C H A P T E R 2�

Goal Area 1: Preventing Initiation of �

Tobacco Use Among Young People�

Goal Area 1

�

Preventing Initiation of Tobacco Use Among Young People

Inputs Activities Outputs Outcomes

▲

19

State health

department

and partners

Community

mobilization

marketing

Schoolbased

Policy and

action

C H A P T E R 2 Goal Area 1: Preventing Initiation of Tobacco Use Among Young People Counter- prevention regulatory anti-tobacco policies and schools tobacco messages

Short-term Intermediate Long-term

Completed activities

to disseminate

anti-tobacco and

knowledge of,

tobacco attitudes

support for

youth initiation

tobacco sales

to minors

Reduced

susceptibility to

experimentation

with tobacco

Reduced

initiation of

tobacco use by

young people

Reduced

tobacco-use

young people

Reduced

tobaccoand mortality

disparities

Completed activities

use of anti-tobacco

curricula in schools

Completed activities

on tobacco sales to

excise tax

Reduced

tobacco industry

influences

access to tobacco

price of tobacco

}

1

2

3

4

5

6

7

8

9

10

11

13

14

15

16

GOAL AREA 1

Increased 

programs in 

Completed activities

to reduce and

counteract propro-health messages Increased improved anti- toward, and increased policies to reduce

Increased

restriction and

enforcement 

of restrictions on

products

prevalence among

related morbidity

Decreased

tobacco-related

to increase tobaccofree policies and

to increase restrictions

minors and to enforce

those restrictions

Completed activities

to increase cigarette

Decreased

products

Increased

products

12

▲

Targeted to 

populations

with tobaccorelated 

disparities
Goal Area 1�

Preventing Initiation of Tobacco Use Among Young People �

Short-term Outcomes

■�Outcome 6: Increased knowledge of, improved anti-tobacco attitudes toward, 

and increased support for policies to reduce youth initiation

▲

▲� ▲

▲

▲

▲

▲

▲

1.6.1� Level of confirmed awareness of anti-tobacco media messages

1.6.2� Level of receptivity to anti-tobacco media messages

1.6.3� Proportion of students who would ever wear or use something with 

a tobacco company name or picture

1.6.4� Level of support for policies, and enforcement of policies, to decrease 

young people’s access to tobacco

1.6.5� Level of support for increasing excise tax on tobacco products

1.6.6� Level of awareness among parents about the importance of discussing 

tobacco use with their children

1.6.7NR� Level of support for creating policies in schools

1.6.8NR Proportion of young people who think that the cigarette companies try 

to get young people to smoke

■ Outcome 7: Increased anti-tobacco policies and programs in schools�

▲

▲

▲

▲

▲

▲

▲

▲

1.7.1� Proportion of schools or school districts reporting the implementation 

of 100% tobacco-free policies

1.7.2� Proportion of schools or school districts that provide instruction on 

tobacco-use prevention that meets CDC guidelines

1.7.3� Proportion of schools or school districts that provide tobacco-use 

prevention education in grades K–12

1.7.4� Proportion of schools or school districts that provide program-specific 

training for teachers

1.7.5� Proportion of schools or school districts that involve families in support 

of school-based programs

1.7.6� Proportion of schools or school districts that support cessation 

interventions for students and staff who use tobacco

1.7.7� Proportion of schools or school districts that assess their tobacco-use 

prevention program at regular intervals

1.7.8� Proportion of students who participate in tobacco-use prevention 

activities

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

20
▲

▲

▲

GOAL AREA 1 

1.7.9 Level of reported exposure to school-based tobacco-use prevention 

curricula that meet CDC guidelines

1.7.10 Perceived compliance with tobacco-free policies in schools

1.7.11 Proportion of schools or school districts with policies that regulate 

display of tobacco industry promotional items

■ Outcome 8: Increased restriction and enforcement of restrictions on tobacco 

sales to minors

▲

▲

▲

▲

▲

▲

▲

1.8.1� Proportion of jurisdictions with policies that ban tobacco vending 

machine sales in places accessible to young people

1.8.2� Proportion of jurisdictions with policies that require retail licenses 

to sell tobacco products

1.8.3� Proportion of jurisdictions with policies that control the location, 

number, and density of retail outlets

1.8.4� Proportion of jurisdictions with policies that control self-service 

tobacco sales

1.8.5� Number of compliance checks conducted by enforcement agencies

1.8.6� Number of warnings, citations, and fines issued for infractions of 

public policies against young people’s access to tobacco products

1.8.7� Changes in state tobacco control laws that preempt stronger local 

tobacco control laws

■ Outcome 9: Reduced tobacco industry influences�

▲

▲

▲

▲

▲

▲

▲

▲

1.9.1� Extent and type of retail tobacco advertising and promotions

1.9.2� Proportion of jurisdictions with policies that regulate the extent and 

type of retail tobacco advertising and promotions

1.9.3� Extent of tobacco advertising outside of stores

1.9.4� Proportion of jurisdictions with policies that regulate the extent of 

tobacco advertising outside of stores 

1.9.5� Extent of tobacco industry sponsorship of public and private events

1.9.6� Proportion of jurisdictions with policies that regulate tobacco industry 

sponsorship of public events

1.9.7� Extent of tobacco advertising on school property, at school events, 

and near schools

1.9.8 � Extent of tobacco advertising in print media

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

21
▲

▲

▲

▲

1.9.9 � Amount and quality of news media stories about tobacco industry 

practices and political lobbying

1.9.10 � Number and type of Master Settlement Agreement violations by 

tobacco companies

1.9.11� Extent of tobacco industry contributions to institutions and groups

1.9.12� Amount of tobacco industry campaign contributions to local and 

state politicians

Intermediate Outcomes

■�Outcome 10: Reduced susceptibility to experimentation with tobacco 

products

▲

▲

▲

▲

▲

1.10.1� Proportion of young people who think that smoking is cool and 

helps them fit in

1.10.2� Proportion of young people who think that young people who smoke 

have more friends

1.10.3� Proportion of young people who report that their parents have 

discussed not smoking with them

1.10.4� Proportion of parents who report that they have discussed not smoking 

with their children

1.10.5� Proportion of young people who are susceptible never-smokers

■ Outcome 11: Decreased access to tobacco products

▲

▲

▲

▲

▲

▲

1.11.1� Proportion of successful attempts to purchase tobacco products 

by young people

1.11.2� Proportion of young people reporting that they have been sold tobacco 

products by a retailer

1.11.3� Proportion of young people reporting that they have been unsuccessful 

in purchasing tobacco products from a retailer

1.11.4� Proportion of young people reporting that they have received tobacco 

products from a social source

1.11.5� Proportion of young people reporting that they purchased cigarettes 

from a vending machine

1.11.6NR Proportion of young people who believe that it is easy to obtain 

tobacco products

■ Outcome 12: Increased price of tobacco products�

▲

1.12.1 Amount of tobacco product excise tax

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

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GOAL AREA 1 

Long-term Outcomes

■ Outcome 13: Reduced initiation of tobacco use by young people

▲

▲

1.13.1 Average age at which young people first smoked a whole cigarette

1.13.2 Proportion of young people who report never having tried a cigarette

■ Outcome 14: Reduced tobacco-use prevalence among young people

▲

▲

1.14.1 Prevalence of tobacco use among young people

1.14.2 Proportion of established young smokers

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

23
K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

24
GOAL AREA 1 

Outcome 6

Outcome 6

▲

Increased Knowledge of, Improved Anti-tobacco Attitudes Toward,

and Increased Support for Policies to Reduce Youth Initiation

The theory of change associated with preventing young people from starting to 

use tobacco begins with increasing their knowledge of the dangers of tobacco use, 

changing their attitudes toward tobacco use, and increasing public support for 

policies that reduce the likelihood that young people will use tobacco. The tobacco 

industry spends more than $12.5 billion per year on marketing.1 Adolescents are 

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

in movies, and by smokers around them. Evidence shows that anti-tobacco media 

campaigns, when combined with other interventions, are effective in reducing 

tobacco use by adolescents.2 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.3 After one 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.3

In addition to changing young people’s attitudes toward tobacco use, it is necessary 

to increase adult support for implementing and enforcing policies that reduce the 

likelihood that young people will begin smoking. Such policies include increasing 

tobacco excise taxes, passing and enforcing strong laws that decrease young people’s 

access to tobacco, and implementing tobacco-free school policies. Policies such as 

these eventually create an environment that supports a smoke-free lifestyle among 

young people. 

Listed below are the indicators associated with this outcome:

▲

▲� ▲

▲

▲

▲

▲

▲

1.6.1� Level of confirmed awareness of anti-tobacco media messages

1.6.2� Level of receptivity to anti-tobacco media messages

1.6.3 � Proportion of students who would ever wear or use something with 

a tobacco company name or picture

1.6.4� Level of support for policies, and enforcement of policies, to decrease 

young people’s access to tobacco

1.6.5 � Level of support for increasing excise tax on tobacco products

1.6.6� Level of awareness among parents about the importance of discussing 

tobacco use with their children

1.6.7NR� Level of support for creating policies in schools

1.6.8NR Proportion of young people who think that the cigarette companies try 

to get young people to smoke

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

25
References

1. �Federal Trade Commission. Cigarette report for 2002. Washington, DC: Federal 

Trade Commission; 2004.

