e., youth rated movies), tobacco portrayal (characters using 

products vs. tobacco imagery), positive or negative framing of tobacco, and number of 

appearances of tobacco.5

Assessing exposure to tobacco in movies is challenging. Commonly used methods 

include using general self-reported exposure items, asking young people to list their 

favorite actors and actresses and then linking this information with content analyses for 

pertinent movies, and asking young people to identify movies that they have seen among 

a lengthy list of movies.1 Each of these methods raises the potential for bias. Evaluators 

should consider methods most appropriate for their needs. 

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

► Outcome 7

154 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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

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

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

3. World Health Organization. Smoke-free Movies: From Evidence to Action. 2009. Available at: 

http://whqlibdoc.who.int/publications/2009/9789241597937_eng.pdf. Accessed December 29, 2011.

4. Centers for Disease Control and Prevention. Smoking in top grossing movies—United States, 1991–2009. 

Morbidity and Mortality Weekly Report. 2010; 59(32):1014–7.

5. Cruz TB. Monitoring the tobacco use epidemic IV. The vector: tobacco industry data sources and 

recommendations for research and evaluation. Preventive Medicine. 2009;48(1 Suppl):S24–S34.

For Further Reading

Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: A review. Pediatrics.

2005;116:1516–28.

Choi K, Forster J, Erickson D, Lazovich D, Southwell BG. The reciprocal relationships between changes in 

adolescent perceived prevalence of smoking in movies and progression of smoking status. Tobacco Control. 2012 

Sep;21(5):492–6.

Glantz SA, Kacirk KW, McCulloch C. Back to the future: Smoking in movies in 2002 compared with 1950 levels. 

American Journal of Public Health. 2004;94(2):261–3.

Titus-Ernstoff L, Dalton MA, Adachi-Mejia AM, Longacre MR, Beach ML. Longitudinal study of viewing smoking 

in movies and initiation of smoking by children. Pediatrics. 2008;121(1):15–21.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

155

Indicator 1.7.eNR

Extent of Pro-Tobacco Internet Presence

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Amount and type of pro-tobacco presence online, including corporate and brand Web

sites, advertising, and social media. Proportion of youth who report seeing 

advertisements or other content on the Internet about tobacco products. Content could 

include industry- and non-industry-sponsored Web sites or advertisements, pro-tobacco 

user-generated content, and retail Web sites that sell cigarettes online. 

Why this indicator is 

useful

While Federal Trade Commission reporting indicates that tobacco companies do not 

report expenditures for advertising their products online via banner advertisements or 

through social media marketing, they do maintain interactive Web sites promoting 

specific brands that could appeal to youth.1-3In addition, consumer-generated content on 

social media and tobacco sales Web sites has the potential to promote tobacco use

indirectly.

4-7 Finally, tobacco products are being sold online at lower prices than in retail 

stores because online retailers do not charge excise taxes, making online purchasing 

potentially more appealing to youth, given youth price sensitivity.8

Example data 

source(s)

Environmental scan of social media Web sites for industry presence and pro-tobacco 

content; monitoring and content analysis of brand and corporate Web sites for age 

identification requirements and messaging

Social media monitoring tools can be used for surveillance. To examine audience 

engagement with pro-tobacco content online, metrics for tobacco-related posts on social 

media sites, such as number of “likes” on Facebook, video views on YouTube, and 

followers on Twitter, are publicly available. Social media monitoring software (e.g., 

Radian6, Attensity, Buzzmetrics) summarizes trends in social media conversations and 

online earned media (e.g., blog posts) using keywords to monitor product and Web site 

mentions.

National Youth Tobacco Survey (NYTS), 2009

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years 

Example survey 

question(s)

From NYTS

When you are using the Internet, how often do you see any ads or promotion for 

cigarettes or other tobacco products?

I do not use the Internet Sometimes

Never Most of the time

Rarely Always

During the past 30 days, where did you buy the last pack of cigarettes you bought?

I did not buy a pack of cigarettes A gas station

 during the past 30 days A convenience store

A grocery store A drugstore

A vending machine I bought them over the Internet

Other______________________________________________________
GOAL AREA 1

► Outcome 7 

156 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Comments Social media monitoring programs are often proprietary and can be quite costly. The 

2012 Surgeon General’s Report concludes that the sheer number of Web pages that 

mention tobacco makes it very difficult to track comprehensively, and verifying that no 

Web site has been established by tobacco companies is also extremely difficult. 9 The 

NYTS item only measures exposure to Internet advertising, but additional items could 

be created to measure the other dimensions of pro-tobacco Internet presence: exposure 

to online tobacco retail Web sites, exposure to brand or corporate Web sites, and 

exposure to social media and other user-generated tobacco content. Any items 

developed by evaluators should undergo cognitive testing and validation before 

widespread use.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

 Denotes no data.

References 

1. Federal Trade Commission. Cigarette report for 2007 and 2008. Washington, DC: Federal Trade Commission; 

2011.

2. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade Commission; 2013. 

3. Wackowski OA, Lewis MJ, Delnevo CD. Qualitative analysis of Camel Snus’ website message board—users’

product perceptions, insights and online interactions. Tobacco Control. 2011 Mar;20(2):e1. 

4. Seidenberg AB, Rodgers EJ, Rees VW, Connolly GN. Youth access, creation, and content of smokeless tobacco 

(“dip”) videos in social media. Journal of Adolescent Health. 2012 Apr;50(4):334–8.

5. Ribisl KM, Lee RE, Henriksen L, Haladjian HH. A content analysis of Web sites promoting smoking culture 

and lifestyle. Health Education & Behavior. 2003;30(1):64–78.

6. Bromberg JE, Augustson EM, Backinger CL. Portrayal of smokeless tobacco in YouTube videos. Nicotine & 

Tobacco Research. 2012 Apr;14(4):455–62.

7. Freeman B. New media and tobacco control. Tobacco Control. 2012; 21(2):139–44.

8. Ayers JW, Ribisl K, Brownstein JS. Using search query surveillance to monitor tax avoidance and smoking 

cessation following the United States’ 2009 “SCHIP” cigarette tax increase. PLoS One. 2011;6(3):e16777. 

9. 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. 
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

157

Indicator 1.7.f

Amount and Quality of News Media Stories About Tobacco Industry 

Practices and Political Lobbying

KOI 2005 1.9.9 

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Quantity and quality of media coverage of tobacco industry practices and political 

lobbying. Quality includes, but is not limited to, timeliness, accuracy, and emotional 

valence.

Why this indicator is 

useful

News media coverage can frame discussion of tobacco-related issues among policy

makers and the general public.1 The quantity, quality, and accuracy of tobacco-related 

media information influences individuals’ knowledge, perceptions, and behaviors 

related to tobacco.2 However, news media coverage can also be a tool exploited by the 

tobacco industry to oppose tobacco control efforts.3 Therefore, public health advocates 

should focus on ensuring that coverage includes accurate health outcomes related to 

proposed or adopted legislation.4 One study found that an increase in the volume of 

newspaper articles per community was associated with increased odds of youth 

perceiving harm in smoking one or more packs of cigarettes per day as well as a 

decreased likelihood of smoking in the past 30 days.5

Example data 

source(s)

Media tracking service (e.g., clipping service)

Information available at: http://kantarmediana.com/intelligence

Population group(s) Not applicable. This indicator is best measured by monitoring and tracking pertinent 

media coverage of tobacco industry practices.

Example survey 

question(s)

Not applicable

Comments Quantitative studies involve counting articles, measuring column-inches, or noting 

article placement. Qualitative studies require detailed content analyses to detect article 

themes and emotional valence.

More information on how to collect data on this indicator is presented in Stillman et al. 

(2001).

6

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

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

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

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

2. Dunlop SM, Romer D. Relation between newspaper coverage of ‘light’ cigarette litigation and beliefs about 

‘lights’ among American adolescents and young adults: the impact on risk perceptions and quitting intentions. 

Tobacco Control. 2010 Aug;19(4):267–73.
GOAL AREA 1

► Outcome 7

158 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

3. Magzamen S, Charlesworth A, Glantz SA. Print media coverage of California’s smoke free bar law. Tobacco 

Control. 2001 Jun;10(2):154–60.

4. Nagelhout GE, van den Putte B, de Vries H, Crone M, Fong GT, Willemsen MC. The influence of newspaper 

coverage and a media campaign on smokers’ support for smoke-free bars and restaurants and on secondhand 

smoke harm awareness: findings from the International Tobacco Control (ITC) Netherlands Survey. Tobacco 

Control. 2012 Jan;21(1):24–9.

5. Smith KC, Wakefield MA, Terry-McElrath Y, Chaloupka FJ, Flay B, Johnston L, et al. Relation between 

newspaper coverage of tobacco issues and smoking attitudes and behaviour among American teens. Tobacco

Control. 2008;17(1):17–24.

6. Stillman F, Cronin K, Evans W, Ulasevich A. Can media advocacy influence newspaper coverage of tobacco: 

measuring the effectiveness of the American Stop Smoking Intervention Study’s (ASSIST) media advocacy 

strategies. Tobacco Control. 2001;10(2):137–44.

For Further Reading

Caburnay CA, Kreuter MW, Luke DA, Logan RA, Jacobsen HA, Reddy VC, et al. The news on health behavior: 

coverage of diet, activity, and tobacco in local newspapers. Health Education & Behavior. 2003;30(6):709–22.

Hicks JJ. The strategy behind Florida’s truth campaign. Tobacco Control. 2001;10(1):3–5.

Lima JC, Siegel M. The tobacco settlement: an analysis of newspaper coverage of a national policy debate, 1997–

98. Tobacco Control. 1999;8(3):247–53.

Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues—United States, 

1985–1996. Journal of Health Communication. 1998;3(4):307–25.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

159

Indicator 1.7.gNR

Extent of Tobacco Industry-Sponsored Tobacco Use Prevention Activities

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Extent of tobacco industry sponsorship of prevention activities and educational 

programs, including publication of self-help booklets, distribution of school-based 

prevention curricula and programs, programs to prevent youth access to tobacco 

products, mass media campaigns advocating that youth not smoke, and communitybased programs for youth

Why this indicator is 

useful

A substantial body of research has demonstrated that anti-tobacco-industry attitudes 

reduce the likelihood of future initiation of smoking among youth and young adults; 

however, industry-sponsored efforts with the stated purpose of preventing youth tobacco 

use could create favorable impressions of the sponsoring tobacco companies among 

young people, their parents, or others in the community.1 Sussman concluded that the 

prevention activities and educational programs developed and/or supported by the 

industry do not include key elements of proven tobacco use prevention programs and 

avoid any reference to the tobacco industry’s role in tobacco initiation and maintenance 

of tobacco use behaviors.2Instead, these programs portray smoking as an “adult choice”

or “adult decision,” which further glamorizes the behavior.

The tobacco industry’s youth smoking prevention activities and programs have not 

provided evidence that they are effective at reducing youth smoking. Indeed, published 

studies by independent academic researchers, as well as unpublished industry studies, 

indicate that industry-sponsored prevention activities and programs are ineffective and 

can lead to a greater likelihood of uptake among youth.

3-5

The tobacco industry receives several benefits from its youth smoking prevention 

initiatives.1 These include promoting positive attitudes among key constituencies (e.g., 

policy makers, the legal system); managing impressions among youth to maintain the 

potential for tobacco use initiation when these children become young adults;5-8 using 

the relationships created with sponsored organizations to counter proposed tobacco 

control legislation;9-11arguing against the need for public-health-funded tobacco control 

strategies because industry-sponsored programs fill the need;12and providing a “cover”

for industry-conducted research on determinants of smoking among youth, which could 

inform tobacco marketing efforts.12

Example data 

source(s)

School district/board or school-level records of curricula adopted or sponsored programs 

and activities

Tobacco industry fiscal reports

Population group(s) Not applicable. This indicator is best measured by reviewing public and tobacco 

industry records.

Example survey 

question(s)

Not applicable

Comments Evaluators may want to categorize the types of activities and programs that are tobacco 

industry-sponsored by the target sector (family, school, community, media), and 

measure the reach of these efforts.
GOAL AREA 1

► Outcome 7 

160 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

     

 Denotes no data.

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. Sussman S. Tobacco industry youth tobacco prevention programming: a review. Prevention Science. 2002; 

3(1):57–67.

3. Donovan RJ, Jalleh G, Carter OBJ. Tobacco industry smoking prevention advertisements’ impact on youth 

motivation for smoking in the future. Social Marketing Quarterly. 2006;12(2):3–13.

4. Henriksen L, Dauphinee AL, Wang Y, Fortmann SP. Industry sponsored anti-smoking ads and adolescent 

reactance: test of a boomerang effect. Tobacco Control. 2006;15(1):13–8. 

5. Wakefield M, Terry-McElrath Y, Emery S, Saffer H, Chaloupka FJ, Szczypka G, et al. Effect of televised, 

tobacco company-funded smoking prevention advertising on youth smoking-related beliefs, intentions, and 

behavior. American Journal of Public Health. 2006;96(12):2154–60.