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. �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.

For Further Reading

Alcaraz R, Klonoff EA, Landrine H. The effects on children of participating in 

studies of minors’ access to tobacco. Preventive Medicine. 1997;26(2):236–40.

Brown J, Caston M, Pollard J. Students and substances: social power in drug 

education. Educational Evaluation and Policy Analysis. 1997;19(1):65–82.

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.

Centers for Disease Control and Prevention. Guidelines for school health programs 

to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

Eischen MH, Brownson RC, Davis JR, Cooperstock LR, Crawford R, Freeman D, 

Howard G, Michael MJ. Grassroots efforts to promote tobacco-free schools in rural 

Missouri. American Journal of Public Health. 1994;84(8):1336–7. 

Elder JP, Perry CL, Stone EJ, Johnson CC, Yang M, Edmundson EW, Smyth MH, 

Galati T, Feldman H, Cribb P, Parcel GS. Tobacco-use measurement, prediction, 

and intervention in elementary schools in four states: the CATCH Study. Preventive 

Medicine. 1996;25(4):486–94.

Flay BR, Brannon BR, Johnson CA, Hansen WB, Ulene AL, Whitney-Saltiel DA, 

et al. The television school and family smoking prevention and cessation project. 

1. Theoretical basis and program development. Preventive Medicine. 1988;17(5):

585–607.

Lantz PM, Jacobson PD, Warner KE, Wasserman J, Pollack HA, Berson J, Ahlstrom A. 

Investing in youth tobacco control: a review of smoking prevention and control 

strategies. Tobacco Control. 2000;9(1):47–63.

Lee DJ, Trapido E, Weatherby N, Rodriguez R. Correlates of participation and 

willingness to participate in anti-tobacco activities among 4th–7th graders. Journal 

of Community Health. 2001;26(6):447–57.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

26
GOAL AREA 1 

Outcome 6 ▲

Lynch BS, Bonnie RJ. Growing up tobacco free: preventing nicotine addiction in 

children and youths. Washington, DC: National Academy Press; 1994.

National Cancer Institute. Smoking and Tobacco Control Monograph, No. 14. 

Changing adolescent smoking prevalence: where it is and why. Bethesda, MD: National 

Cancer Institute; 2001. NIH Publication No. 02-5086. 

Pentz M. Primary prevention of adolescent drug abuse: applied developmental psychology.

Columbus, OH: McGraw-Hill; 1994. pp. 435–74.

Pentz MA, Brannon BR, Charlin VL, Barrett EJ, MacKinnon DP, Flay BR. The 

power of policy: the relationship of smoking policy to adolescent smoking. 

American Journal of Public Health. 1989;79(7):857–62.

Peterson AV Jr, Kealey KA, Mann SL, Marek PM, Sarason IG. Hutchinson Smoking 

Prevention Project: long-term randomized trial in school-based tobacco use prevention—results on smoking. Journal of the National Cancer Institute. 2000;92(24):1979–91.

Thomas R. School-based programmes for preventing smoking. The Cochrane Database 

of Systematic Reviews, 2002;(4):CD001293. DOI: 10.1002/14651858.CD001293. 

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

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

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 Research. 1999;14(6):751–63. 

Winkleby MA, Feighery EC, Altman DA, Kole S, Tencati E. Engaging ethnically 

diverse teens in a substance use prevention advocacy program. American Journal 

of Health Promotion. 2001;15(6):433–6.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

27
Outcome 6�

Increased Knowledge of, Improved Anti-tobacco Attitudes Toward,

and Increased Support for Policies to Reduce Youth Initiation Indicator Rating

better

Number Indicator� Overall quality

low high

1.6.1 Level of confirmed awareness of anti-tobacco media 

messages | | | | | | $$

1.6.2 Level of receptivity to anti-tobacco media messages | | | | | | $$

1.6.3 Proportion of students who would ever wear or use 

something with a tobacco company name or picture | | | | | |† $$

1.6.4 Level of support for policies, and enforcement of 

policies, to decrease young people’s access to tobacco | | | | | | $$

1.6.5 Level of support for increasing excise tax on tobacco 

products | | | | | | $$†

1.6.6 Level of awareness among parents about the importance 

of discussing tobacco use with their children | | | | | |† $$ †

1.6.7NR Level of support for creating policies in schools | | | | | |

1.6.8NR Proportion of young people who think that the cigarette 

companies try to get young people to smoke | | | | | |

Resources

needed

Strength of

evaluation evidence

Utility

Face validity

Accepted

practice

†�Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this indicator were within one 

point of each other (see Appendix B for an explanation).

Denotes no data.� NR Denotes an indicator that is not rated (see Appendix B for an explanation).�

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

28
________________________________________________________________________

________________________________________________________________________

GOAL AREA 1 

▲Outcome 6

Indicator 1.6.1

Level of Confirmed Awareness of Anti-tobacco Media Messages

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation 

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

Why this indicator� Evaluators should measure exposure to anti-tobacco media messages to confirm

is useful� awareness of these messages by asking respondents to provide specific information 

about the message.1

Example data Legacy Media Tracking Survey (LMTS), 2003

source(s) Information on LMTS available at: http://tobacco.rti.org/data/lmts.cfm

Population group(s) Young people aged less than 18 years

Example survey 

question(s)

From LMTS 

Have you recently seen an anti-smoking or anti-tobacco ad on TV that 

shows _____________________________________________________? 

Yes Maybe, not sure No Refused to answer

What happens in this advertisement? (DO NOT READ RESPONSE CATEGORIES) 

What do you think the main message of this ad was? 

(DO NOT READ RESPONSE CATEGORIES)

Comments� The example questions could be asked of adults.

Evaluators may want to categorize awareness of the medium (e.g., billboard, 

television, print) through which respondents learned of the anti-tobacco message.

Programs may want to evaluate confirmed awareness of an advertisement by 

respondents’ smoking status (current, former, or never) and addiction level 

(e.g., light, moderate, or heavy), because awareness levels may differ significantly 

among groups with different levels of addiction.

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� Overall quality Resources Strength of Utility Face validity Accepted

high needed evaluation � practice

evidence

low

| | | | | | $$

better

Reference

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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

29
Indicator 1.6.2�

Level of Receptivity to Anti-tobacco Media Messages

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation 

What to measure� The level of receptivity to media messages by the intended audience. Receptivity is 

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

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

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

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

Why this indicator

is useful

Message awareness is necessary but not sufficient to change the knowledge, 

attitudes, and intentions of young people. Media campaigns are effective only 

if their messages reach and resonate with the intended audience. A well-received 

message helps ensure campaign effectiveness.2–5 One study found that receptivity 

to anti-tobacco messages was a significant predictor of lower rates of intention 

to smoke.6

Example data Legacy Media Tracking Survey (LMTS), 2003

source(s) Information on LMTS available at: http://tobacco.rti.org/data/lmts.cfm

Population group(s) Young people aged less than 18 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

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

Comments The example questions could be asked of adults.

Evaluators may want to assess receptivity by the medium through which respondents 

learned of the media message (e.g., television, print, or radio).

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 Overall quality

low high

Resources 

needed

$$

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

better

| | | | | |

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

30
GOAL AREA 1 

▲Outcome 6

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;10:9–15. 

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

1984;13(3):299–319.

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

4. �Carter WB. Health behavior as a rational process: theory of reasoned action and multiattribute utility theory. In: Glanz K, 

Lewis F, Rimer B, editors. Health behavior and health education: theory, research, and practice. San Francisco, CA: Jossey-Bass; 

1990. p. 63–91.

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

Thousand Oaks, CA: Sage; 1995.

6. �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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

31
Indicator 1.6.3�

Proportion of Students Who Would Ever Wear or 

Use Something with a Tobacco Company Name or Picture

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation

What to measure Proportion of students who are willing to buy or receive a cigarette promotional item 

(e.g., sports gear, clothing, lighters, or sunglasses)

Why this indicator� Evidence suggests a causal relationship between adolescents’ willingness to wear

is useful� or use tobacco promotional items and the likelihood that they will experiment with 

cigarettes.1–5 Young people who are highly receptive to tobacco marketing are more than 

twice as likely to become established smokers as those with a low level of receptivity 

to tobacco marketing.3

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years �

Example survey From YTS

question(s) Would you ever use or wear something that has a tobacco company name or picture 

on it, such as a lighter, t-shirt, hat, or sunglasses?

Definitely yes Probably yes Probably not Definitely not

Comments None 

Rating� Overall quality Resources Strength of Utility Face validity Accepted

high needed evaluation � practice

evidence

low 

| | | | | |† $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

2. �Gilpin EA, Pierce JP, Rosbrook B. Are adolescents receptive to current sales promotion practices of the tobacco industry? 

Preventive Medicine. 1997;26(1):14–21.

3. �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.

4. �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.

5. �Feighery EC, Borzekowski DL, Schooler C, Flora J. Seeing, wanting, owning: the relationship between receptivity to 

tobacco marketing and smoking susceptibility in young people. Tobacco Control. 1998;7:123–8.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

32
GOAL AREA 1 

▲Outcome 6

Indicator 1.6.4

Level of Support for Policies, and Enforcement of Policies,

to Decrease Young People’s Access to Tobacco

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation

What to measure Proportion of adults who support policies and enforcement of policies restricting young 

people’s access to tobacco products

Why this indicator� Tobacco-free policies are unlikely to be adopted without support from business owners,

is useful� policy makers, and the general public.1–4 In 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.5

Example data Adult Tobacco Survey (ATS): CDC Recommended Questions: Supplemental Section F:

source(s) Policy Issues, 2003

Population group(s) Adults aged 18 years or older �

Example survey 

question(s)

From ATS

How important is it that communities keep stores from selling tobacco products to 

teenagers? Would you say it is 

Very important Somewhat important Not very important 

Not important at all No opinion/Don’t know Refused

How strongly do you agree or disagree with the following statement: Store owners 

should be required to have a license to sell tobacco products, similar to alcohol, so that 

teens can’t buy tobacco products. Would you say it is

Very important Somewhat important Not very important 

Not important at all No opinion/Don’t know Refused

Comments The example questions could be asked of decision makers or retailers.�

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

access to tobacco by respondent’s tobacco use.�

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Denotes no data.

References

1.�U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta. GA: Centers 

for Disease Control and Prevention; 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. �Thompson GW, Wilson N. Public attitudes about tobacco smoke in workplaces: the importance of workers’ rights in 

survey questions. Tobacco Control. 2003;13:206–8.

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. �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 from: http://repositories.cdlib.org/tc/surveys/CTS1999/.Accessed December 2004.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

33
Indicator 1.6.5�

Level of Support for Increasing Excise Tax on Tobacco Products �

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation

What to measure Proportion of adults who support an increase in excise tax on cigarettes and the amount 

of tax increase they support

Why this indicator� Public opinion is a major determinant of the feasibility of enacting an excise tax increase

is useful� on tobacco products. Tobacco policies are unlikely to be adopted without support from 

business owners, policy makers, and the general public.1–4 Measuring policy makers’ 

support for a tax increase will assess their willingness to support legislation for a tax 

increase.5

Example data Adult Tobacco Survey (ATS): CDC Recommended Questions: Supplemental Section F:

source(s) Policy Issues, 2003

Population group(s) Adults aged 18 years or older�

Example survey From ATS

question(s) How much additional tax on a pack of cigarettes would you be willing to support if 

some or all the money raised was used to support tobacco control programs?

More than two dollars a pack Less than fifty cents a pack

Two dollars a pack No tax increase

One dollar a pack Don’t know/Not sure

Fifty to ninety-nine cents a pack Refused

Comments� The example questions could be asked of decision makers or opinion leaders.

Evaluators may want to analyze the level of support for increasing an excise tax on 

tobacco products according to the smoking status of the respondent. 

To gather more complete data on tobacco use, evaluators can also ask questions about 

the use of other tobacco products such as spit tobacco (smokeless), bidis, small cigars, 

and loose tobacco (roll-your-own). 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$†

better

† �Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Denotes no data.

References

1. �U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA: Centers 

for Disease Control and Prevention; 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. �Thompson GW, Wilson N. Public attitudes about tobacco smoke in workplaces: the importance of workers’ rights in 

survey questions. Tobacco Control. 2003;13:206–8.

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. �O’Connell P. Tobacco control in the land of the golden leaf. Has political perception kept pace with reality? North Carolina 

Medical Journal. 2002;63(3):175–6. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

34
GOAL AREA 1 

▲Outcome 6

Indicator 1.6.6

Level of Awareness Among Parents About the Importance 

of Discussing Tobacco Use with Their Children

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation

What to measure Proportion of parents who believe that discussing tobacco use with their children 

is important

Why this indicator� Although studies show that parental discussion about tobacco can reduce young people’s

is useful� tobacco use, many parents do not discuss tobacco use with their children.1–3 Increasing 

awareness among parents of the importance of discussing tobacco use with their children 

is an important step in reducing tobacco initiation and use.

Example data No commonly used data sources were found

source(s)

Population group(s) Parents of young people aged less than 18 years �

Example survey How important is it that you discuss tobacco use with your child(ren)? Would you

question(s) say it is

Very important Somewhat important Not very important

Not important at all No opinion/Don’t know Refused to answer

Comments The authors created this example question. It does not come from any commonly 

used data source.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $$ †

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �Clark PI, Scarisbrick-Hauser A, Gautam SP, Wirk SJ. Anti-tobacco socialization in homes of African-American and white 

parents, and smoking and nonsmoking parents. Journal of Adolescent Health. 1999;24:329–39.

2. �Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, and smoking onset among children. 

Addictive Behaviors. 1997;22(1):107–14.

3. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

35
Indicator 1.6.7NR

Level of Support for Creating Policies in Schools 

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation

What to measure Proportion of adults who support creating and actively enforcing tobacco-free policies 

in schools

Why this indicator Young people’s attitudes about the acceptability of smoking are influenced by what they

is useful see their peers and educators doing at school. Strong school anti-tobacco policies require 

the support of parents, teachers, principals, policy makers, and the general public.1

Example data � ▲

▲

▲

Adult Tobacco Survey (ATS): CDC Recommended Questions: Supplemental

source(s) Section F: Policy Issues, 2003

University of California at San Diego, California Tobacco Survey (CTS): Adult 

Attitudes and Practices, 1996 

Information on CTS available at: 

• http://ssdc.ucsd.edu/tobacco 

• http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/Evaluation_Resources.htm

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

Module, 2000

Population group(s) Adults aged 18 years or older�

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 CTS

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

gear with tobacco brand logos to school?

Yes No

From BRFSS

Do you think that smoking should be allowed in all areas of schools, restaurants, 

day care, and indoor work areas, some areas, or not allowed at all?

All areas Some areas�

Not allowed � Refused to answer

Comments The example questions could also be asked of decision makers.

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

in schools based on the respondent’s tobacco use.�

This indicator was not rated by the panel of experts and, therefore, no rating information �

is provided. See Appendix B for an explanation.�

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

36
GOAL AREA 1 

▲Outcome 6

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | |

better

Denotes no data.

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

Reference

1. �Task Force on Community Preventive Services Meeting. February 25, 2004. Meeting minutes available at 

www.thecommunityguide.org. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

37
Indicator 1.6.8NR

Proportion of Young People Who Think That the 

Cigarette Companies Try to Get Young People to Smoke

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 6 Increased knowledge of, improved anti-tobacco attitudes toward, and increased support 

for policies to reduce youth initiation

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

people to start smoking

Why this indicator If young people are aware of the tobacco industry’s attempts to persuade them

is useful to start smoking, they may become less susceptible to the tobacco industry’s 

marketing tactics.1

Example data � California Independent Evaluation: Youth Survey, 2000

source(s)� Information available at: http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/

Evaluation_Resources.htm

Population group(s) Young people aged less than 18 years�

Example survey From California Independent Evaluation: Youth Survey

question(s) Do tobacco companies try to get young people to start smoking by using advertisements 

that are attractive to young people?

Yes, definitely Yes, maybe Probably not Not sure

Comments This indicator was not rated by the panel of experts and, therefore, no rating information 

is provided. See Appendix B for an explanation.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | |

better

Denotes no data.

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

Reference

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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

38
GOAL AREA 1 

Outcome 7

Outcome 7

▲

Increased Anti-tobacco Policies and Programs in Schools

To prevent and reduce tobacco use by young people, schools should implement 

comprehensive anti-tobacco policies and programs that reinforce tobacco-free 

norms. Young people spend much of their time in school and are influenced by 

school policies and programs and by the actions of their peers and of adults.1

Evidence shows that education programs that include instruction on the shortand long-term physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms, and life skills can prevent or reduce tobacco use 

among students.2,3 School-based interventions that are combined with mass media 

campaigns and additional community-wide educational anti-tobacco activities show 

evidence of effectiveness in reducing tobacco use among young people.3

 The Community Guide to Preventive Services Task Force, however, states that insufficient 

evidence is available to indicate that either school-based education programs 

(e.g., classroom programs) or student-delivered community education (e.g., Students 

Working Against Tobacco [SWAT]) are effective when implemented alone, without 

other community activities to supplement or reinforce them.3

The demand for effective tobacco-use cessation interventions for young people has 

been growing.4 As with all public health programs, such interventions must be based 

on evidence that proves that they work. Unfortunately, few rigorous scientific studies 

exist on which to base recommendations that would help young smokers quit.4

CDC provides guidelines for school health programs to prevent tobacco use and 

addiction.2

 The guidelines include recommendations on policies, curricula and 

instruction, teacher training, parental involvement, tobacco-use cessation, and 

evaluation. The guidelines are based on research, scientific theory, and practice. 