6. Thrasher JF, Niederdeppe JD, Jackson C, Farrelly MC. Using anti-tobacco industry messages to prevent 

smoking among high-risk adolescents. Health Education Research. 2006;21(3):325–37.

7. Ling PM, Neilands TB, Glantz SA. The effect of support for action against the tobacco industry on smoking 

among young adults. American Journal of Public Health. 2007;97(8):1449–56. 

8. Ling PM, Neilands TB, Glantz SA. Young adult smoking behavior: a national survey. American Journal of 

Preventive Medicine. 2009;36(5):389–94.

9. Forster JL, Wolfson M. Youth access to tobacco: policies and politics. Annual Review of Public Health.

1998;19:203–35.

10. Landman A, Ling PM, Glantz SA. Tobacco industry youth smoking prevention programs: protecting the 

industry and hurting tobacco control. American Journal of Public Health. 2002;92(6):917–30.

11. Apollonio DE, Malone RE. The “We Card” program: tobacco industry youth smoking prevention as industry 

self-preservation. American Journal of Public Health. 2010;100(7):1188–201.

12. Mandel LL, Bialous SA, Glantz SA. Avoiding “truth”: tobacco industry promotion of life skills training. 

Journal of Adolescent Health. 2006;39(6):868–79.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

161

Indicator 1.7.h

Amount of Tobacco Industry Contributions to Institutions and Groups

KOI 2005 1.9.11 

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Amount of funds contributed by the tobacco industry to institutions and groups (e.g., 

universities and higher education, hospitality industry, movie industry, sports 

organizations, civic groups). See additional notes in “Comments” below.

Why this indicator is 

useful

Corporate philanthropy is one way for the tobacco industry to simultaneously engage 

local and national institutions while building their influence; the amount of the tobacco 

industry’s influence on these groups is directly related to the amount it contributes.1-5

Tobacco companies strategically use such campaigns to improve public opinion and 

company image.6 This type of corporate philanthropy not only legitimizes the tobacco 

industry, but also has been shown to weaken tobacco control efforts.6-9 Tracking this 

indicator will help to understand tobacco industry influence. 

Example data 

source(s)

Public records of political contributions

Information available from the Office of the State Secretary or equivalent in each state

Center for Responsive Politics (CRP)

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

Tobacco industry fiscal reports

Population group(s) Not applicable. This indicator is best measured by reviewing public and tobacco 

industry records.

Example survey 

question(s)

Not applicable

Comments Tobacco control programs may want to examine the source of industry contributions to 

assist with media advocacy intended to expose the tobacco industry, its lobbying and 

public relations firms, and tobacco industry front groups as the source of contributions 

to legitimate causes and organizations.

Evaluators may want to categorize their findings by type of business or organization 

(e.g., hospitality industry, movie industry, sports organizations, civic groups) that 

received funds from the tobacco industry.

More information on how to collect data on this indicator is presented in Tesler and 

Malone.

6

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$*

* Denotes low reviewer response, defined as fewer than 75% of valid ratings on a 

criterion for an indicator.
GOAL AREA 1

► Outcome 7

162 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References

1. Ritch WA, Begay ME. Strange bedfellows: the history of collaboration between the Massachusetts Restaurant 

Association and the tobacco industry. American Journal of Public Health. 2001;91(4):598–603.

2. Rosenberg NJ, Siegel M. Use of corporate sponsorship as a tobacco marketing tool: a review of tobacco 

industry sponsorship in the USA, 1995–99. Tobacco Control. 2001;10(3):239–46.

3. Dearlove JV, Bialous SA, Glantz SA. Tobacco industry manipulation of the hospitality industry to maintain 

smoking in public places. Tobacco Control. 2002;11(2):94–104.

4. Mekemson C, Glantz SA. How the tobacco industry built its relationship with Hollywood. Tobacco Control. 

2002;11(Suppl 1):i81–91.

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

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

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

6. Tesler LE, Malone RE. Corporate philanthropy, lobbying, and public health policy. American Journal of Public 

Health. 2008 Dec;98(12):2123–33.

7. McDaniel PA, Smith EA, Malone RE. Philip Morris’s Project Sunrise: weakening tobacco control by working 

with it. Tobacco Control. 2006;15(3):215–23.

8. Yang JS, Malone RE. “Working to shape what society’s expectations of us should be”: Philip Morris’ societal 

alignment strategy. Tobacco Control. 2008;17(6):391–8.

9. Mandel LL, Bialous SA, Glantz SA. Avoiding “truth”: tobacco industry promotion of life skills training. 

Journal of Adolescent Health. 2006;39(6):868–79.

For Further Reading

Balbach ED, Campbell RB. Union women, the tobacco industry, and excise taxes: a lesson in unintended 

consequences. American Journal of Preventive Medicine. 2009 Aug;37(2 Suppl):S121–5.

Balbach ED, Herzberg A, Barbeau EM. Political coalitions and working women: how the tobacco industry built a 

relationship with the Coalition of Labor Union Women. Journal of Epidemiology and Community Health. 2006 

Sep;60(Suppl 2):27–32.

Campbell RB, Balbach ED. Building alliances in unlikely places: progressive allies and the Tobacco Institute’s 

coalition strategy on cigarette excise taxes. American Journal of Public Health. 2009 Jul;99(7):1188–96.

Campbell R, Balbach ED. Mobilising public opinion for the tobacco industry: the Consumer Tax Alliance and 

excise taxes. Tobacco Control. 2008 Oct;17(5):351–6.

Raebeck A, Campbell R, Balbach E. Unhealthy partnerships: the tobacco industry and African American and Latino 

labor organizations. Journal of Immigrant and Minority Health. 2010 Apr;12(2):228–33.

Yerger VB, Malone RE. African American leadership groups: smoking with the enemy. Tobacco Control. 2002 

Dec;11(4):336–45.
GOAL AREA 1

► Outcome 7 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

163

Indicator 1.7.i

Amount of Tobacco Industry Campaign Contributions to Local and State 

Politicians

KOI 2005 1.9.12

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco industry influence

What to measure Amount of funds contributed to aid local and state politicians by the tobacco industry

Why this indicator is 

useful

During the 2008 campaign cycle, the tobacco industry donated $4.4 million to federal 

political interests, including presidential, senatorial, and congressional candidates.1

Studies show an association between political contributions from the tobacco industry 

and pro-tobacco legislation.2-4 There is a positive association between the amount of 

money received by a congressman and his/her propensity to vote pro-tobacco, even after 

controlling for political party and state of origin.4 Thus, tobacco industry contributions 

are a significant predictor of the industry’s political influence, including its influence on 

votes for tobacco-related legislation.2-5 Tracking this indicator may help states to 

publicize and counter the influence of the tobacco industry.

Example data 

source(s)

Public records of political contributions

Information available from the Office of the State Secretary or equivalent in each state

Federal Election Commission (FEC)

Searchable database available at: http://www.fec.gov

Center for Responsive Politics (CRP)

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

Population group(s) Not applicable. This indicator is best measured by reviewing public records.

Example survey 

question(s)

Not applicable

Comments More information on how to collect data on this indicator is presented in Givel and 

Glantz (2001)

6

and Morley et al. (2002).7

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $$$*

* Denotes low reviewer response, defined as fewer than 75% of valid ratings on a 

criterion for an indicator.

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

► Outcome 7 

164 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

References 

1. Center for Responsive Politics. Tobacco Background. 2010. Available at: 

http://www.opensecrets.org/industries/background.php?cycle=2010&ind=A02. Accessed August 15, 2011. 

2. Glantz SA, Begay ME. Tobacco industry campaign contributions are affecting tobacco control policymaking in 

California. Journal of the American Medical Association. 1994;272(15):1176–82. 

3. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legislative behavior? 

American Journal of Public Health. 1998;88(6):918–23.

4. Luke DA, Krauss M. Where there’s smoke there’s money: tobacco industry campaign contributions and U.S. 

Congressional voting. American Journal of Preventive Medicine. 2004;27(5):363–72.

5. Offen N, Arvey SR, Smith EA, Malone RE. Forcing the Navy to sell cigarettes on ships: how the tobacco 

industry and politicians torpedoed Navy tobacco control. American Journal of Public Health. 2011;101(3): 

404–11. 

6. Givel MS, Glantz SA. Tobacco lobby political influence on U.S. state legislatures in the 1990s. Tobacco 

Control. 2001;10(2):124–34. 

7. Morley CP, Cummings KM, Hyland A, Giovino GA, Horan JK. Tobacco Institute lobbying at the state and 

local levels of government in the 1990s. Tobacco Control. 2002;11(Suppl 1):102–9.
GOAL AREA 1

► Outcome 8 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

165

Outcome 8 

Increased Price of Tobacco Products 

Raising the retail price of tobacco products through excise tax increases is one of five strategic 

actions endorsed by the U.S. Department of Health and Human Services to end the tobacco 

epidemic.1 Studies show an inverse relationship between cigarette price and smoking prevalence 

by youth and young adults.2 Additionally, some evidence has shown an inverse relationship 

between price of other tobacco products (e.g., cigars and smokeless tobacco) and propensity of 

use, intensity of use, and prevalence of tobacco use among youth.2 Increasing excise taxes on 

cigarettes is an effective method of increasing the purchase price of cigarettes.2 Not only can 

high tobacco taxes serve directly as a barrier to tobacco use initiation and as a motivator for 

quitting among current users, but tax-driven price increases also can indirectly reduce tobacco 

use if a portion of the excise tax revenue is dedicated to tobacco control efforts.3

Maintaining higher real prices of tobacco products requires ongoing tax increases to offset the 

effects of inflation and industry practices designed to control retail product prices.2 The industry 

employs a variety of marketing mechanisms to control the price of tobacco products; in fact, 

price-reducing promotions have become a key marketing strategy for the tobacco industry, which 

can mitigate the impact of tobacco taxes.2 Historically price competition in the industry has been 

rare, but it has been increasing over time. The cigarette manufacturers spent 84% of their annual 

marketing budget to reduce retail cigarette prices in 2011, compared to 60% in 1988.4

 In the 

1980s, discount brands were created to offset the increasing price of cigarettes due to federal 

taxes and an ailing economy. By the 1990s, discount brands accounted for 40% of consumption. 

When Philip Morris slashed prices on Marlboro brand cigarettes by introducing price-reducing 

promotions in 1993, other companies followed suit, stopping the decline in U.S. cigarette sales 

for at least a few years, while smoking among youth rose dramatically.2

More recently, the industry has responded to cigarette tax increases by engaging in a variety of 

price-related marketing strategies to control prices charged consumers. These strategies include 

distributing coupons via print ads, at the point of sale, and via direct mail, and offering multipack 

discounts.2In response to the 2009 increase in the federal excise tax on cigarettes, Philip Morris 

increased prices on its brands while simultaneously engaging in marketing messages blaming the 

entire increase on the federal government and promoting coupons and special offers for its 

customers to counteract the increase.2 The tobacco industry also engages in price discrimination, 

wherein cigarette prices are lower in states with stronger tobacco control policies to offset the 

impact of these policies on tobacco use.5-6 Studies of internal tobacco documents have shown 

that the industry employs price-reducing strategies with the knowledge that youth and young 

adults are more responsive to price increases than adults and that this knowledge has informed 

their use of price-reducing promotions.2

The following indicators are associated with this outcome: 

► 1.8.a Amount of tobacco product taxes and fees 

► 1.8.b Price paid for tobacco products 
GOAL AREA 1

► Outcome 8

166 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

► 1.8.c Extent and type of consumer-focused industry promotions

► 1.8.d Extent and type of merchant-focused industry promotions

References

1. U.S. Department of Health and Human Services. Ending the tobacco epidemic: a tobacco 

control strategic action plan for the U.S. Department of Health and Human Services.

Washington, DC: Office of the Assistant Secretary for Health; November 2010.

2. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012.

3. 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.

4. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade 

Commission; 2013.

5. Slater SJ, Chaloupka FJ, Wakefield M. State variation in retail promotions and advertising 

for Marlboro cigarettes. Tobacco Control. 2001;10(4):337–9.

6. Loomis BR, Farrelly MC, Mann NH. The association of retail promotions for cigarettes with 

the Master Settlement Agreement, tobacco control programmes and cigarette excise taxes. 

Tobacco Control. 2006;15(6):458–63.

For Further Reading

Chaloupka FJ. Cigarettes: old firms facing new challenges. In: Tremblay VJ, Tremblay CH, eds. 

Industry and firm studies, 4th ed. Armonk, NY: ME Sharpe; 2007:80–118.

Chaloupka FJ, Cummings KM, Morley CP, Horan JK. Tax, price and cigarette smoking: 

evidence from the tobacco documents and implications for tobacco company marketing 

strategies. Tobacco Control. 2002;11(Suppl 1):i62–i72.

Henriksen L. Comprehensive tobacco marketing restrictions: promotion, packaging, price and 

place. Tobacco Control. 2012;21(2):147–53.

Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail 

cigarette marketing practices on youth smoking uptake. Archives of Pediatrics & Adolescent 

Medicine. 2007;161(5):440–5.
GOAL AREA 1

► Outcome 8 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

167

Outcome 8 

Increased Price of Tobacco Products 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.8.a Amount of tobacco product taxes 

and fees

$$

1.8.b Price paid for tobacco products $

1.8.c Extent and type of consumerfocused industry promotions

$$$

1.8.d Extent and type of merchantfocused industry promotions

$$$†

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

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

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

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

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±1 point of the 

median for this indicator-specific criterion. 
GOAL AREA 1

► Outcome 8 

168 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.8.a

Amount of Tobacco Product Taxes and Fees

KOI 2005 1.12.1 Revised Title (Previously: “Amount of tobacco product excise tax”)

Goal area Preventing initiation of tobacco use

Outcome box Increased price of tobacco products

What to measure (1) Excise tax per individual unit of tobacco product, (2) sales tax per unit of tobacco 

product, (3) applicable fees per unit, and (4) percentage of the total price of a unit of 

tobacco product that is attributable to taxes and fees

Why this indicator is 

useful

The level of excise tax on tobacco products is one of the most fundamental and reliable 

indicators of the success of a tobacco control program.1Increasing tax on tobacco 

products increases the price of tobacco products, and higher tobacco prices are 

associated with overall reductions in tobacco use prevalence and tobacco consumption. 

These outcomes are achieved by preventing initiation and uptake by young people and 

promoting cessation and lowering consumption among tobacco users, especially pricesensitive populations (e.g., young people, ethnic or racial disparate populations).

2-10

Example data 

source(s)

CDC State Tobacco Activities Tracking and Evaluation (STATE) system

Data available at: http://apps.nccd.cdc.gov/statesystem/Default/Default.aspx

Campaign For Tobacco-Free Kids (CTFK)

Information available at: http://tobaccofreekids.org/research/factsheets

State departments of revenue

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring state excise 

and sales tax and fees on tobacco products.

Example survey 

question(s)

Not applicable

Comments To gather more complete data on tobacco price, evaluators should consider collecting 

data on other tobacco products, such as smokeless tobacco, snus, small cigars, and loose 

tobacco (roll-your-own).

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$

References 

1. Centers for Disease Control and Prevention. Tobacco Control State Highlights 2010. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

2. 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. 

3. Task Force on Community Preventive Services. The guide to community preventive services: what works to 

promote health? New York, NY: Oxford University Press; 2005. 
GOAL AREA 1

► Outcome 8

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

169

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

National Academies Press; 2007.

5. Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult 

smoking prevalence. American Journal of Preventive Medicine. 2009 Apr;36(4):285–91.

6. Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tobacco Control. 

2011;20(3):235–8.

7. Chaloupka FJ. Macro-social influences: The effects of prices and tobacco-control policies on the demand for 

tobacco products. Nicotine & Tobacco Research. 1999;1(Suppl 1):S105–9.

8. Farrelly MC, Loomis BR, Mann NH. Do increases in cigarette prices lead to increases in sales of cigarettes with 

high tar and nicotine yields? Nicotine & Tobacco Research. 2007;9(10):1015–20.

9. Feighery E, Rogers T, Ribisl K. Tobacco retail price manipulation policy strategy summit proceedings. 

Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2009. 

Available at: http://www.cdph.ca.gov/programs/tobacco/documents/ctcppricestrategysummit2009.pdf

10. Hyland A, Bauer JE, Li Q, Abrams SM, Higbee C, Peppone L, Cummings KM. Higher cigarette prices 

influence cigarette purchase patterns. Tobacco Control. 2005;14(2):86–92.

For Further Reading

American Lung Association. State Legislative Actions on Tobacco Issues (SLATI) Overview. 2009. Available at: 

http://slati.lungusa.org/StateLegislateAction.asp

Centers for Disease Control and Prevention. Federal and state cigarette excise taxes—United States, 1995–2009. 

Morbidity and Mortality Weekly Report. 2009;58(19):524–7.

National Cancer Institute. Evaluating ASSIST: a blueprint for understanding state-level tobacco control. Tobacco 

Control Monograph No. 17. NIH Publication. No. 06-6058. Bethesda, MD: U.S. Department of Health and Human 

Services, National Institutes of Health, National Cancer Institute; October 2006.

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.

NIH State of the Science Panel. NIH State-of-the-Science Conference Statement on Tobacco Use: Prevention, 

Cessation, and Control. Annals of Internal Medicine. 2006;145:839–44.

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

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

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

Health; 2012.
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170 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.8.b

Price Paid for Tobacco Products

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased price of tobacco products

What to measure Price paid by a consumer for a unit of tobacco product adjusted for inflation and 

including industry discounts and applicable taxes and fees

Why this indicator is 

useful

There is a strong, inverse relationship between cigarette price and smoking prevalence, 

particularly among price-sensitive populations (e.g., young people).1-6 Additionally, 

lower cigarette prices are associated with increased smoking initiation among youth.7,8

Example data 

source(s)

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Scanner data

Retail observation

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NATS

What price did you pay for the last pack of cigarettes you bought?

____________________________________________________________________

What price did you pay for the last carton of cigarettes you bought?

____________________________________________________________________

The last time you bought cigarettes, did you take advantage of coupons, rebates, buy 1 

get 1 free, 2 for 1, or any other special promotions for cigarettes?

Yes No

Comments States can track the price of tobacco products using retail scanner data that provide 

information on volume, price, brand, product type, package type, and promotions; 

however, scanner data are generally only available for designated market areas (DMAs) 

that may not correspond with state borders. Additionally, scanner data can be costly to 

obtain and complex to analyze.

States may also use retail observation to capture price information with the benefits of 

flexibility in obtaining unique price data (e.g., advertised prices), specific pricepromotional strategies, and compliance with certain policies such as minimum price law. 

Additionally, evaluators may adjust the sampling frame and link observational data to 

census tract or other ecological data depending on study needs; however, it can be costly 

to collect observational data, difficult to ensure high inter-rater reliability, and 

challenging to develop and test new valid and reliable measures.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

171

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. Task Force on Community Preventive Services. The guide to community preventive services: what works to 

promote health? New York, NY: Oxford University Press; 2005.

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

National Academies Press; 2007.

4. Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult 

smoking prevalence. American Journal of Preventive Medicine. 2009 Apr;36(4):285–91.

5. Pierce JP, Gilmer TP, Lee L, Gilpin EA, Beyer J, Messer K. Tobacco industry price-subsidizing promotions 

may overcome the downward pressure of higher prices on initiation of regular smoking. Health Economics. 

2005;14(10):1061–71.

6. National Cancer Institute. Evaluating ASSIST: a blueprint for understanding state-level tobacco control. 

Tobacco Control Monograph No. 17. NIH Publication No. 06-6058. Bethesda, MD: U.S. Department of Health 

and Human Services, National Institutes of Health, National Cancer Institute; October 2006.

7. Slater S, Chaloupka F, Wakefield M, Johnston L, O’Malley P. The impact of retail cigarette marketing practices 

on youth smoking uptake. Archives of Pediatrics & Adolescent Medicine. 2007;161(5):440–5.

8. Pierce J. Tobacco industry marketing, population-based tobacco control, and smoking behavior. American 

Journal of Preventive Medicine. 2007;33(6 Suppl):S327–4.

For Further Reading

Centers for Disease Control and Prevention. Federal and state cigarette excise taxes—United States, 1995–2009. 

Morbidity and Mortality Weekly Report. 2009;58(19):524–7.

Hyland A, Bauer JE, Li Q, Abrams SM, Higbee C, Peppone L, Cummings KM. Higher cigarette prices influence 

cigarette purchase patterns. Tobacco Control. 2005;14(2):86–92.

Loomis BR, Farrelly MC, Mann NH. The association of retail promotions for cigarettes with the master settlement 

agreement, tobacco control programs, and cigarette excise taxes. Tobacco Control. 2006;15(6):458–63.

Loomis BR, Farrelly MC, Nonnemaker JM, Mann NH. Point of purchase cigarette promotions before and after the 

Master Settlement Agreement: exploring retail scanner data. Tobacco Control. 2006;15(2):140–2.

Tauras JA, Peck RM, Chaloupka FJ. The role of retail prices and promotions in determining cigarette brand market 

shares. Review of Industrial Organization. 2006;28(3):253–84.
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172 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.8.c

Extent and Type of Consumer-Focused Industry Promotions

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased price of tobacco products

What to measure Level and type of consumer-focused tobacco industry promotions, such as sale price, 

rebates, coupons, and buy-one-get-one-free offers. See “Comments” below for 

additional information.

Why this indicator is 

useful

Greater availability of cigarette promotions and lower cigarette prices are associated 

with increased initiation and uptake among youth and decreased quit attempts among 

current smokers.1-7

Example data 

source(s)

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Retail observation

Operation Storefront: Youth Against Tobacco Advertising and Promotion Initiative 

Information available at: 

http://www.dhs.ca.gov/tobacco/html/Evaluation_Resources.htm

New York State’s Retail Advertising Tobacco Survey (RATS) Information available at: 

http://www.health.ny.gov/prevention/tobacco_control/ 

docs/tobacco_marketing_exposure_rpt.pdf

Scanner data

Population group(s) Not applicable. This indicator is best measured by observation.

Example survey 

question(s)

From NATS

In the past 30 days, did you use coupons, rebates, buy 1 get 1 free, 2 for 1, or any other 

special promotions when you bought cigarettes?

Yes No Not applicable

Comments States can track the price of tobacco products using retail scanner data that provide 

information on volume, price, brand, product type, package type, and promotions; 

however, scanner data are generally only available for designated market areas (DMAs) 

that may not correspond with state borders. Additionally, scanner data can be costly to 

obtain and complex to analyze.

States may also use retail observation to capture price information with the benefits of 

flexibility in obtaining unique price data (e.g., advertised prices), specific pricepromotional strategies, and compliance with certain policies such as minimum price law. 

Additionally, evaluators may adjust the sampling frame and link observational data to 

census tract or other ecological data depending on study needs; however, it can be costly 

to collect observational data, difficult to ensure high inter-rater reliability, and 

challenging to develop and test new valid and reliable measures. Suggested variables for 

retail observation include

• tobacco product prices and promotions (sale price, rebates, coupons, buy one get 

one free, bundles, gifts with purchase),

• average number of tobacco promotions, and

• percentage of tobacco retailers with promotions.
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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

173

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$

References 

1. Loomis BR, Farrelly MC, Mann NH. The association of retail promotions for cigarettes with the master 

settlement agreement, tobacco control programs, and cigarette excise taxes. Tobacco Control. 2006;15(6):458–

63. 

2. Loomis BR, Farrelly MC, Nonnemaker JM, Mann NH. Point-of-purchase cigarette promotions before and after 

the Master Settlement Agreement: exploring retail scanner data. Tobacco Control. 2006;15(2):140–2.

3. Slater S, Chaloupka F, Wakefield M, Johnston L, O’Malley P. The impact of retail cigarette marketing practices 

on youth smoking uptake. Archives of Pediatrics & Adolescent Medicine. 2007;161(5):440–5. 

4. Henriksen L, Feighery E, Schleicher N, Cowling D, Kline R, Fortmann S. Is adolescent smoking related to the 

density and proximity of tobacco outlets and retail cigarette advertising near schools? Preventive Medicine. 

2008;47(2):210–4. 

5. Pierce JP, Gilmer TP, Lee L, Gilpin EA, Beyer J, Messer K. Tobacco industry price-subsidizing promotions 

may overcome the downward pressure of higher prices on initiation of regular smoking. Health Economics. 

2005;14(1):1061–71. 

6. Pierce J. Tobacco industry marketing, population-based tobacco control, and smoking behavior. American 

Journal of Preventive Medicine. 2007;33(6 Suppl):S327–4. 

7. Tauras JA, Peck RM, Chaloupka FJ. The role of retail prices and promotions in determining cigarette brand 

market shares. Review of Industrial Organization. 2006;28(3):253–84.

For Further Reading 

Chuang Y, Cubbin C, Ahn D, Winkleby M. Effects of neighbourhood socioeconomic status and convenience store 

concentration on individual level smoking. Journal of Epidemiology and Community Health. 2005;59(7):568–73.

Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8.

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

Academies Press; 2007. 
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174 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.8.d

Extent and Type of Merchant-Focused Industry Promotions

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Increased price of tobacco products

What to measure The level and type of merchant-focused tobacco industry promotions. These promotions 

include those where tobacco manufacturers provide retail and/or wholesale discounts on 

tobacco products or payments in return for prime advertising space. Merchant-focused 

promotions may include allowances paid to retailers, slotting fees, price discounts, and 

buy-downs paid to retailers rather than directly to consumers. 