Listed below are the indicators associated with this outcome:

▲

▲

▲

▲

▲

▲

▲

1.7.1� Proportion of schools or school districts reporting the implementation 

of 100% tobacco-free policies

1.7.2� Proportion of schools or school districts that provide instruction on 

tobacco-use prevention that meets CDC guidelines

1.7.3� Proportion of schools or school districts that provide tobacco-use 

prevention education in grades K–12

1.7.4� Proportion of schools or school districts that provide program-specific 

training for teachers

1.7.5� Proportion of schools or school districts that involve families in support 

of school-based programs

1.7.6� Proportion of schools or school districts that support cessation 

interventions for students and staff who use tobacco

1.7.7� Proportion of schools or school districts that assess their tobacco-use 

prevention program at regular intervals

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

39
▲

▲

▲

▲

1.7.8� Proportion of students who participate in tobacco-use prevention �

activities �

1.7.9� Level of reported exposure to school-based tobacco-use prevention �

curricula that meet CDC guidelines�

1.7.10� Perceived compliance with tobacco-free policies in schools

1.7.11� Proportion of schools or school districts with policies that regulate �

display of tobacco industry promotional items�

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among 

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

2. �Centers for Disease Control and Prevention. Guidelines for school health 

programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly 

Report Recommendations and Reports. 1994;43(RR-2):1–18. Available from: 

http://www.cdc.gov/mmwr/PDF/RR/RR4302.pdf. Accessed March 2005. 

3. �Task Force on Community Preventive Services Meeting. February 25, 2004. 

Meeting minutes available at www.thecommunityguide.org. 

4. �Milton MH, Maule CO, Yee SL, Backinger C, Malarcher AM, Husten CG. Youth 

tobacco cessation: a guide for making informed decisions. Atlanta, GA: Centers for 

Disease Control and Prevention; 2004.

For Further Reading

Alcaraz R, Klonoff EA, Landrine H. The effects on children of participating in studies 

of minors’ access to tobacco. Preventive Medicine. 1997;26(2):236–40.

Epstein JA, Griffin KW, Botvin GJ. Competence skills help deter smoking among 

inner city adolescents. Tobacco Control. 2000;9(1):33–9.

Farrelly MC, Healton CG, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting 

to the truth: evaluating national tobacco countermarketing campaigns. American

Journal of Public Health. 2002;92(6):901–7. Erratum in: American Journal of Public 

Health. 2003;93(5):703.

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.

Huang TT, Unger JB, Rohrbach LA. Exposure to, and perceived usefulness of, schoolbased tobacco-prevention programs: associations with susceptibility to smoking 

among adolescents. Journal of Adolescent Health. 2000;27(4):248–54.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

40
GOAL AREA 1 

Outcome 7 ▲

Lee DJ, Trapido E, Weatherby N, Rodriguez R. Correlates of participation and 

willingness to participate in anti-tobacco activities among 4th–7th graders. Journal 

of Community Health. 2001;26(6):447–57.

Lewit EM, Hyland A, Kerrebrock N, Cummings KM. Price, public policy, and 

smoking in young people. Tobacco Control. 1997;6(Suppl 2):S17–24.

National Cancer Institute. Smoking and Tobacco Control Monograph, No. 14. 

Changing adolescent smoking prevalence: where it is and why. Bethesda, MD: National 

Cancer Institute; 2001. NIH Publication No. 02-5086.

Pierce JP, Gilpin EA, Emery SL, White MM, Rosbrook B, Berry CC, Farkas AJ. Has the 

California tobacco control program reduced smoking? Journal of the American Medical 

Association. 1998;280(10):893–9.

Rohrbach LA, Howard-Pitney B, Unger JB, Dent CW, Howard KA, Cruz TB, Ribisl 

KM, Norman GJ, Fishbein H, Johnson CA. Independent evaluation of the California 

Tobacco Control Program: relationships between program exposure and outcomes, 

1996–1998. American Journal of Public Health. 2002;92(6):975–83.

Sargent JD, Dalton MA, Beach M, Bernhardt A, Pullin D, Stevens M. Cigarette 

promotional items in public schools. Archives of Pediatrics & Adolescent Medicine. 

1997;151(12):1189–96.

Siegel M, Biener L. The impact of an antismoking media campaign on progression 

to established smoking: results of a longitudinal youth study. American Journal of 

Public Health. 2000;90(3):380–6.

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.

Sly DF, Trapido E, Ray S. Evidence of the dose effects of an antitobacco counteradvertising campaign. Preventive Medicine. 2002;35(5):511–8.

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.

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.

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

people: a report of the Surgeon General. Atlanta, GA: Centers for Disease Control and 

Prevention; 1994.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

41
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. 

Winkleby MA, Feighery EC, Altman DA, Kole S, Tencati E. Engaging ethnically 

diverse teens in a substance-use prevention advocacy program. American Journal of 

Health Promotion. 2001;15(6):433–6.

Zucker D, Hopkins R, Sly D, Urich J, Mendoza Kershaw J, Solari S. Florida’s “truth” 

campaign: a counter-marketing, anti-tobacco media campaign. Journal of Public Health 

Management and Practice. 2000;6(3):1–6. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

42
GOAL AREA 1 

▲Outcome 7

Outcome 7

Increased Anti-tobacco Policies 

and Programs in Schools Indicator Rating

better

Number Indicator Overall quality Stren

evaluatio

Resources

Face v

needed

low high n

gth of

evidence

Utility

alidity

practice

Accepted

1.7.1 Proportion of schools or school districts reporting 

the implementation of 100% tobacco-free policies | | | | | |† $$

1.7.2 Proportion of schools or school districts that provide 

instruction on tobacco-use prevention that meets 

CDC guidelines

| | | | | | $$ †

1.7.3 Proportion of schools or school districts that provide 

tobacco-use prevention education in grades K–12 | | | | | |† $$ †

1.7.4 Proportion of schools or school districts that provide 

program-specific training for teachers | | | | | | $$

1.7.5 Proportion of schools or school districts that involve 

families in support of school-based programs | | | | | |† $$

1.7.6 Proportion of schools or school districts that support 

cessation interventions for students and staff who 

use tobacco

| | | | | | $$

1.7.7 Proportion of schools or school districts that assess their 

tobacco-use prevention program at regular intervals | | | | | |† $$$ †

1.7.8 Proportion of students who participate in tobacco-use 

prevention activities | | | | | |† $$

1.7.9 Level of reported exposure to school-based tobacco-use 

prevention curricula that meet CDC guidelines | | | | | | $$

1.7.10 Perceived compliance with tobacco-free policies in 

schools | | | | | | $$

1.7.11 Proportion of schools or school districts with policies that 

regulate display of tobacco industry promotional items | | | | | | $$

†�Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this indicator were within one 

point of each other (see Appendix B for an explanation).

Denotes no data.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

43
Indicator 1.7.1�

Proportion of Schools or School Districts Reporting �

the Implementation of 100% Tobacco-free Policies �

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure� Proportion of schools or school districts that report having a policy that prohibits 

anyone from using tobacco at all times on school grounds, at all school-sponsored 

functions, and in school vehicles

Why this indicator Young people spend much of their formative years in school. Their attitudes toward

is useful the acceptability of smoking in general are influenced by the actions of their peers 

and educators at school.1,2

Example data CDC School Health Profiles: School Principal Questionnaire (Profiles), 2002

source(s)

Population group(s) School principals�

Example survey From Profiles

question(s) 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 for 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 for the following groups?

Time Students Faculty/Staff Visitors

Yes No Yes No Yes No

• �During school hours

• �During non-school hours

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, school-�

sponsored events �

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

44
GOAL AREA 1 

▲Outcome 7

Comments� To measure this indicator fully, evaluators should use all four example questions, not 

just one or two.

Evaluators could also collect information on school districts in order to measure the 

proportion of students in the district who attend schools with anti-tobacco policies.

This indicator can be used to measure progress toward achieving Recommendation 1 of 

CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.”1

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report 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: Centers for Disease Control and Prevention; 1994.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

45
Indicator 1.7.2�

Proportion of Schools or School Districts That Provide Instruction 

on Tobacco-use Prevention That Meets CDC Guidelines

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure� Proportion of schools or school districts that report providing instruction on (1) the 

physiologic and social consequences of tobacco use and (2) the social influences on 

tobacco use, peer norms, and life skills

Why this indicator Evidence suggests that programs that include instruction on the short- and long-term

is useful physiologic and social consequences of tobacco use, social influences on tobacco use, 

peer norms, and life skills can prevent or reduce tobacco use among students.1,2

Example data � ▲

▲

▲�▲

CDC School Health Profiles: Lead Health Education Teacher Questionnaire

source(s)� (Profiles), 2002

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

Health education teachers

Teachers and school administrators

Population group(s)�

Example survey 

question(s)

From Profiles

During this school year, did teachers in this school teach each of the following tobacco

use prevention topics in a required health education course for students in any of 

grades 6 through 12? Mark yes or no for each topic.

Yes No

a. �Short- and long-term health consequences of cigarette smoking 

(such as stained teeth, bad breath, heart disease, and cancer) 

b. �Benefits of not smoking cigarettes (including long- and short-term health

benefits, social benefits, environmental benefits, and financial benefits) 

c. �Risks of cigar or pipe smoking 

d. �Short- and long-term health consequences of using smokeless tobacco 

e. �Benefits of not using smokeless tobacco 

f. �Addictive effects of nicotine in tobacco products 

g. �How many young people use tobacco 

h. �The number of illnesses and deaths related to tobacco use 

i. �Influence of families on tobacco use 

j. �Influence of the media on tobacco use 

k. �Social or cultural influences on tobacco use 

l. �How to find valid information or services related to tobacco-use 

cessation 

m. Making a personal commitment not to use tobacco 

n. �How students can influence or support others in efforts to prevent

tobacco use 

o. �How students can influence or support others in efforts to quit 

using tobacco 

p. �How to say no to tobacco use 

q. �The health effects of environmental tobacco smoke (ETS) or

second-hand smoke 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

46
GOAL AREA 1 

▲Outcome 7

Example survey �

question(s) (cont.)�

From California Tobacco Use Prevention Education Evaluation: Teacher Survey 

During the last school year (2002–2003), which of the following topics did 

you cover in your tobacco use prevention lessons? (Mark all that apply). 