Why this indicator is 

useful

Tobacco manufacturers have increasingly focused marketing resources on price 

promotions in the years since the 1998 Master Settlement Agreement.1In 2011, $8.4

billion was spent on cigarette advertising and promotion expenditures, with 

approximately $6.99 billion of these expenditures directed at price discounts paid to 

cigarette retailers or wholesalers to reduce the price of cigarettes.2 The tobacco industry 

uses merchant-directed industry promotions to counteract the impact of advertising 

restrictions.3 Retailers that participate in tobacco company incentive programs have 

more prominent placement of cigarettes and advertising.4 These price promotions may 

be contributing to tobacco-related disparities as research shows that price-related 

promotions are accelerating disproportionately among retailers in neighborhoods with 

lower socioeconomic status and higher proportions of racial and ethnic populations 

experiencing health disparities.5

Example data 

source(s)

Tobacco Industry document reviews (e.g., Legacy Tobacco Documents Library, 

available at http://legacy.library.ucsf.edu/)

Retail observation

Interviews with retailers

Population group(s) Tobacco retailers

Example survey 

question(s)

Not applicable

Comments Retailer interview protocols that include the following topics may enhance application 

of indicator information for tobacco control program use. See Feighery et al. (2003) for 

more information:

6

• Types of merchant incentive programs offered by tobacco companies

• How these merchant incentive programs function

• How these programs affect the store environment

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$$$†

† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings 

within ±1 point of the median for this indicator-specific criterion.
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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

175

References 

1. Feighery E, Schleicher N, Boley Cruz T, Unger JB. An examination of trends in amount and type of cigarette 

advertising and sales promotions in California stores, 2002–2005. Tobacco Control. 2008;17(2):93–8.

2. Federal Trade Commission. Cigarette report for 2011. Washington, DC: Federal Trade Commission; 2013. 

3. Lavack AM, Toth G. Tobacco point-of-purchase promotion: examining tobacco industry documents. Tobacco 

Control. 2006;15(5):377–84. 

4. Feighery EC, Ribisl KM, Schleicher NC, Clark PI. Retailer participation in cigarette company incentive 

programs is related to increased levels of cigarette advertising and cheaper cigarette prices in stores. Preventive 

Medicine. 2004;38(6):876–84. 

5. Bloom PN. Role of slotting fees and trade promotions in shaping how tobacco is marketed in retail stores. 

Tobacco Control. 2001 Dec;10(4):340–4. 

6. Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their 

advertising and products in stores: interviews with retailers about tobacco company incentive programmes. 

Tobacco Control. 2003 Jun;12(2):184–8.

For Further Reading 

Cruz TB. Monitoring the tobacco use epidemic IV. The vector: tobacco industry data sources and recommendations 

for research and evaluation. Preventive Medicine. 2009;48(1 Suppl):S24–S34. 

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

Academies Press; 2007. 
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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

177

Outcome 9 

Reduced Initiation of Tobacco Use 

Tobacco use begins primarily during adolescence, several decades earlier than when the health, 

social, and economic impacts associated with tobacco use are likely to occur.1 The earlier young 

people begin using tobacco products, the more likely they are to use them as adults and the 

longer they are likely to be users.1 The process of nicotine addiction ensures that many of today’s 

adolescent smokers will use tobacco regularly when they are adults.2

Smoking initiation is most likely to occur at age 15 or 16.2 Virtually no daily smokers begin to 

smoke as adults; almost 90% of adult daily smokers report having tried their first cigarette by the 

time they were 18 years old, and few transitions to daily smoking occur after young adulthood 

(i.e., after 26 years of age).2 In recent years, initiation rates for youth and young adult cigarette 

smoking have been stable. Initiation of cigar smoking among youth has decreased in recent 

years; however, from 2006 to 2010, initiation of cigar smoking among young adults remained 

level for all groups except Hispanics for whom initiation rates increased.2 During this same time 

period, initiation of smokeless tobacco use did not increase among youth or young adults overall, 

except for an increase in initiation among young adult women.2 The use of multiple tobacco 

products is common among some youth and young adults, although the sequence of initiation of 

two or more tobacco products is unknown.2

The following indicators are associated with this outcome: 

► 1.9.a Average age at which young people first smoked a whole cigarette 

► 1.9.b Average age at which young people first tried a commercial tobacco product other 

than cigarettes 

► 1.9.c Proportion of young people who report never having tried a tobacco product 

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

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

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

Institute; June 2008. 
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178 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

For Further Reading

Freedman KS, Nelson NM, Feldman LL. Smoking initiation among young adults in the United 

States and Canada, 1998–2010: a systematic review. Preventing Chronic Disease. 2012;9:E05. 

doi:http://dx.doi.org/10.5888/pcd9.110037

Go MH, Tucker JS, Green HD, Pollard M, Kennedy D. Social distance and homophily in 

adolescent smoking initiation. Drug and Alcohol Dependence. 2012 Aug;124(3):347–54.

Hermes ED, Wells TS, Smith B, Boyko EJ, Gackstetter GG, Miller SC, Smith TC, Millennium 

Cohort Study Team. Smokeless tobacco use related to military deployment, cigarettes and mental 

health symptoms in a large, prospective cohort study among US service members. Addiction. 

2012;107(5):983–94. doi:10.1111/j.1360-0443.2011.03737.x

Pabayo R, O’Loughlin J, Barnett TA, Cohen JE, Gauvin L. Does intolerance of smoking at 

school, or in restaurants or corner stores decrease cigarette use initiation in adolescents? Nicotine 

& Tobacco Research. 2012 Oct;14(10):1154–60.

Pierce JP, White VM, Emery SL. What public health strategies are needed to reduce smoking 

initiation? Tobacco Control. 2012 Mar;21(2):258–64.
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

179

Outcome 9 

Reduced Initiation of Tobacco Use 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.9.a Average age at which young 

people first smoked a whole 

cigarette

†† $

1.9.b Average age at which young 

people first tried a commercial 

tobacco product other than 

cigarettes

$

1.9.c Proportion of young people who 

report never having tried a tobacco 

product

$

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

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

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

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

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings being within ±2 points of the 

median for overall quality of the indicator. 
GOAL AREA 1

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180 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.9.a

Average Age at Which Young People First Smoked a Whole Cigarette

KOI 2005 1.13.1

Goal area Preventing initiation of tobacco use

Outcome box Reduced initiation of tobacco use

What to measure Average age at which young smokers first smoked a whole cigarette

Why this indicator is 

useful

The age at which someone first smokes a whole cigarette is significantly related to that 

person’s long-term smoking habits. Recent estimates demonstrate that more than onethird of adults that ever smoked cigarettes reported trying their first cigarette by age 14,

whereas approximately one out of every six adults report first trying a cigarette between 

the ages of 18 and 26.1 The younger people are when they start using tobacco, the more 

likely they are to use tobacco products and the less likely they are to quit smoking and 

achieve prolonged abstinence as adults.2,3

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

CDC Youth Risk Behavior Surveillance System (YRBSS), 2012–2013

Information available at: http://www.cdc.gov/HealthyYouth/yrbs/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS and YRBSS

How old were you when you smoked a whole cigarette for the first time?

I have never smoked cigarettes

8 years or younger

9 or 10 years

11 or 12 years

13 or 14 years

15 or 16 years

17 years or older

From NATS

How old were you when you first smoked a whole cigarette for the first time?

Comments To gather more complete data on tobacco use, evaluators can also ask questions about the 

use of other tobacco products, such as smokeless tobacco, bidis, small cigars, and loose 

tobacco (roll-your-own). 

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

†† $

†† Denotes low agreement among reviewers, defined as fewer than 75% of valid ratings

within ±2 points of the median for overall quality of the indicator.
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

181

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. 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.

3. Kerr DC, Owen LD, Capaldi DM. The timing of smoking onset, prolonged abstinence and relapse in men: a 

prospective study from ages 18 to 32 years. Addiction. 2011 Nov;106(11):2031–8.
GOAL AREA 1

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182 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.9.b

Average Age at Which Young People First Tried a Commercial Tobacco 

Product Other than Cigarettes

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced initiation of tobacco use

What to measure Average age at which young tobacco users first tried a commercially sold tobacco 

product other than cigarettes. Other commercial tobacco products include smokeless 

tobacco (e.g., chew tobacco, snus), dissolvable tobacco (e.g., sticks, strips, and tablets),

orbs, water pipes (hookahs), cigars, cigarillos, clove cigars, and electronic cigarettes.

Why this indicator is 

useful

Smokeless tobacco initiation has continued to increase in recent years for both youth and 

young adults.1 Approximately half of smokeless tobacco users try the product before the 

age of 16.2In addition to the direct health consequences of smokeless tobacco, its use 

also has been associated with initiation of weekly smoking.3 Future monitoring of the 

use of other commercially available tobacco products, including emerging products, is 

needed.

1

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2011

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

National Adult Tobacco Survey (NATS), 2012–2013

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

How old were you when you first tried smoking a cigar, cigarillo, or little cigar even one 

or two puffs?

____________________________________________________________________

How old were you when you used chewing tobaccos, snuff, or dip for the first time?

____________________________________________________________________

From NATS

How old were you when you first smoked a cigarette, even if only one or two puffs?

____________________________________________________________________

How old were you when you first smoked any tobacco product other than cigarettes, 

even if only one or two puffs?

____________________________________________________________________

How old were you when you first tried any smokeless tobacco product, such as chewing 

tobacco, snuff, dip, snus, or dissolvable tobacco?

____________________________________________________________________

Comments Evaluators may want to capture and report those other commercially available tobacco 

products most pertinent to unique state and local markets. 

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

183

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. Timberlake DS, Huh J. Demographic profiles of smokeless tobacco users in the U.S. American Journal of 

Preventive Medicine. 2009;37(1):29–34.

3. Forrester K, Biglan A, Severson HH, Smolkowski K. Predictors of smoking onset over two years. Nicotine & 

Tobacco Research. 2007 Dec;9(12):1259–67.
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184 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.9.c

Proportion of Young People Who Report Never Having Tried a Tobacco 

Product

KOI 2005 1.13.2 Revised Title (Previously: “Proportion of young people who report never having 

tried a cigarette”)

Goal area Preventing initiation of tobacco use

Outcome box Reduced initiation of tobacco use

What to measure Proportion of young people who have never tried smoking or using any other tobacco 

products 

Why this indicator is 

useful

Almost one-third of individuals who have ever tried smoking a cigarette become 

dependent on smoking.1 Reducing the number of youth who experiment with tobacco 

will decrease the number who become established tobacco users.2,3 Given that the 

tobacco industry is diversifying its tobacco product mix, monitoring experimentation 

across many product types as well as the proportion of young people who have never 

tried any tobacco product will continue to be important for program and evaluation 

planning.4

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

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

CDC Youth Risk Behavior Surveillance System (YRBSS), 2011

Information available at: http://www.cdc.gov/healthyyouth/yrbs/index.htm

National Adult Tobacco Survey (NATS), 2010

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

Have you ever tried smoking cigars, cigarillos, or little cigars, even one or two puffs?

Yes No

Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, 

Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?

Yes No

Have you ever tried smoking tobacco in a pipe, even one or two puffs?

Yes No

Have you ever tried smoking any of the following, even one or two puffs:

I have never smoked bidis (small brown cigarettes wrapped in a leaf) or kreteks 

(clove cigarettes)

Bidis Kreteks I have tried both bidis and kreteks

Which of the following tobacco products have you ever tried, even just one time?

Roll-your-own cigarettes

Flavored cigarettes, such as Camel Crush

Clove cigars

Flavored little cigars

Smoking tobacco from a hookah or a waterpipe

Snus, such as Camel or Marlboro Snus

Dissolvable tobacco products, such as Ariva, Stonewall, Camel orbs, Camel sticks, 

or Camel strips
GOAL AREA 1

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CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

185

Electronic cigarettes or E-cigarettes, such as Ruyan or NJOY

Some other new tobacco products not listed here

I have never tried any of the products listed above or any new tobacco product

From YRBSS

Have you ever tried cigarette smoking, even one or two puffs?

Yes No

From NATS

Have you ever tried cigarette smoking, even one or two puffs?

Yes No

Have you ever tried chewing tobacco, snuff, or dip, such as Skoal, Copenhagen, Grizzly, 

Levi Garrett, Red Man, or Day’s?

Yes No Don’t know/Not sure Refused

Have you ever tried snus, even just one time in your entire life?

Yes No Don’t know/Not sure Refused

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

Comments None noted

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

References 

1. U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and 

behavioral basis for smoking-attributable diseases: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 

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

3. Paul SL, Blizzard L, Patton GC, Dwyer T, Venn A. Parental smoking and smoking experimentation in 

childhood increase the risk of being a smoker 20 years later: the Childhood Determinants of Adult Health 

Study. Addiction. 2008 May;103(5):846–53.

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. 
GOAL AREA 1

► Outcome 9 

186 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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GOAL AREA 1

► Outcome 10 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

187

Outcome 10

Reduced Tobacco-Use Prevalence Among Young People 

According to the 2012 Surgeon General’s Report on tobacco use among youth and young adults, 

one-fourth (23.2%) of U.S. high school seniors currently smoke cigarettes (smoked in the past 30 

days).1 More than one-third of young adults in the United States aged 18 to 25 currently smoke 

cigarettes (34.2%), the highest prevalence of any age group.1 One in 10 high school males 

currently use smokeless tobacco, whereas 15.0% of high school males smoke cigars.1

 Twelve 

percent of young adult males use smokeless tobacco, and 16.6% currently smoke cigars.1 Female 

youth and young adults use smokeless tobacco and cigars at much lower rates than their male 

counterparts.1 Concurrent use of multiple tobacco products is common in some subgroups of 

youth; indeed, fewer than half of high school male tobacco users report using only a single 

product in the past 30 days.1 Heavy smoking has declined dramatically in this group over the 

past several decades, but in 2010 prevalence of light smoking (less than one cigarette per day in 

the past 30 days) was 8.5% among high school seniors, and intermittent smoking (one to five 

cigarettes per day in the past 30 days) was 6.1%.1

These prevalence rates translate to approximately 4.3 million high school students and about 

984,000 middle school students using any tobacco product (including cigarettes, smokeless 

tobacco, and cigars).1 Additionally, almost 14 million young adults used a tobacco product 

within the past month.1 Dual or poly-tobacco use among youth is concerning, as the tobacco 

industry has diversified its product offerings to introduce novel tobacco products to the market 

that can be used where smoking is not allowed.1 These include dissolvable and smokeless 

tobacco products as well electronic cigarettes that come in a variety of flavors that could appeal 

to youth and young adults.1 

Brand preference for tobacco products begins in adolescence and carries over into adulthood. 

The most popular brands among youth and young adults also have the greatest market share in 

the United States: Marlboro (46%), Newport (22%), and Camel (12%).1 Skoal and Grizzly are 

the most popular brands of moist snuff smokeless tobacco among youth and young adults, and 

Black & Mild is the most popular brand of cigar. These data are also consistent with market 

share for each type of product.1

Smoking during childhood and adolescence is associated with serious health problems, such as 

reduced lung function and impaired lung growth.1 Smoking by young people also increases the 

likelihood that they will continue to smoke through adulthood, increasing their risk of tobaccorelated diseases later in life, such as lung and other cancers, heart disease, and emphysema.2 

Duration of smoking is a determinant of risk for many tobacco-related cancers, and the 

mechanisms by which smoking causes cancer are first put in place with the initiation of active 

smoking, regardless of age. About one-third of youth smokers who continue smoking into 

adulthood will die prematurely from tobacco-related disease.1 

The following indicators are associated with this outcome: 

► 1.10.a Prevalence of tobacco use among young people 

► 1.10.b Proportion of established young tobacco users 
GOAL AREA 1

► Outcome 10

188 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

► 1.10.c Type and brand preferences of young tobacco users

► 1.10.d Proportion of poly-tobacco product use among young people

► 1.10.e Level of tobacco use among young people

References

1. U.S. Department of Health and Human Services. Preventing tobacco use among youth and 

young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

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

Disease Prevention and Health Promotion, Office on Smoking and Health; 2012.

2. U.S. Department of Health and Human Services. How tobacco smoke causes disease: the 

biology and behavioral basis for smoking-attributable disease: a report of the Surgeon 

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

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

Promotion, Office on Smoking and Health; 2010.

For Further Reading

Bombard JM, Rock VJ, Pederson LL, Asman KJ. Monitoring polytobacco use among 

adolescents: do cigarette smokers use other forms of tobacco? Nicotine & Tobacco Research. 

2008 Nov;10(11):1581–9.

Centers for Disease Control and Prevention. Cigarette use among high school students—United 

States, 1991–2009. Morbidity and Mortality Weekly Report. 2010 Jul 9;59(26);797–801.

Centers for Disease Control and Prevention. Targeting tobacco use: the nation’s leading cause of 

death, 2004 [At a Glance]. Atlanta, GA: Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion; 2004. Available at: 

http://www.cdc.gov/nccdphp/aag/aag_osh.htm

Centers for Disease Control and Prevention. Tobacco use among middle and high school 

students—United States, 2000–2009. Morbidity and Mortality Weekly Report. 2010 Aug 

27;59(33):1063–8.

Regan AK, Dube SR, Arrazola R. Smokeless and flavored tobacco products in the U.S.: 2009 

Styles survey results. American Journal of Preventive Medicine. 2012 Jan;42(1):29–36.

Richardson A, Xiao H, Vallone DM. Primary and dual users of cigars and cigarettes: profiles, 

tobacco use patterns and relevance to policy. Nicotine & Tobacco Research. 2012

Aug;14(8):927–32.

Saunders C, Geletko K. Adolescent cigarette smokers’ and non-cigarette smokers’ use of 

alternative tobacco products. Nicotine & Tobacco Research. 2012 Aug;14(8):977–85.

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.
GOAL AREA 1

► Outcome 10 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

189

Outcome 10

Reduced Tobacco-Use Prevalence among Young People 

Number Indicator

Resources Needed

Strength of Evaluation

Evidence

Utility

Face

Validity

Accepted Practice

1.10.a Prevalence of tobacco use among 

young people

$

1.10.b Proportion of established young 

tobacco users

$

1.10.c Type and brand preferences of

young tobacco users

$

1.10.d Proportion of poly-tobacco product 

use among young people

$

1.10.e Level of tobacco use among young 

people

$

$ 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. 
GOAL AREA 1

► Outcome 10

190 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.10.a

Prevalence of Tobacco Use Among Young People

KOI 2005 1.14.1

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco-use prevalence among young people

What to measure Proportion of young people who have smoked or used some type of other tobacco 

product at least 1 day during the previous 30 days

Why this indicator is 

useful

One-half of all long-term smokers, especially those who begin smoking in adolescence, 

will eventually die from their tobacco use.1 Reducing tobacco use among youth 

decreases their chances of smoking as adults and consequent smoking-attributable 

morbidity and mortality.

2

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

During the past 30 days, on how many days did you smoke cigarettes? (Subsequent 

questions ask about other tobacco products, such as cigars, chewing tobacco, and snuff)

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 use chewing tobacco, snuff, or dip, 

[such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen]?

0 days 1 or 2 days 3 to 5 days 6 to 9 days

10 to 19 days 20 to 29 days All 30 days

From NATS

During the past 30 days, on how many days did you smoke cigarettes?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you use snus?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke cigars, cigarillos, or very 

small cigars that look like cigarettes?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke tobacco in a water pipe?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke tobacco in a pipe other than 

a water pipe?

Number of days ________________ Don’t know/Not sure Refused
GOAL AREA 1

► Outcome 10 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

191

Comments To gather more complete data on tobacco use, evaluators can also ask questions about 

the use of other tobacco products, such as smokeless tobacco, bidis, small cigars, and 

loose tobacco (roll-your-own).

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

References 

1. U.S. Department of Health and Human Services. How tobacco smoke causes disease: The biology and 

behavioral basis for smoking-attributable diseases: a report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010.

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

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

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

on Smoking and Health; 2012. 

For Further Reading 

Centers for Disease Control and Prevention. Cigarette use among high school students—United States, 1991–2007. 

Morbidity and Mortality Weekly Report. 2008;57(25);689–91. 

Centers for Disease Control and Prevention. Racial/ethnic differences among youths in cigarette smoking and 

susceptibility to start smoking—United States, 2002–2004. Morbidity and Mortality Weekly Report. 

2006;55(47);1275–7.

Farrelly MC, Davis KC, Lyndon Haviland M, Messeri P, Healton CG. Evidence of dose-response relationship 

between “truth” antismoking ads and youth smoking prevalence. American Journal of Public Health. 

2005;95(3):425–31. 

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

Academies Press; 2007. 

Nelson DE, Mowery P, Asman K, Pederson LL, O’Malley PM, Malarcher A, et al. Long-term trends in adolescent 

and young adult smoking in the United States: metapatterns and implications. American Journal of Public Health. 

2008;98(5):905–15. 
GOAL AREA 1

► Outcome 10

192 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.10.b

Proportion of Established Young Tobacco Users

KOI 2005 1.14.2

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco-use prevalence among young people

What to measure Proportion of young people who smoked 100 cigarettes or more during their lifetimes

Why this indicator is 

useful

Youth who are established smokers are at high risk of becoming addicted to cigarettes 

and continuing to smoke as adults.1 Young people who are nicotine dependent are more 

likely to become daily smokers and to increase their smoking intensity over time.2-4

Example data 

source(s)

National Youth Tobacco Survey (NYTS): CDC Recommended Questions: Core, 2011 

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

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

About how many cigarettes have you smoked in your entire life?

I have never smoked cigarettes, not even one or two puffs

1 or more puffs but never a whole cigarette

1 cigarette

2 to 5 cigarettes

6 to 15 cigarettes (about 1/2 a pack total)

16 to 25 cigarettes (about 1 pack total)

26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

100 or more cigarettes (5 or more packs)

From NATS

Have you smoked at least 100 cigarettes in your entire life?

Yes No Don’t know/Not sure Refused

Do you now smoke cigarettes every day, some days, or not at all?

Every day Some days Not at all Don’t know Refused

Comments To gather more complete data on tobacco use, evaluators can also ask questions about 

the use of other tobacco products, such as smokeless tobacco, bidis, small cigars, 

hookah, e-cigarettes, and loose tobacco (roll-your-own).

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$
GOAL AREA 1

► Outcome 10

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

193

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. Doubeni CA, Reed G, DiFranza JR. Early course of nicotine dependence in adolescent smokers. Pediatrics. 

2010;125(6):1127–33.

3. Wellman RJ, DiFranza JR, Savageau JA, Dussault GF. Short term patterns of early smoking acquisition. 

Tobacco Control. 2004;13(3):251–7.

4. Saunders C. Access to cigarettes by daily smokers in Florida’s public middle schools and high schools. Nicotine 

& Tobacco Research. 2011;13(7):589–98.

For Further Reading

Centers for Disease Control and Prevention. Cigarette use among high school students—United States, 1991–2003. 

Morbidity and Mortality Weekly Report. 2004;53(23):499–502.

Centers for Disease Control and Prevention. Global Youth Tobacco Surveillance, 2000–2007. MMWR Surveillance 

Summaries. 2008;57(SS01):1–21.

Nelson DE, Mowery P, Asman K, Pederson LL, O’Malley PM, Malarcher A, et al. Long-term trends in adolescent 

and young adult smoking in the United States: metapatterns and implications. American Journal of Public Health. 

2008;98(5):905–15.
GOAL AREA 1

► Outcome 10

194 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.10.c 

Type and Brand Preferences of Young Tobacco Users

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco-use prevalence among young people

What to measure Type and brand of tobacco products young people used in the past 30 days

Why this indicator is 

useful

Research suggests a link between exposure to tobacco advertising and brand 

preference.1,2 Knowing the brand preference of young people can highlight why they are 

influenced to start smoking and what makes them continue to smoke, and provides 

information that can be incorporated into targeted mass media campaigns to counter 

industry messages and reduce smoking initiation.3 Brand preference among youth and 

young adults is aligned with market share data (i.e., the top preferred brands among 

these populations are the most widely sold brands in the United States).

4 Knowing

tobacco type and brand preferences of young tobacco users helps tobacco control 

programs tailor their prevention messages for mass-reach health communication efforts, 

identify the need for youth access and related interventions in the retail setting, and also 

provides insight into receptivity to tobacco industry advertising, which in turn, predicts 

initiation among youth.

4

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2011

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SearchResults.aspx

National Survey on Drug Use and Health (NSDUH), 2009

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

From NYTS

In the past 30 days, which of the following products have you used on at least one day? 

(You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

Roll-your-own cigarettes

Flavored cigarettes, such as Camel Crush

Clove cigars

Flavored little cigars

Smoking tobacco from a hookah or a water pipe

Snus, such as Camel or Marlboro Snus

Dissolvable tobacco products, such as Ariva, Stonewall, Camel orbs, Camel sticks,

 or Camel strips

Electronic cigarettes or E-cigarettes, such as Ruyan or NJOY

Some other new tobacco products not listed here

During the past 30 days, what brand of cigarettes did you usually smoke? (CHOOSE 

ONLY ONE ANSWER)

I did not smoke cigarettes during I did not smoke a usual brand

 the past 30 days American Spirit

Camel GPC, Basic, or Doral

Kool Lucky Strike

Marlboro Newport

Parliament Virginia Slims

Some other brand not listed here
GOAL AREA 1

► Outcome 10 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

195

From NATS

During the past 30 days, that is since ______, what brand of cigarettes did you buy most 

often?

During the past 30 days, that is since ______, what brand of cigarettes did you smoke 

most often?

During the past 30 days, that is since ______, what brand of smokeless tobacco did you 

use most often?

From NSDUH

During the past 30 days, what type of cigarettes did you smoke most often?

Lights Ultra lights Mediums Full flavor

Were the cigarettes you smoked during the past 30 days menthol?

Yes No

During the past 30 days, what brand of cigar did you smoke most often?