I did not teach tobacco prevention lessons 

Effects of tobacco on health

How many young people smoke 

Reasons why young people smoke

Social consequences of using tobacco

Secondhand smoke

Social influences that promote tobacco use 

Behavioral skills for resisting tobacco offers

General personal and social skills (e.g., problem solving, �

assertiveness, communication, and goal setting)�

Tobacco cessation 

Tobacco advertising and marketing 

Cigar use

Other (specify):________________________________________ 

Comments� It would be useful for evaluators to obtain information on the specific curriculum 

taught. Further information on the anti-tobacco curriculum being taught could be 

collected using a student survey. 

This indicator can be used to measure progress toward achieving Recommendation 2 

of CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and 

Addiction.”2

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$ †

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

2. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

47
Indicator 1.7.3�

Proportion of Schools or School Districts That 

Provide Tobacco-use Prevention Education in Grades K–12

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure Proportion of schools or school districts that report providing tobacco-use prevention 

education in grades K–12

Why this indicator� Research, theory, and current practice demonstrate that the success of school-based

is useful� prevention programs dissipates over time. CDC’s “Guidelines for School Health 

Programs to Prevent Tobacco Use and Addiction,” therefore, calls for tobacco use 

prevention to be taught in each grade, with increasing intensity in middle school 

and reinforcement in high school grades.1

Example data CDC School Health Profiles: Lead Health Education Teacher Questionnaire

source(s) (Profiles), 2002

Population group(s) Health education teachers�

Example survey 

question(s)

From Profiles

During the school year, in which of the following grades was information on tobaccouse prevention provided? 

Yes No

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Are required tobacco-use prevention units or lessons taught in each of the following 

courses in the school?

Course � Yes No

a. �Science 

b. �Home economics or family 

and consumer education 

c. �Physical education 

d. �Family life education 

or life skills 

e. �Special education 

Comments� This indicator can be used to measure progress toward achieving Recommendation 3 

of CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and 

Addiction.”1

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

48
GOAL AREA 1 

▲Outcome 7

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | † $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Reference

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

49
Indicator 1.7.4�

Proportion of Schools or School Districts That �

Provide Program-specific Training for Teachers �

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure Proportion of schools or school districts that report providing tobacco-use prevention 

education training for school educators

Why this indicator CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction”

is useful state that curriculum implementation and overall program effectiveness are improved 

when teachers are trained to deliver the program as designed.1

Example data � ▲

▲

▲

▲

▲

▲

CDC School Health Profiles: Lead Health Education Teacher Questionnaire,

source(s) (Profiles), 2002

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

California Tobacco Use Prevention Education Evaluation: District Coordinator 

Survey, 2003

Information available at: http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/

Evaluation_Resources.htm

Health education teachers

Teachers

District coordinators

Population group(s)�

Example survey 

question(s)

From Profiles

During the past two years, did you receive staff development (such as workshops, 

conferences, continuing education, or any other kind of in-service training) on each 

of the following topics? [22 health topics (letters a–v) are listed; tobacco-use prevention 

is one topic] Mark yes or no for each topic.

Would you like to receive staff development on each of these [22] health education topics?

Mark yes or no for each topic.

From California Tobacco Use Prevention Education Evaluation: Teacher Survey 

During the past five years, how much tobacco use prevention training have you 

received? 

None

More than one full day of in-service training

One full-day of in-service training

Less than a full-day of in-service training 

I don’t remember 

During the past five years, were you trained to deliver a specific published tobaccouse prevention curriculum? 

Yes No I don’t remember

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

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GOAL AREA 1 

▲Outcome 7

Example survey �

question(s) (cont.)�

Overall, to what extent do you feel you are prepared to teach tobacco use prevention 

lessons? 

A great deal Somewhat Not too much Not at all Does not apply

From California Tobacco Use Prevention Education Evaluation: District Coordinator Survey 

During the 2002–2003 school year, how many tobacco-specific in-service trainings, �

workshops, or staff development sessions has your school district sponsored or �

attended? �

_____ Number of trainings, workshops, or staff development sessions. �

I do not know/I’m not sure

If your district did sponsor or attend tobacco-specific in-service trainings, workshops, �

or staff development sessions during the last school year (2002–2003), how many schools �

were represented? �

Number of schools represented: _______�

Comments This indicator can be used to measure progress toward achieving Recommendation 4 of 

CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.”1

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Reference

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

51
Indicator 1.7.5�

Proportion of Schools or School Districts That 

Involve Families in Support of School-based Programs

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure Proportion of schools or school districts that attempt to get students’ parents or families 

involved in school-based tobacco-use prevention or cessation programs

Why this indicator� CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction”

is useful� recognizes the important role that parents and families play in providing social and 

environmental support that will help young people remain tobacco-free. Families are 

part of the greater community to which schools should be connecting their programs.1,2

Example data � ▲

▲

▲�▲

CDC School Health Profiles: Lead Health Education Teacher Questionnaire

source(s)� (Profiles), 2002

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

Health education teachers

Teachers

Population group(s)�

Example survey From Profiles

question(s) During this school year, has this school done each of the following activities? 

Mark yes or no for each activity. Yes No

• �Provided families with information on the health education program 

• �Met with a parents’ organization such as the PTA or PTO to discuss

the health education program 

• �Invited family members to attend a health education class 

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 Extent That You Tried to �

Get Parents Involved

(Please mark a response for each)

Not Very Small Modest Great Very

at all�small extent extent extent great

extent extent

• 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)_________________________

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

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GOAL AREA 1 

▲Outcome 7

Comments� The example survey questions are limited to the perspective of educators. They cannot 

be used to assess parents’ actual involvement or desire to be involved in school-based 

tobacco control activities.

This indicator can be used to measure progress toward achieving Recommendation 5 

of CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and 

Addiction.”1

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

2. �Task Force on Community Preventive Services Meeting. February 25, 2004. Meeting minutes available at 

www.thecommunityguide.org. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

53
Indicator 1.7.6�

Proportion of Schools or School Districts That Support Cessation 

Interventions for Students and Staff Who Use Tobacco

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure� Proportion of schools or school districts that report providing tobacco cessation support 

(e.g., counseling for students and staff who use tobacco or referrals to tobacco-cessation 

programs)

Why this indicator CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction”

is useful recommends that schools support cessation for staff and students, either by providing 

referrals to cessation services or by sponsoring cessation programs.1,2

Example data CDC School Health Profiles: School Principal Questionnaire (Profiles), 2002

source(s)

Population group(s) School principals�

Example survey From Profiles

question(s) Does your school provide referrals to tobacco cessation programs for each of the 

following groups?

Group Yes No

• �Faculty and staff

• �Students

Comments A survey question could be added regarding (1) the cessation services at the school or 

(2) the type of cessation programs to which students and faculty are referred.

This indicator can be used to measure progress toward achieving Recommendation 6 of 

CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.”1

Rating Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

| | | | | | $$

better

References

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

2. �Milton MH, Maule CO, Yee SL, Backinger C, Malarcher AM, Husten CG. Youth tobacco cessation: a guide for making 

informed decisions. Atlanta, GA: Centers for Disease Control and Prevention; 2004.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

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GOAL AREA 1 

▲Outcome 7

Indicator 1.7.7

Proportion of Schools or School Districts That Assess 

Their Tobacco-use Prevention Program at Regular Intervals

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure Proportion of schools or school districts that report having an evaluation system in 

place and using it to assess their tobacco-use prevention program at regular intervals

Why this indicator CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction”

is useful recommend that schools assess their tobacco-use prevention programs at regular 

intervals.1

Example data No commonly used data sources were found

source(s)

Population group(s)� ▲

▲

School principals

Health education teachers

Example survey Does your school (or school district) assess your tobacco-use prevention program

question(s) at regular intervals?

Yes No Not sure

Comments� The authors created this example question. It does not come from any commonly used 

data source.

This indicator can be used to measure progress toward achieving Recommendation 7 of 

CDC’s “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.”1

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | † $$$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Reference

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

55
Indicator 1.7.8�

Proportion of Students Who Participate in Tobacco-use Prevention Activities �

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 7 Increased anti-tobacco policies and programs in schools

What to measure Proportion of students who report participating in at least one tobacco-use prevention 

activity in the past 12 months

Why this indicator An intervention with growing popularity is involving young people in anti-tobacco

is useful activities. These activities help reduce young people’s susceptibility to experimenting 

with tobacco by changing the social norm regarding tobacco use.1,2

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years�

Example survey From YTS

question(s) During the past 12 months, have you participated in any community activities to 

discourage people your age from using cigarettes, chewing tobacco, snuff, dip, or cigars?

Yes No, I did not know about any activities

Comments� Evaluators may choose to categorize data by grade level and type of school (elementary, 

middle, high school, private, parochial, public). 