Al Capone Antonio y Cleopatra Arturo Fuente

Backwoods Black & Mild Blackstone

Captain Black Cohiba Cuesta-Rey

Dutch Masters El Producto Garcia y Vega

Havatampa King Edward La Corona

Little Nippers Macanudos Montecristo

Muriel Partagas Phillies

Punch Romeo y Julieta Swisher Sweets

Thompson Tijuana Smalls White Owl

Winchester A brand not on this list

During the past 30 days, what brand of snuff did you use most often?

Copenhagen Cougar Gold River

Grizzly Happy Days Hawken

Kodiak Red Seal Redwood

Rooster Silver Creek Skoal

Timber Wolf A brand not on this list

During the past 30 days, what brand of chewing tobacco did you use most often?

Beech-Nut Chattanooga Chew Day’s Work

Granger H.B. Scott Levi Garrett

Red Fox Redman Taylor’s Pride

Totems Work Horse A brand not on this list

Comments Note that the example survey questions expand beyond tobacco products and include 

nicotine devices.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

References 

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

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

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

2. Wakefield M, Ruel E, Chaloupka F, Slater S, Kaufmann N. Association of point-of-purchase tobacco 

advertising and promotions with choice of usual brand among teenage smokers. Journal of Health 

Communication. 2002;7(2):113–21.
GOAL AREA 1

► Outcome 10

196 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

3. Centers for Disease Control and Prevention. Cigarette brand preference among middle and high school students 

who are established smokers—United States, 2004 and 2006. Morbidity and Mortality Weekly Report. 2009; 

58(05):112–5.

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.

For Further Reading 

Carpenter C, Connolly G, Ayo-Yusuf O, Wayne G. Developing smokeless tobacco products for smokers: an 

examination of tobacco industry documents. Tobacco Control. 2009 Feb;18(1):54–9.

Centers for Disease Control and Prevention. Cigarette use among high school students—United States, 1991–2003. 

Morbidity and Mortality Weekly Report. 2004;53(23):499–502. 
GOAL AREA 1

► Outcome 10 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

197

Indicator 1.10.d 

Proportion of Poly-Tobacco Product Use Among Young People

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco-use prevalence among young people

What to measure Proportion of young people who report having smoked on at least 1 day during the 

previous 30 days and who also report having used other tobacco products in the past 30 

days

Why this indicator is 

useful

Internal tobacco industry documents outline the increasing importance of the 

development of smokeless tobacco products to offset reductions in smoking by 

promoting poly-tobacco use as a means for addressing clean indoor air laws.1 New 

smokeless tobacco products (i.e., snus and dissolvable products containing nicotine) are 

being marketed to current smokers as a way of temporarily addressing smoke-free 

policies in public places.2-5 More than half of male high school tobacco users report 

using more than one tobacco product.2 Monitoring poly-tobacco product use among 

young people helps to assess important prevalence trends. 

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2011

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

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

In the past 30 days, which of the following products have you used on at least one day? 

(You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

Roll-your-own cigarettes

Flavored cigarettes, such as Camel Crush

Clove cigars

Flavored little cigars

Smoking tobacco from a hookah or a waterpipe

Snus, such as Camel or Marlboro Snus

Dissolvable tobacco products, such as Ariva, Stonewall, Camel orbs, Camel sticks,

 or Camel strips

Electronic cigarettes or E-cigarettes, such as Ruyan or NJOY

Some other new tobacco products not listed here

I have not used any of the products listed above or any new tobacco product

During the past 30 days, on how many days did you smoke cigars, cigarillos, 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
GOAL AREA 1

► Outcome 10

198 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, 

[such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen]?

0 days 1 or 2 days 3 to 5 days 6 to 9 days

10 to 19 days 20 to 29 days All 30 days

From NATS

During the past 30 days, on how many days did you smoke cigarettes?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you use snus?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke cigars, cigarillos, or very 

small cigars that look like cigarettes?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke tobacco in a water pipe?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke tobacco in a pipe other than 

a water pipe?

Number of days ________________ Don’t know/Not sure Refused

Comments Note that evaluators may choose to combine responses from multiple tobacco products 

to assess current poly-tobacco product use. Other tobacco products may include cigars 

and little cigars, smokeless tobacco products, dissolvable tobacco products, e-cigarettes, 

and hookah.

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

References 

1. Carpenter CM, Connolly GN, Ayo-Yusuf OA, Wayne GF. Developing smokeless tobacco products for 

smokers: an examination of tobacco industry documents. Tobacco Control. 2009 Feb;18(1):54–9.

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. Mejia AB, Ling PM. Tobacco industry consumer research on smokeless tobacco users and product 

development. American Journal of Public Health. 2010;100(1):78–87.

4. Mejia AB, Ling PM, Glantz SA. Quantifying the effects of promoting smokeless tobacco as a harm reduction 

strategy in the USA. Tobacco Control. 2010;19(4):297–305. 

5. Timberlake DS, Pechmann C, Tran SY, Au V. A content analysis of Camel Snus advertisements in print media. 

Nicotine & Tobacco Research. 2011 Jun;13(6):431–9.

For Further Reading 

Bombard JM, Rock VJ, Pederson LL, Asman KJ. Monitoring polytobacco use among adolescents: do cigarette 

smokers use other forms of tobacco? Nicotine & Tobacco Research. 2008 Nov;10(11):1581–9.
GOAL AREA 1

► Outcome 10

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

199

Rogers JD, Biener L, Clark PI. Test marketing of new smokeless tobacco products in four U.S. cities. Nicotine & 

Tobacco Research. 2010 Jan;12(1):69–72.
GOAL AREA 1

► Outcome 10

200 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Indicator 1.10.e 

Level of Tobacco Use Among Young People

KOI 2005 New

Goal area Preventing initiation of tobacco use

Outcome box Reduced tobacco-use prevalence among young people

What to measure Level of reported tobacco use during the past 30 days

Why this indicator is 

useful

The more an individual smokes, the more likely he or she is to become nicotine 

dependent.1 Young adults reporting daily smoking are more likely to feel addicted and 

have trouble quitting smoking than those reporting intermittent smoking.2 Capturing the 

level of tobacco use among young people is important to understanding the progression 

to addiction and the subsequent impact on prevalence and smoking-attributable 

morbidity and mortality. 

Example data 

source(s)

National Youth Tobacco Survey (NYTS), 2011

Information available at: 

http://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

National Adult Tobacco Survey (NATS), 2010

Information available at: http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?SurveyId=30

Population group(s) Youth aged younger than 18 years and young adults aged 18 to 25 years

Example survey 

question(s)

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 the days you smoked, how many cigarettes did you smoke 

per day?

I did not smoke cigarettes during the past 30 days

Less than 1 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

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 use chewing tobacco, snuff, or dip, 

[such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen]?

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 1

► Outcome 10

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

201

From NATS

Do you now smoke cigarettes every day, some days, or not at all?

EVERY DAY,

SOME DAYS,

NOT AT ALL,

DON’T KNOW

Refused

During the past 30 days, on how many days did you smoke cigarettes?

Number of days ________________ Don’t know/Not sure Refused

On the average, about how many cigarettes a day do you now smoke? _____________

During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you use snus?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke cigars, cigarillos, or very 

small cigars that look like cigarettes?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke tobacco in a water pipe?

Number of days ________________ Don’t know/Not sure Refused

During the past 30 days, on how many days did you smoke tobacco in a pipe other than 

a water pipe?

Number of days ________________ Don’t know/Not sure Refused

Comments None noted

Rating

Resources 

needed

Strength of 

evaluation 

evidence Utility

Face 

validity

Accepted 

practice

$

References 

1. U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and

behavioral basis for smoking-attributable diseases: a report of the Surgeon General. Atlanta, GA: U.S.

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010.

2. Lenk KM, Chen V, Bernat DH, Forster JL, Rode PA. Characterizing and comparing young adult intermittent

and daily smokers. Substance Use and Misuse. 2009;44(14):2128–40.

For Further Reading 

Caraballo RS, Novak SP, Asman K. Linking quantity and frequency profiles of cigarette smoking to the presence of 

nicotine dependence symptoms among adolescent smokers: findings from the 2004 National Youth Tobacco Survey. 

Nicotine & Tobacco Research. 2009 Jan;11(1):49–57. 

Carpenter MJ, Garrett-Mayer E, Vitoc C, Cartmell K, Biggers S, Alberg AJ. Adolescent nondaily smokers: 

favorable views of tobacco yet receptive to cessation. Nicotine & Tobacco Research. 2009 Apr;11(4):348–55. 

Centers for Disease Control and Prevention. Cigarette use among high school students—United States, 1991–2003. 

Morbidity and Mortality Weekly Report. 2004;53(23):499–502. 
GOAL AREA 1

► Outcome 10

202 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

Dierker L, He J, Kalaydjian A, Swendsen J, Degenhardt L, Glantz M, et al. The importance of timing of transitions 

for risk of regular smoking and nicotine dependence. Annals of Behavioral Medicine. 2008 Aug;36(1):87–92. 

Van De Ven MO, Greenwood PA, Engels RC, Olsson CA, Patton GC. Patterns of adolescent smoking and later 

nicotine dependence in young adults: a 10-year prospective study. Public Health. 2010 Feb;124(2):65–70.
GOAL AREA 1

► Outcome 10 

CHAPTER 2 ► Goal Area 1: Preventing Initiation of Tobacco Use

203

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Appendices and Glossary
206 PREVENTING INITIATION OF TOBACCO USE: OUTCOME INDICATORS for Comprehensive Tobacco Control Programs—2014

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APPENDIX A

207

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
PREVENTING INITIATION OF TOBACCO USE OUTCOME INDICATORS for Comprehensive Tobacco Control Programs‒2014

208

► Surgeon General Reports related to tobacco prevention and control4-8

► The Guide to Community Preventive Services: Tobacco Use Prevention and Control9

References 

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

control programs—2007. Atlanta, GA: U.S. Department of Health and Human Services, 

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

Prevention and Health Promotion, Office on Smoking and Health; October 2007. 

2. 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. 

8. U.S. Department of Health and Human Services. Tobacco use among U.S. racial/ethnic 

minority groups—African Americans, American Indians and Alaska Natives, Asian 

Americans and Pacific Islanders, and Hispanics: a report of the Surgeon General. Atlanta, 

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

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

on Smoking and Health; 1998. 

9. Task Force on Community Preventive Services. The guide to community preventive 

services: tobacco use prevention and control. American Journal of Preventive Medicine. 

2001;20(Suppl 2):1–88. 
APPENDIX B 

209

APPENDIX B 

Expert Panel Members

We thank the following panel of expert members (in alphabetical order) who rated the indicators. 

Without their generosity in sharing their expertise and donating their time, this publication would 

not have been possible. 

Carsten Baumann, MA 

Evaluator 

Epidemiology, Planning and Evaluation Branch 

Prevention Services Division 

Colorado Department of Public Health and Environment 

Lois Biener, PhD 

Senior Research Fellow 

Center for Survey Research 

University of Massachusetts Boston 

Greg Connolly, DMD, MPH 

Director 

Center for Global Tobacco Control 

Professor 

Department of Society, Human Development and Health 

Harvard University School of Public Health 

Ellen Feighery, MS, RN 

Associate Director for International Research 

Campaign for Tobacco-Free Kids 

Jean Forster, PhD, MPH 

Professor 

Division of Epidemiology and Community Health

University of Minnesota 

Stan Glantz, PhD 

Professor 

Director, Center for Tobacco Control Research and Education

Co-Leader, Tobacco Control Program, Helen Diller Family Comprehensive Cancer Center 

University of California, San Francisco 

Bruce Gutelius, MD, MPH 

Medical Epidemiologist 

Tobacco Prevention & Education Program, Oregon Department of Human Services 
PREVENTING INITIATION OF TOBACCO USE OUTCOME INDICATORS for Comprehensive Tobacco Control Programs‒2014

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Andrew Hyland, PhD 

Chair

Department of Health Behavior 

Division of Cancer Prevention & Population Sciences 

Roswell Park Cancer Institute 

Lois Keithly, PhD 

Director 

Massachusetts Tobacco Control Program 

Massachusetts Department of Public Health 

Jessica Rath, PhD 

Assistant Director, Research and Evaluation 

American Legacy Foundation 

Kurt Ribisl, PhD 

Professor 

Department of Health Behavior 

UNC Gillings School of Global Public Health 

University of North Carolina at Chapel Hill 

April Roeseler, BSN, MSPH 

Chief 

Programs and Media Operations Section 

California Tobacco Control Program 

California Department of Public Health 
APPENDIX B 

211

Outcome Indicator Workgroup

We thank the following individuals for their assistance in preparing and reviewing this 

publication.

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

Health Promotion, Centers for Disease Control and Prevention: 

► Susan Brown, MPH 

► Shanta Dube, PhD, MPH 

► Martha Engstrom, MS 

► Jami Fraze, PhD 

► Erika Fulmer, MHA 

► Nicole Kuiper, MPH 

► Joann Lee, DrPH 

► Michael Tynan, BA 

From RTI International: 

► Todd Rogers, PhD 

► LeTonya Chapman, MPH 

► LaShawn Curtis, DrPH 

► Laurel Curry, MPH 

► Sandhya Joshi, BA
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APPENDIX C 

213

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 1: Preventing Initiation of Tobacco Use Among Young 

People from the Key Outcome Indicators for Evaluating Comprehensive Tobacco Control 

Programs published in 2005 (KOI 2005). The 2005 Guide was developed by updating previously 

published logic models for three of the four goal areas of the National Tobacco Control Program 

(NTCP): 

► Preventing initiation of tobacco use among young people. 

► Eliminating nonsmokers’ exposure to secondhand smoke. 

► Promoting quitting among adults and young people. 

Initial Outcome Indicator Development 

KOI 2005 used an extensive review of published and fugitive literature to select candidate 

indicators for the outcome components of each NTCP goal area’s logic model. Once selected, the 

scientific evidence was then reviewed to determine whether an association existed between the 

candidate indicators and the outcome components in the NTCP logic models. 

Candidate indicators that demonstrated an association were included in further development, 

including the selection of example data sources and survey questions for each indicator. The 

selection of example data sources was focused on choosing data sources that were readily 

available to state tobacco control programs. 

Candidate indicators with example data sources and survey questions 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 1 Outcome Indicators 

Revising the Candidate List of Indicators 

In 2009, an initial step taken to update the Goal 1 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 1 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, 
PREVENTING INITIATION OF TOBACCO USE OUTCOME INDICATORS for Comprehensive Tobacco Control Programs‒2014

214

and Institute of Medicine reports published from 2005 to 2009. We also conducted targeted 

literature searches via PubMed. These efforts yielded 120 peer-reviewed articles and reviews, 

two Surgeon General Reports, three NCI Monographs, 18 Morbidity and Mortality Weekly 

Report articles, two state tobacco control evaluation reports, and a variety of NCI conference 

statements and practice guidelines.

The 2009 literature review identified the need for additional and more nuanced indicators related 

to reducing tobacco industry influence on consumers and potential consumers, as well as efforts 

by the industry to influence voters and policy makers. The issue of tobacco industry influence 

became more salient with the passage of the Family Smoking Prevention and Tobacco Control 

Act (Tobacco Control Act) in 2009. The Office on Smoking and Health (OSH) initiated the 

“Tobacco Industry Monitoring Summit” in the summer of 2010 to encourage information 

exchange related to the topic among a distinguished group of tobacco control research and 

practice experts. These experts provided individual advice and recommendations on 

opportunities and options for monitoring the actions and influences of the tobacco industry. The 

meeting addressed six primary topic areas related to tobacco industry influence:

► Advertising

► Pricing

► Impact on the Consumer

► Impact on the Public

► Retail Distribution

► Alternative Distribution

The Summit provided a wealth of information, including 47 individual recommendations for 

surveillance and evaluation action. These were synthesized and systematically reviewed by an 

OSH multidisciplinary workgroup, which rated the recommendations on several criteria: 

alignment with OSH strategic priorities, potential impact, longevity, timeliness, and feasibility. 

High priority recommendations and information from the 2009 literature review were used to 

modify the existing goal area logic models and Goal 1 indicator lists. Ultimately, 23 new, 

candidate indicators were added to the Goal 1 list, and 15 indicators from KOI 2005 were 

removed.

The draft list of candidate indicators was sent to six external reviewers for informal feedback. As 

part of this brief review activity, we also asked reviewers to consider the revised Goal 1 logic 

model and provide comments regarding gaps or errors in the implied logic; missing elements, 

issues, or indicators; confusing language or terminology; and duplicative indicators. Based on 

this feedback, we made additional revisions to the list of indicators and developed 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 1. Of the 16 invited 
APPENDIX C

215

experts, 12 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 on pages 216 through 

219 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. The resources needed for 

data collection and analysis are less 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.

► 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,
PREVENTING INITIATION OF TOBACCO USE OUTCOME INDICATORS for Comprehensive Tobacco Control Programs‒2014

216

► 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 (1999–2011) national data sources,

including federal sour

Considering Stakeholder Input: Updating Outcome Indicators 

ces, such as the National Adult Tobacco Survey (NATS), National Youth 

Tobacco Survey 

(NYTS), 

STATE System, 

CDC OSH 

News Media 

Surveillance 

System, Youth 

Risk Behavior 

Survey (YRBS), 

School Health 

Profiles, 

National Survey 

on Drug Use 

and Health 

(NSDUH) 

(Substance 

Abuse and 

Mental Health 

Services 

Administration 

[SAMHSA]), Synar reports, and Federal Trade Commission reports; and non-federal sources, 

including Legacy Media Tracking Survey, Center for Responsive Politics, National Institute on 

Money in State Politics, and state tobacco control program evaluation reports. 

Rationale statements and supporting references for each candidate indicator were updated using 

the 2009 literature review as well as topic-specific PubMed searches for more recent evidence 

published since 2009. 

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 
APPENDIX C

217

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 1.7.h: Amount of tobacco industry 

contributions to institutions and groups.

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

strength of evaluation evidence, utility, face validity, and accepted practice criteria, a rating 

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

responses were within ±1 point of the median. For the overall quality criterion, a rating was 

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

were within ±2 points of the median (denoted by a double dagger ††). An example of a 

rating with a low level of agreement is the overall quality score for 1.9.a: Average age at 

which young people first smoked a whole cigarette. This low level of agreement represents 

a relatively high degree of variability in the raters’ responses for the criterion.

Expert panel members rated and offered comments on 63 candidate indicators. After reviewing 

the expert panel ratings and comments carefully, five indicators were added to address gaps 

identified by the expert reviewers and OSH staff. These new indicators were not rated by the 

expert panel, noted by an “NR” suffix to the indicator number in this publication. However, 

some information about these “NR” indicators is provided in the indicator profiles. Expert panel 

ratings and comments noted that some indicators were considered to be “not essential,” so we 

deleted four indicators and merged two indicators with two other similar indicators. Thus, this 

publication contains information on a total of 62 Goal Area 1 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 38 

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.
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CDC/OSH Key Indicators Report: Instructions for Expert Panel 

Reviewers

CDC/OSH Key Outcome Indicator 2011 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.

There have been substantial changes and advances in tobacco control since the release of the KOI 

Guide. The passage of the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) 

in 2009 expanded federal, state, and local governments’ ability to regulate tobacco. The Tobacco 

Control Act provides an opportunity for expanding tobacco prevention and control policy efforts, 

especially those focused on reducing tobacco industry influences through marketing, pricing, and 

promotion. Given these changes in the national policy environment, OSH recognized the need to revisit 

the key outcome indicators.

As a first step, indicators in OSH Goal Area 1 (Preventing Initiation of Tobacco Use) have been 

reviewed and revised internally by OSH staff and expert consultants. During this process, some existing 

key outcome indicators have been removed, others have been substantially revised, and several new 

indicators have been added. Our intention is to implement an external expert review process similar to 

what was used during the initial indicator development effort.

The updated KOI Guide will serve the same functions as the initial report, including

► serving as a companion to OSH’s Best Practices for Comprehensive Tobacco Control Programs

and Introduction to Program Evaluation for Comprehensive Tobacco Control Programs;

► describing key outcome indicators for evaluation of statewide, comprehensive tobacco control 

programs, and suggesting appropriate data sources and measures for these indicators;

► encouraging states to use consistent evaluation measures and comparable data sources; and

► guiding the provision of consistent 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, including those who participated in the 

OSH Tobacco Industry Monitoring Summit that was held in July 2010. Each of the proposed indicators 

included in this document is linked to a component of the revised Goal Area 1 logic model.

Internal indicator selection decisions were guided by a need to highlight key indicators for planning and 

evaluating comprehensive tobacco control programs. Linkages connecting antecedent and consequent 

logic model components (boxes) and nested indicators were reviewed for evidence of association. An 

initial list of draft indicators was sent to a handful of external experts for preliminary review and 

comment, and their feedback was used to update the indicator list and inform indicator profile 

development.
APPENDIX C 

219

As part of the update process, each of the original KOI Guide Goal 1 indicators and their respective 

profiles were reviewed internally. 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 at present 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 for use in planning and evaluating comprehensive state 

tobacco control programs, and the data sources and measures that would be most useful for tracking 

these indicators. Reviewers are asked to do the following:

► Rate each indicator on a set of criteria (similar to those used to produce the original KOI Guide).

► Comment on the data sources and measures that have been identified for each proposed indicator.

► Suggest alternative data sources and measures.

► Offer additional indicators that may be useful for state tobacco control program evaluation.

The final product will be similar to the original KOI Guide in that it will include tables displaying the 

indicators, ratings of the indicators along the review criteria, and detail summary information on each 

indicator.

We would like you to rate the indicators based on your expertise and experience in this substantive area 

using the following criteria:

► Strength of evidence

► Resources (funds, time, and effort) required to collect and analyze indicator data

► Utility

► Face validity

► Uniqueness

► Conformity with accepted practice

► Overall quality

Below you will find additional clarification and guidance regarding these rating criteria.

Rating Form

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
PREVENTING INITIATION OF TOBACCO USE OUTCOME INDICATORS for Comprehensive Tobacco Control Programs‒2014

220

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.

Rating Criteria

The following criteria are to be used to rate each indicator:

1. Strength of the evaluation evidence—Extent to which you believe that the literature supports use 

of the indicator for the evaluation of comprehensive, statewide tobacco control programs, as 

characterized by the logic model. The references included on each indicator rating form are 

intended to provide guidance 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.

2. 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.

3. Utility—Extent to which you believe that the indicator would help to answer important 

comprehensive tobacco control program evaluation questions. Although these indicators may also 

be appropriate and useful for community-level evaluation, the utility criterion refers primarily to 

statewide efforts.

4. Face validity—Your estimation of how face valid the indicator would appear to be in the eyes of 

policy makers and decision makers who may be users of tobacco control program evaluation 

results.

5. Uniqueness—Your opinion of whether the indicator contributes distinct information for the 

evaluation of tobacco control efforts. If you believe that the indicator is not unique, please note the 

redundant indicator in the space provided.

6. Conformity with accepted practice—Your opinion of the degree to which use of the indicator is 

consistent with currently accepted, real-world tobacco control practice.

7. Overall quality—A summary rating that reflects your opinion of the overall quality of the 

indicator.
APPENDIX C 

221

Reviewer Comments

Please provide comments and suggestions regarding the proposed indicator, data sources, and measures 

in the spaces provided. The electronic copy of the review materials limits where you may add 

information; however, if you prefer marking up a hard copy, you may print the document and add 

handwritten notes anywhere on the rating forms to provide additional information, references, or other 

documentation, as necessary. If you choose to print the materials and write your responses on the rating 

forms, please contact OSH to arrange for return of the materials. If you are using the electronic version 

of the rating forms, please save a copy and return as an e-mail attachment.

For More Information

If you have any questions regarding the review process or content of the materials, please contact Erika 

Fulmer at OSH by telephone (770-488-5334) or e-mail (efulmer@cdc.gov). Thank you very much for 

your time and effort. 

[RATING FORM]
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APPENDIX D 

223

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 

Programs1or Surveillance and Evaluation Data Resources for Comprehensive Tobacco Control 

Programs.

2

Data source Indicator number For more information

Adult Tobacco Survey (ATS) : 

Questions Recommended for 

Specific Purposes, Section F: 

Policy Issues, 2009

1.1.d ► http://apps.nccd.cdc.gov/QIT/QuickSearch.aspx

American College Health 

Association (ACHA) College 

Campus Tobacco Cessation and 

Prevention Survey, 2005 

1.2.a ► http://www.acha.org/

American Lung Association’s 

State Legislated Actions on 

Tobacco Issues (SLATI) 

1.3.d ► http://slati.lungusa.org

Americans for Nonsmokers’

Rights (ANR) 

1.3.b; 1.3.c; 1.3.d; 

1.3.g; 1.4.a

► http://www.no-smoke.org

► See “Policy tracking system”

Behavioral Risk Factor 

Surveillance System (BRFSS), 

Tobacco Use Prevention Module, 

2000 

1.1.d ► http://www.cdc.gov/brfss/

California Adult Tobacco Survey 

(CATS), 2008

1.1.c ► http://www.cdph.ca.gov/programs/tobacco/Docum

ents/CTCPCaliforniaAdultTobaccoSurvey2008.pdf

California Adult Tobacco Survey 

(CSTS), 2011

1.1.e ► http://www.cdph.ca.gov/data/surveys/Pages/Califo

rniaTobaccoSurveys.aspx

California Tobacco Survey (CTS), 

1999

1.1.d ► http://libraries.ucsd.edu/locations/sshl/data-govinfo-gis/ssds/guides/tobacco-surveys.html

California Tobacco Survey (CTS), 

2005

1.1.d ► http://libraries.ucsd.edu/locations/sshl/data-govinfo-gis/ssds/guides/tobacco-surveys.html

California Tobacco Control 

Program: Enforcement Survey, 

2008

1.3.e; 1.4.g ► http://www.cdph.ca.gov/programs/tobacco/Docum

ents/CTCPEnforcementReport08-05.pdf
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Data source Indicator number For more information

California Tobacco Industry 

Monitoring Evaluation: Project 

SMART Money 

1.4.h; 1.7.b ► http://tobaccocontrol.bmj.com/content/19/Suppl_1/i

21.full

► See “Tobacco industry monitoring system.”