Evaluators may want to assess young people’s awareness of anti-smoking activities at 

school and outside school. 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | |† $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �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. 

2. �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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

56
GOAL AREA 1 

▲Outcome 7

Indicator 1.7.9

Level of Reported Exposure to School-based Tobacco-use 

Prevention Curricula That Meet CDC Guidelines

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 7 Increased anti-tobacco policies and programs in schools

What to measure Proportion of students who report receiving tobacco prevention education in class�

Why this indicator Measuring students’ recall of tobacco education helps verify curriculum delivery

is useful and saliency.1

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004 �

California Independent Evaluation: Youth Survey, 2000�

Information available at: http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/�

Evaluation_Resources.htm�

Population group(s) Young people aged less than 18 years�

Example survey 

question(s)

From YTS

During this school year, did you practice ways to say NO to tobacco in any of your 

classes (for example, by role-playing)?

Yes No Not sure

During this school year, were you taught in any of your classes about the dangers 

of tobacco use?

Yes No Not sure

From California Independent Evaluation: Youth Survey 

During the last year (12 months), did you discuss the reasons why people 

your age smoke during any of your classes?

Yes No I don’t know/I’m not sure

During the last year (12 months), did you discuss how many people your age 

smoke during any of your classes? 

Yes No I don’t know/I’m not sure

Comments Evaluators may also choose to categorize data by grade level and type of school 

(elementary, middle, high school, private, parochial, public). 

Student perceptions of tobacco prevention education should also be evaluated; students 

who perceive the education as helpful are less susceptible to smoking than those who do 

not perceive it as useful.2

Rating Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

| | | | | | $$

better

References

1. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

2. �Huang TTK, 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. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

57
Indicator 1.7.10�

Perceived Compliance with Tobacco-free Policies in Schools �

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure Proportion of students who report that the school population is complying with the 

school’s tobacco-free policy

Why this indicator Perceived compliance with tobacco-free policies is one measure of actual compliance with

is useful these policies.1,2 If tobacco-free policies are not observed, they are not likely to be effective 

in changing social norms or inhibiting tobacco use among young people.

Example data �

source(s)�

▲

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004�

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003 �

California Independent Evaluation: Youth Survey, 2000�

Information available at: http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/�

Evaluation_Resources.htm�

Population group(s) Young people aged less than 18 years�

Example survey 

question(s)

From YTS and YRBSS 

During the past 30 days, on how many days did you smoke cigarettes 

on school property?

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 on school property?

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 California Independent Evaluation: Youth Survey 

Is there a rule at your school that no one is allowed to smoke cigarettes in the 

school building or on the school yard?

Yes No I don’t know/I’m not sure

Have you seen any students break that rule?

Yes No My school does not have a no-smoking rule 

I don’t know/I’m not sure

How many students who are smokers break that rule?

None A few Some Most All of them 

My school does not have a no-smoking rule I don’t know/I’m not sure

Have you seen adults break that rule?

Yes No My school does not have a no-smoking rule 

I don’t know/I’m not sure 

Is there a rule at your school that no one is allowed to use chewing tobacco or snuff 

in the school building or on the school yard?

Yes No I don’t know/I’m not sure

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

58
GOAL AREA 1 

▲Outcome 7

Comments� If students report on the YTS or YRBSS instruments (1) the existence of a tobacco-free 

school policy and (2) having personally used tobacco products more than 1 day on school 

property, they are considered noncompliant. 

Evaluators may categorize data by grade level and type of school (elementary, middle, 

high school, private, parochial, public). 

Evaluators should determine the scope of the tobacco-free policies before evaluating 

perceived compliance with them. 

The example survey questions could be asked of teachers and principals.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Denotes no data.

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;12:269–73.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

59
Indicator 1.7.11�

Proportion of Schools or School Districts with Policies 

That Regulate Display of Tobacco Industry Promotional Items

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 7 Increased anti-tobacco policies and programs in schools�

What to measure� Proportion of schools and school districts that have policies that regulate the display 

of tobacco advertising in the school, on school grounds, on school vehicles, or in 

school publications. This policy should cover apparel and other merchandise showing 

tobacco logos.

Why this indicator Studies have consistently associated possession of or willingness to use tobacco industry

is useful promotional items with increased smoking among youth.1,2 Restrictions on the display of 

these promotional items at school contribute to an anti-tobacco social norm. 

Example data CDC School Health Profiles: School Principal Questionnaire (Profiles), 2002

source(s)

Population group(s) School principals�

Example survey From Profiles

question(s) Is tobacco advertising prohibited in each of the following locations?

Location Yes No

• In the school building 

• On the school grounds, including on the outside of

the building, on playing fields, or other areas of the campus 

• On school buses or other vehicles used to transport students 

• In school publications 

Is tobacco advertising through sponsorship of school events prohibited? 

Are students at your school prohibited from wearing tobacco brand-name

apparel or carrying merchandise with tobacco company names, logos, or 

cartoon characters on it? 

Does your school post signs marking a tobacco-free school zone (that is, a

specified distance from school grounds where tobacco use by students, 

faculty and staff, and visitors is not allowed?) 

Comments Evaluators may also choose to categorize data by grade level and type of school 

(elementary, middle, high school, private, parochial, public). 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

References

1. �Sargent JD, Dalton MA, Beach M, Bernhardt A, Pullin D, Stevens M. Cigarette promotional items in public schools.

Archives of Pediatrics & Adolescent Medicine. 1997;151(12):1189–96.

2. �Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. 

Morbidity and Mortality Weekly Report Recommendations and Reports. 1994;43(RR-2):1–18.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

60
GOAL AREA 1 

Outcome 8

Outcome 8

▲

Increased Restriction and Enforcement of Restrictions 

on Tobacco Sales to Minors

Activities to decrease young people’s access to tobacco products are recognized 

components of a comprehensive approach to reducing the number of young people 

who start smoking. Efforts to reduce young people’s access to tobacco products 

are based on the rationale that making it more difficult for young people to obtain 

tobacco products will discourage them from beginning or continuing to use tobacco 

and thus reduce the prevalence of tobacco use. One strategy is to attempt to reduce 

retail tobacco sales to minors through activities such as (1) passing laws that restrict 

young people’s access to tobacco (including laws barring the sale of tobacco products 

to minors, bans on self-service displays of tobacco products, and bans or restrictions 

on tobacco vending machines), (2) educating merchants about these laws, (3) enforcing compliance with these laws, (4) educating the community and the media about 

the value of these laws, and (5) mobilizing the community to support these laws. 

Experience shows that adoption and sustained enforcement of strong laws are 

prerequisites for reducing young people’s access to tobacco. Although this approach 

is necessary for success, it is not sufficient. Compliance checks show that laws against 

selling tobacco products to young people, when accompanied by retailer education 

and enforcement, can reduce the proportion of retailers who are willing to sell these 

products to minors. But, these reductions do not automatically translate into reductions in young people’s self-reported or perceived access to tobacco products, or into 

reductions in their tobacco use—the ultimate goal of youth access interventions.1

Some studies suggest that even if only a few retail outlets in a community sell tobacco 

to minors, young people who use tobacco are likely to know of these outlets and to 

frequent them.2

According to the Guide to Community Preventive Services, the most effective approach 

to preventing young people 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—most importantly—community mobilization to generate community 

support for efforts to reduce youth access to tobacco products.3 As with other aspects 

of tobacco control, community mobilization may play a particularly important role 

because of its ability to change social norms—in this case, norms regarding the social 

acceptability of selling or otherwise providing tobacco products to minors. The Guide

to Community Preventive Services indicates that none of the interventions listed above 

have been shown to be effective when implemented in isolation, in particular when 

implemented without a strong link to community mobilization initiatives.3

Moreover, even if illegal sales to minors were eliminated completely, young people 

could still acquire tobacco products through other, noncommercial or social sources, 

including shoplifting, stealing from parents and other relatives, borrowing from 

friends and relatives, and asking older friends or strangers to buy tobacco products 

for them. In fact, younger children (who have less success than older children in 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

61
▲

▲

▲

▲

▲

▲

▲

purchasing tobacco products at retail outlets) often rely on these alternative sources 

to obtain tobacco products. Thus, even interventions that are successful in reducing 

young people’s self-reported or perceived access to tobacco products through commercial sources will not necessarily reduce their overall access to or use of these 

products. Accordingly, as rates of retail sales to minors decline, interventions to 

address these other sources of access will become increasingly important. 

Listed below are the indicators associated with this outcome:

1.8.1� Proportion of jurisdictions with policies that ban tobacco vending �

machine sales in places accessible to young people�

1.8.2� Proportion of jurisdictions with policies that require retail licenses �

to sell tobacco products�

1.8.3� Proportion of jurisdictions with policies that control the location, �

number, and density of retail outlets�

1.8.4� Proportion of jurisdictions with policies that control self-service �

tobacco sales�

1.8.5� Number of compliance checks conducted by enforcement agencies

1.8.6� Number of warnings, citations, and fines issued for infractions of �

public policies against young people’s access to tobacco products�

1.8.7� Changes in state tobacco control laws that preempt stronger local �

tobacco control laws�

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;337:1044–51.