California Tobacco Use 

Prevention Education Evaluation: 

Teacher Survey, 2003

1.2.b ► http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/ 

Evaluation_Resources.htm

California Tobacco Use 

Prevention Evaluation 

1.2.d ► http://www.cdph.ca.gov/programs/tobacco/Docum

ents/CTCPTUPE07-08-sm.pdf

Campaign For Tobacco-Free Kids 

(CTFK) 

1.8.a ► http://tobaccofreekids.org/research/factsheets

CDC School Health Profiles: 

School Principal Questionnaire 

(Profiles), 2010 

1.2.a; 1.2.b ► http://www.cdc.gov/healthyyouth/profiles/

CDC School Health Profiles: 

School Teacher Questionnaire 

(Profiles), 2010 

1.2.b ► http://www.cdc.gov/healthyyouth/profiles/

CDC State Tobacco Activities 

Tracking and Evaluation 

(STATE) system 

1.3.b; 1.3.d; 1.3.h; 

1.4.a; 1.8.a

► http://apps.nccd.cdc.gov/statesystem/Default/Defau

lt.aspx

Center for Responsive Politics 

(CRP) 

1.7.h; 1.7.i ► http://www.opensecrets.org

Environmental scan of social 

media Web sites for industry 

presence and pro-tobacco 

content; monitoring and content 

analysis of brand and corporate 

Web sites for age identification 

requirements and messaging 

1.7.e ► Social media monitoring tools can be used for 

surveillance. For example, keywords can be used to 

monitor product and Web site mentions on Twitter, 

blogs, and other social media sites.

Environmental scan of tobacco 

advertising in retail outlets

1.7.a ► Operation Storefront: Youth Against Tobacco 

Advertising and Promotion Initiative

► http://www.dhs.ca.gov/tobacco/html/Evaluation_R

esources.htm

Event sponsorship tracking 

system 

1.7.b ► Rosenberg NJ, Siegel M. Use of corporate 

sponsorship as a tobacco marketing tool: a review 

of tobacco industry sponsorship in the USA, 1995–

99. Tobacco Control. 2001;10(3):239–46.

► Project SMART Money http://www.ttac.org/enews/ 

mailer09-30-03full.html#LinkF

FDA, Compliance Check 

Inspection of Tobacco Product 

Retailers 

1.3.e; 1.4.g; 1.6.c ► http://www.accessdata.fda.gov/scripts/oce/inspecti

ons/oce_insp_searching.cfm

Federal Election Commission 

(FEC) 

1.7.i ► http://www.fec.gov
APPENDIX D

225

Data source Indicator number For more information

International Tobacco Control 

Survey (ITC), 2009 

1.1.f ► http://www.itcproject.org/

Legacy Media Tracking Survey 

(LMTS), 2003

1.5.a; 1.5.c ► http://www.legacyforhealth.org/

Legacy Media Tracking Survey 

(LMTS), 2004

1.1.a; 1.1.b ► http://www.legacyforhealth.org/

Massachusetts Adult Tobacco 

Survey (MTS), 2005 

1.6.b ► http://apps.nccd.cdc.gov/QIT/QuickSearch.aspx

Media Tracking Service (e.g., 

clipping service) 

1.7.f ► http://kantarmediana.com/intelligence

Minnesota Adult Tobacco Survey 

(MATS), 2007 

1.1.f ► http://www.mntobacco.nonprofitoffice.com/

Mississippi Social Climate 

Survey of Tobacco Control (SCSTC), 2011

1.1.c ► http://surveillance.mstobaccodata.org/mississippitobacco-control-data/social-climate-of-tobaccoadult-survey/

Monitoring the Future (MTF), 

2010 

1.6.b ► http://monitoringthefuture.org/

National Adult Tobacco Survey 

(NATS), 2010

1.5.f; 1.8.b; 1.9.a; 

1.9.c; 1.10.a; 1.10.b; 

1.10.c; 1.10.d; 1.10.e

► http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?S

urveyId=30

National Adult Tobacco Survey 

(NATS), 2012-2013

1.1.b; 1.6.d; 1.6.g; 

1.8.c; 1.9.b

► http://apps.nccd.cdc.gov/QIT/SurveyDetails.aspx?S

urveyId=30

National Survey on Drug Use 

and Health (NSDUH), 2009

1.1.f; 1.10.c ► http://www.samhsa.gov/data/NSDUH.aspx

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2000

1.1.f ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2002

1.2.c ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2004

1.6.e ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2006

1.1.f ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2009

1.1.f; 1.7.e ► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/
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Data source Indicator number For more information

National Youth Tobacco Survey 

(NYTS): CDC Recommended 

Questions: Core, 2011

1.1.e; 1.2.c; 1.2.d; 

1.2.e; 1.5.a; 1.5.b; 

1.5.e; 1.5.f; 1.6.d; 

1.6.f; 1.6.g; 1.6.h; 

1.7.c; 1.9.a; 1.9.b; 

1.9.c; 1.10.a; 1.10.b; 

1.10.c; 1.10.d;1.10.e

► http://www.cdc.gov/tobacco/data_statistics/surveys

/nyts/

New York State’s Retail 

Advertising Tracking Study 

(RATS) 

1.7.a; 1.8.c ► http://www.health.ny.gov/prevention/tobacco_cont

rol/docs/tobacco_marketing_exposure_rpt.pdf

Policy tracking system 1.3.a; 1.3.b; 1.3.c; 

1.3.d; 1.3.f; 1.3.g; 

1.4.a; 1.4.b; 1.4.c;

1.4.d; 1.4.e; 1.4.f

► Americans for Nonsmokers’ Rights 

(http://www.no-smoke.org)

► State Legislated Actions on Tobacco Issues (SLATI) 

online database (http://slati.lungusa.org) 

Public records of political 

contributions 

1.7.h; 1.7.i ► Collected by the Office of State Secretary or 

equivalent at local level in each state 

Retail observation 1.8.b; 1.8.c; 1.8.d ► Operation Storefront: Youth Against Tobacco 

Advertising and Promotion Initiative

► http://www.dhs.ca.gov/tobacco/html/Evaluation_R

esources.htm

Scanner data 1.8.b; 1.8.c

Scene Smoking, “Thumbs Up! 

Thumbs Down!” 

1.7.d ► http://www.scenesmoking.org/frame.htm

School district/board or schoollevel records of curricula adopted 

or sponsored programs and 

activities 

1.7.g ► Surveys of school or school district administrators

State departments of revenue 1.8.a ► State tax sales data, tobacco product excise taxes

Substance Abuse and Mental 

Health Services Administration 

(SAMHSA) compliance checks 

1.6.c ► http://prevention.samhsa.gov/tobacco/guidance.asp

Tobacco industry fiscal reports 1.7.g; 1.7.h

Tobacco industry monitoring 

system 

1.4.h ► http://tobaccocontrol.bmj.com/content/19/Suppl_1/i

21.full

► See “California Tobacco Industry Monitoring”

Print, Internet Media Monitoring: 

Kantar Media Intelligence’s 

StradegyTM database

1.7.c ► http://kantarmediana.com/intelligence

Youth Risk Behavior 

Surveillance System (YRBSS), 

2011

1.9.a; 1.9.c ► http://www.cdc.gov/HealthyYouth/yrbs/index.htm
APPENDIX D 

227

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. 

3. Johnston LD, O’Malley PM, Bachman JG. Monitoring the Future national survey results on 

drug use, 1975–2001. Volume I: Secondary school students (NIH Publication No. 02-

5106). Bethesda, MD: National Institute on Drug Abuse; 2002.
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GLOSSARY

229

Glossary and Acronyms

Activities 

The events or actions that are part of a tobacco control program. 

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. 

Buy-downs 

The [tobacco] manufacturer offers a retailer a rebate for sales of a particular brand of tobacco 

product. The retailer is given the rebate either for selling a specific quantity of that product or 

for selling a minimum quantity of that product over a predetermined period of time. 1

Capacity 

The resources (e.g., staff, data collection systems, funds) needed to conduct a tobacco control 

program or to evaluate such a program. 

CDC

Centers for Disease Control and Prevention. 

Cognitive-behavioral interventions 

Activities based on the premise that people can learn new behaviors to use in response to 

stimuli and that the thought processes that serve as intermediate steps between stimuli and 

behaviors can be altered, thereby influencing behavior. Basic applications of this theory for 

tobacco-use cessation are 

► establishing self-awareness of tobacco use, 

► providing the motivation to quit, 

► preparing to quit, and 

► providing strategies to maintain abstinence. 

 

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
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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. 

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 

A person who gives a positive answer to the question, “Have you tried cigarette smoking, 

even one or two puffs?”

Example data source 

Surveys or surveillance systems used to measure an indicator and the population on which 

the data are needed. 

Face validity 

The degree to which data on an indicator appear reliable to stakeholders and policy makers. 

Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) 

Gives the Food and Drug Administration (FDA) the authority to regulate the manufacture, 

distribution, and marketing of tobacco products to protect public health. 

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. 

Indicator profile 

The term used in this manual for a table with detailed information on one indicator listed in 

this publication (see page 33 for an example). 
GLOSSARY

231

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 33 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. 

Morbidity 

Disease or disease rate. 

NCI

National Cancer Institute. 

Never-smoker 

A person who gives a negative answer to the question, “Have you tried cigarette smoking, 

even one or two puffs?”

NIH 

National Institutes of Health. 

NTCP 

National Tobacco Control Program. 

Observation 

A method of collecting data that does not involve any communication with the subjects being 

studied. The investigators merely watch for particular behaviors and record what they see. 

Opinion leader survey 

Collection of information (data) from leaders in the community. 
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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 29 for an example). 

Outputs 

The direct products of a program (e.g., the materials needed for a media campaign). 

Payers 

Health insurance organizations that reimburse providers for services when coverage is 

purchased by companies, government agencies, or other consortia. Also self-insured 

companies, government agencies, or other consortia that purchase health care benefits for a 

group of individuals and use an insurer as a fiscal intermediary to process claims and 

reimburse for services. 

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. 

Price discounts 

[Tobacco] manufacturers’ reductions in the prices paid by retailers and/or wholesalers for 

tobacco products, who in turn reduce the prices to consumers, such as off-invoice discounts, 

buy-downs, and voluntary price reductions.2

 

2 Ibid. 
GLOSSARY

233

Process evaluation 

Systematic collection of information to determine how well a program is implemented and 

operated. 

Program evaluation 

Systematic collection of information about activities, characteristics, and outcomes of 

programs, used to make judgments about a program, improve its effectiveness, or inform 

decisions about future program activities. 

Purchaser 

Purchasers include companies, government agencies, or other consortia that purchase health 

care benefits for a group of individuals. 

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. 

Self-service tobacco sales 

Sales that allow customers to handle tobacco products before purchasing them. 

Slotting fees 

Payments for stocking, shelving, displaying and merchandising [tobacco] brands in a certain 

manner.3

Social source 

A person or location from which tobacco products are obtained other than a tobacco product 

retailer. 

Some-day smoker 

A current smoker who gives a “smoked on some days” response. 

 

3 Ibid. 
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234

Stakeholder 

The persons or organizations that have a vested interest in what will be learned from an 

evaluation and what will be done with the information. 

Surveillance 

The ongoing, systematic collection, analysis, and interpretation of data about a hazard, risk 

factor, exposure, or health event. 

Survey 

A quantitative method of collecting information on a target population at one point in time. 

Surveys can be conducted by interview (in person or by telephone) or by questionnaire. 

Susceptibility

The intention to smoke or the absence of a strong intention not to smoke. 

Sustained abstinence 

Complete cessation of tobacco use for 6 months or longer. 

Theory of change 

Intellectual framework for understanding the process of behavior change. 

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 Tobacco Use, Attitudes Against Tobacco Use, and 

Support for Policies to Reduce Tobacco Use Initiation

Indicator number

1.1.a

Goal area Outcome component 

within the goal 

Indicator

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

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

Resources needed: Dollar signs show the amount of resources (funds, time, and effort) needed to collect 

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

(maximum four), the more resources needed. The dollar signs do not represent specific amounts because 

the actual cost of measuring and analyzing an indicator varies according to the existing capacity of a state 

health department or organization to evaluate its programs.

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

implementing interventions to effect change in a given indicator will lead to a measurable downstream 

outcome. This includes the extent to which reviewers believed that the scientific literature supports use 

of the indicator for the evaluation of comprehensive, statewide tobacco control programs and considers 

conflicting evidence as well as concerns regarding the methodology of supporting studies. 

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

program evaluation questions.

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

stakeholders, such as policy and decision makers who may be users of tobacco control program evaluation 

results.

Accepted practice: The degree to which use of the indicator is consistent with currently accepted, realworld tobacco control practice.
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