2. �DiFranza JR, Coleman M. Source of tobacco for youths in communities with 

strong enforcement of youth access laws. Tobacco Control. 2001;10(4):323–8.

3. �Fielding JE, Briss PA, Carande-Kulis VG, Hopkins DP, Husten CG, Pechacek TF, 

et al. Tobacco. In: Briss PA, Zaza S, Harris KW, editors. The guide to community 

preventive services. New York: Oxford University Press; in press 2005.

For Further Reading

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.

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. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

62
GOAL AREA 1 

Outcome 8 ▲

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.

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.

Jackson C, Dickinson D. Can parents who smoke socialise their children against 

smoking? Results from the Smoke-Free Kids intervention trial. Tobacco Control. 

2003;12(1):52–9.

Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, 

and smoking onset among children. Addictive Behaviors. 1997;22(1):107–14.

Lantz PM, Jacobson PD, Warner KE, Wasserman J, Pollack HA, Berson J, Ahlstrom A. 

Investing in youth tobacco control: a review of smoking prevention and control 

strategies. Tobacco Control. 2000;9(1):47–63.

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.

Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. Journal of Health Economics. 2000;19(6):1117–37.

Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents 

from becoming established smokers? Pediatrics. 2001;108(6):1256–62.

Schooler C, Feighery E, Flora JA. Seventh graders’ self-reported exposure to cigarette 

marketing and its relationship to their smoking behavior. American Journal of Public 

Health. 1996;86(9):1216–21.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

63
Outcome 8�

Increased Restriction and Enforcement of Indicator Rating Restrictions on Tobacco Sales to Minors better

Number Indicator Overall quality Stren

evaluatio

Resources

Face v

needed

low high n evidence

gth of

Utility

alidity

practice

Accepted

1.8.1 Proportion of jurisdictions with policies that ban 

tobacco vending machine sales in places accessible | | | | | | $$$ †

to young people

1.8.2 Proportion of jurisdictions with policies that require 

retail licenses to sell tobacco products | | | | | | $$$

1.8.3 Proportion of jurisdictions with policies that control the 

location, number, and density of retail outlets | | | | | | $$$ * *

1.8.4 Proportion of jurisdictions with policies that control 

self-service tobacco sales | | | | | | $$$

1.8.5 Number of compliance checks conducted by 

enforcement agencies | | | | | |† $$$

1.8.6 Number of warnings, citations, and fines issued for 

infractions of public policies against young people’s 

access to tobacco products

| | | | | |† $$$

1.8.7 Changes in state tobacco control laws that preempt 

stronger local tobacco control laws | | | | | |† $

* �Denotes low reviewer response: that is, greater than 75% of the experts either did not rate the indicator, or gave the 

criterion an invalid rating (see Appendix B for an explanation).

†�Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this indicator were within one 

point of each other (see Appendix B for an explanation).

Denotes no data.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

64
GOAL AREA 1 

▲Outcome 8

Indicator 1.8.1

Proportion of Jurisdictions with Policies That Ban Tobacco 

Vending Machine Sales in Places Accessible to Young People

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors�

What to measure Proportion of local jurisdictions that have enforceable policies banning tobacco �

vending machine sales in locations accessible to minors�

Why this indicator� Accessible vending machines provide virtually unrestricted access to tobacco and can be

is useful� used by even the youngest children. As of 2004, 46 states and the District of Columbia 

restricted minors’ access to tobacco through vending machines, and 30 states and the 

District of Columbia banned vending machines in locations that are accessible to young 

people.1

Example data �

source(s)�

▲

▲

▲

Policy tracking system�

Americans for Nonsmokers’ Rights (ANR)�

Information on ANR available at: http://www.no-smoke.org�

American Lung Association’s State Legislated Actions on Tobacco Issues (SLATI) �

Information on SLATI available at: http://slati.lungusa.org�

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey Not applicable

question(s)

Comments� Evaluators may want to assess the levels of restrictions on tobacco vending machines 

(e.g., restrictions on placement of vending machines).

Evaluators may also choose to gather data on the size and demographics of the 

population affected by the relevant laws or ordinances. 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | † $$$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Reference

1. �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 from: http://www.cdc.gov/tobacco/statesystem. 

Accessed February 2005. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

65
Indicator 1.8.2�

Proportion of Jurisdictions with Policies That 

Require Retail Licenses to Sell Tobacco Products

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors�

What to measure Proportion of local jurisdictions that have public policies requiring retailers to have 

a license in order to sell tobacco products

Why this indicator

is useful

Licensing laws that include graduated penalties for illegal sales and provisions for 

suspension or revocation for repeated violations may be an incentive for merchants to 

obey the law.1

 Requiring licenses allows evaluators to develop a comprehensive list of 

tobacco merchants that can be used to conduct compliance checks. In addition, licensing 

fees can be used to support the cost of compliance checks. As of 2004, 39 states and the 

District of Columbia required tobacco retailers to obtain a license for over-the-counter 

tobacco sales and 27 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 on ANR 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 Not applicable

question(s)

Comments Evaluators may also choose to gather data on the size and demographics of the �

population affected by the relevant laws or ordinances. �

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$

better

References

1. �Forster JL, Wolfson M. Youth access to tobacco: policies and politics. Annual Review of Public Health. 1998;19:203–35. 

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 from: http://www.cdc.gov/tobacco/statesystem. 

Accessed February 2005. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

66
GOAL AREA 1 

▲Outcome 8

Indicator 1.8.3

Proportion of Jurisdictions with Policies That Control 

the Location, Number, and Density of Retail Outlets

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors�

What to measure Proportion of local jurisdictions that have public policies controlling the location, 

number, and density of tobacco retail outlets

Why this indicator� Limiting the number of retail tobacco outlets decreases the availability of tobacco

is useful� products and the number of pro-tobacco messages in a community. It also means that 

fewer stores need to be monitored for compliance with laws that prohibit young people’s 

access to tobacco.1,2

Example data �

source(s)�

▲

▲

Policy tracking system�

Americans for Nonsmokers’ Rights (ANR) �

Information on ANR 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 Not applicable

question(s)

Comments Evaluators may also choose to gather data on the size and demographics of the 

population affected by the relevant laws or ordinances.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | |� * * $$$

better

* Denotes low reviewer response: that is, greater than 75% of the experts either did not rate 

the indicator, or gave the criterion an invalid rating (see Appendix B for an explanation).

References

1. �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.

2. �Hyland A, Travers MJ, Cummings KM, Bauer J, Alford T, Wieczorek WF. Demographics and tobacco outlet density. 

[Letter]. American Journal of Public Health. 2003;93(11):1794. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

67
Indicator 1.8.4�

Proportion of Jurisdictions with Policies That Control Self-service Tobacco Sales�

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors�

What to measure� Proportion of local jurisdictions that have public policies controlling self-service 

tobacco sales (i.e., sales that allow customers to handle tobacco products before 

purchasing them)

Why this indicator� Self-service displays contribute to the visibility of tobacco and pro-tobacco messages

is useful� in stores; they also make shoplifting tobacco products easier for minors. Illegal sales 

are more common when young people can access tobacco products directly through 

self-service displays rather than having to ask clerks for assistance.1,2

Example data �

source(s)�

▲

▲

Policy tracking system�

Americans for Nonsmokers’ Rights (ANR)�

Information on ANR 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 Not applicable

question(s)

Comments Evaluators may also choose to gather data on the size and demographics of the �

population affected by the relevant laws or ordinances. �

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$

better

References

1. �Lee RE, Feighery EC, Schleicher NC, Halvorson S. The relation between community bans of self-service tobacco displays 

and store environment and between tobacco accessibility and merchant incentives. American Journal of Public Health.

2001;91(12):2019–21.

2. �Teall AM, Graham MC. Youth access to tobacco in two communities. Journal of Nursing Scholarship. 2001;33(2):175–8.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

68
GOAL AREA 1 

▲Outcome 8

Indicator 1.8.5

Number of Compliance Checks Conducted by Enforcement Agencies

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors

What to measure� The number of checks conducted by enforcement agencies (e.g., police, health department inspectors, or building inspectors) to assess the level of retailer compliance with 

laws, regulations, or ordinances related to the sale of tobacco to minors

Why this indicator� An effective means of enforcing tobacco-free public policies is to conduct regular compliis useful� ance checks, which reduce illegal sales.1

 Compliance checks are also a method of assessing rates of compliance with laws regulating tobacco sales to minors. Such checks convey 

the message that policy makers and the public care about tobacco-free policies and are 

serious about enforcing them.2,3

Example data �

source(s)�

▲

▲

Enforcement Agency Survey�

California Independent Evaluation: Policy Enforcement Survey: Youth Access 

to Tobacco, 2000

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 From California Independent Evaluation: Policy Enforcement Survey: Youth Access to Tobacco

question(s) During the past 12 months, how many sting operations did your agency conduct 

to enforce PC §308(a) (illegal tobacco sales by merchants)?

Comments Survey respondents may not have access to all requested information.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $$$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

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. �Kiser D, Boschert T. Eliminating smoking in bars, restaurants, and gaming clubs in California: BREATH, the 

California smoke-free bar program. Journal of Public Health Policy. 2001;22(i):81–7.

3. �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;12:269–73.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

69
Indicator 1.8.6�

Number of Warnings, Citations, and Fines Issued for Infractions 

of Public Policies Against Young People’s Access to Tobacco Products

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors�

What to measure The number of warnings, citations, and fines issued to retailers for infractions of public 

policies against young people’s access to tobacco

Why this indicator Studies show that aggressive enforcement of laws regulating tobacco sales to young

is useful people results in significantly reduced sales to minors and may also result in reduced 

smoking prevalence among teenagers.1-3

Example data �

source(s)�

▲

▲

Enforcement Agency Survey�

California Independent Evaluation: Policy Enforcement Survey: Youth Access to 

Tobacco, 2000

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 California Independent Evaluation: Policy Enforcement Survey: Youth Access to Tobacco

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 

Comments� Evaluators may want to assess the effects that different penalties (e.g., graduated fines, 

loss of license to sell tobacco) have on illegal tobacco sale to minors.

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� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $$$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

70
GOAL AREA 1 

▲Outcome 8

Indicator 1.8.7

Changes in State Tobacco Control Laws That �

Preempt Stronger Local Tobacco Control Laws�

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 8 Increased restriction and enforcement of restrictions on tobacco sales to minors�

What to measure� Any change in legislation that prevents local jurisdictions from enacting restrictions 

that are more stringent than the state’s restrictions on minors’ access to tobacco or 

tobacco-related marketing

Why this indicator

is useful

Preemptive legislation is the tobacco industry’s chief strategy for eradicating local 

tobacco control ordinances.1

 Because of the striking increase in the number of local 

tobacco control ordinances from the mid-1980s to the mid-1990s, the tobacco industry 

aggressively pushed for states to pass legislation that preempted local regulation of 

tobacco in various areas, including minors’ access, smoke-free indoor air, and marketing.2

As of September 1998, 21 states preempted at least one provision of local minors’ access 

restrictions.3 As of December 31, 2004, only two states, Maine and Delaware, have successfully repealed preemption laws in their entirety in any area of tobacco control policy. 

Preemptive laws prevent communities from engaging in the process of public education, 

mobilization, and debate that occurs when a local ordinance is under consideration, 

a process that can increase awareness and change social norms. They also pose a barrier to local enforcement, because communities and local enforcement agencies may be 

less likely to enforce state laws that they were not directly involved in adopting than to 

enforce local ordinances.2

Example data CDC State Tobacco Activities Tracking and Evaluation (STATE) system

source(s) Data 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 Not applicable

question(s)

Comments None

Rating Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

† | | | | | | $

better

† �Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Denotes no data.

References

1. �National Cancer Institute. Smoking and Tobacco Control Monograph No. 11. State and local legislative action to reduce tobacco 

use. Bethesda, MD: National Cancer Institute; 2000. NIH Publication No. 00-4804.

2. �Centers for Disease Control and Prevention. Preemptive state tobacco-control laws—United States, 1982–1998. Morbidity 

and Mortality Weekly Report. 1999;47(51 & 52):1112–4.

3. �Centers for Disease Control and Prevention. State laws on tobacco control—United States, 1998. Morbidity and Mortality 

Weekly Report CDC Surveillance Summaries. 1999;48(SS-3):21–40.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

71
Outcome 9�

Reduced Tobacco Industry Influences

use.

According to the most recent Federal Trade Commission tobacco report, the U.S. 

tobacco industry spent almost $12.5 billion in 2002 to advertise and promote its 

products.1

 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.2

Moreover, researchers have found that receptivity to tobacco industry marketing 

is associated with susceptibility towards tobacco use, that teenagers are three 

times more sensitive to cigarette advertising than adults, and that young people 

who approve of tobacco advertising and identify with the images portrayed in the 

advertisements are more likely than non-approving young people to start smoking.2–8

In addition, tobacco advertising can distort young people’s perceptions of tobacco 

2, 6–8 An indirect result of heavy tobacco industry advertising is the dampening 

effect it has on the number and quality of media stories about the health risks of 

smoking.2

 By promoting smoking, the tobacco industry undermines the ability of 

parents to prevent adolescents from starting to smoke.9

Many of the tobacco industry’s advertising expenditures are in retail stores.1

Retail stores are saturated with pro-tobacco signage, branded objects, and tobacco 

displays. Many of these objects are clustered around the cash registers, making it 

virtually impossible for anyone, including children, not to be exposed to pro-tobacco 

messages. 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 tobacco industry also spends considerable resources to sponsor or support 

public events, the arts, and other worthy causes.1

 It is clear that the tobacco industry 

influences policy makers through contributions and lobbying, which results in a more 

favorable, pro-tobacco policy environment.11

Listed below are the indicators associated with this outcome:

1.9.1 ▲Extent and type of retail tobacco advertising and promotions

1.9.2 ▲Proportion of jurisdictions with policies that regulate the extent and 

type of retail tobacco advertising and promotions

1.9.3 ▲Extent of tobacco advertising outside of stores

1.9.4 ▲Proportion of jurisdictions with policies that regulate the extent of 

tobacco advertising outside of stores

1.9.5 ▲Extent of tobacco industry sponsorship of public and private events

1.9.6 ▲Proportion of jurisdictions with policies that regulate tobacco industry 

sponsorship of public events

1.9.7 ▲Extent of tobacco advertising on school property, at school events, and 

near schools

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

72
GOAL AREA 1 

Outcome 9 ▲

▲

▲

▲

▲

▲

1.9.8� Extent of tobacco advertising in print media

1.9.9� Amount and quality of news media stories about tobacco industry 

practices and political lobbying

1.9.10� Number and type of Master Settlement Agreement violations by 

tobacco companies

1.9.11� Extent of tobacco industry contributions to institutions and groups

1.9.12� Amount of tobacco industry campaign contributions to local and 

state politicians

References

1. �Federal Trade Commission. Cigarette report for 2002. Washington, DC: Federal 

Trade Commission; 2004.

2. �U.S. Department of Health and Human Services. Preventing tobacco use among 

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

3. �Pollay RW, Siddarth S, Siegel M, Haddix A, Merritt RK, Giovino GA, et al. The 

last straw? Cigarette advertising and realized market shares among youths and 

adults. Journal of Marketing. 1996;60(2):1–16.

4. �Schooler C, Feighery E, Flora JA. Seventh graders’ self-reported exposure to 

cigarette marketing and its relationship to their smoking behavior. American 

Journal of Public Health. 1996;86(9):1216–21.

5. �Feighery E, Borzekowski DL, Schooler C, Flora J. Seeing, wanting, owning: the 

relationship between receptivity to tobacco marketing and smoking susceptibility 

in young people. Tobacco Control. 1998;7(2):123–128.

6. �Borzekowski DL, Flora JA, Feighery E, Schooler C. The perceived influence of 

cigarette advertisements and smoking susceptibility among seventh graders. 

Journal of Health Communication. 1999;4(2):105–118.

7. �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.

8. �Henriksen L, Flora JA, Feighery E, Fortmann SP. Effects on youth of exposure to 

retail tobacco advertising. Journal of Applied Social Psychology. 2002;32(9):1771–89.

9. �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.

10. Dewhirst T. POP goes the power wall? Taking aim at tobacco promotional strategies utilised at retail. Tobacco Control. 2004;13(2):209–10.

11. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing 

state legislative behavior? American Journal of Public Health. 1998;88(6):918–23.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

73
For Further Reading

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.

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.

Forster JL, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The 

effects of community policies to reduce youth access to tobacco. American Journal of 

Public Health. 1998;88(8):1193–8. 

Guthrie B. Tobacco advertising near schools. British Medical Journal. 1994 May 

7;308(6929):658.

Lewit EM, Hyland A, Kerrebrock N, Cummings KM. Price, public policy, and smoking in young people. Tobacco Control. 1997;6(Suppl 2):S17–24.

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.

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):i102–9.

Pucci L, Siegel M. Exposure to brand-specific cigarette advertising in magazines 

and its impact on youth smoking. Preventive Medicine. 1999;29(5):313–20.

Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. Journal of Health Economics. 2000;19(6):1117–37.

Siegel M, Biener L, Rigotti NA. The effect of local tobacco sales laws on adolescent 

smoking initiation. Preventive Medicine. 1999;29(5):334–42.

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.

Vaidya SG, Vaidya JS, Naik UD. Sports sponsorship by cigarette companies influences 

the adolescent children’s mind and helps initiate smoking: results of a national study 

in India. Journal of the Indian Medical Association. 1999;97(9):354–6, 359.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

74
GOAL AREA 1 

▲Outcome 9

Outcome 9

Reduced Tobacco Industry Influences� Indicator Rating

better

Number Indicator Overall quality Stren

evaluatio

Resources

Face v

needed

low high n evidence

gth of

Utility

alidity

practice

Accepted

1.9.1 Extent and type of retail tobacco advertising and 

promotions | | | | | | $$$$◊

1.9.2 Proportion of jurisdictions with policies that regulate 

the extent and type of retail tobacco advertising and 

promotions

| | | | | | $$$

1.9.3 Extent of tobacco advertising outside of stores | | | | | | $$$$◊

1.9.4 Proportion of jurisdictions with policies that regulate 

the extent of tobacco advertising outside of stores | | | | | | $$$†

1.9.5 Extent of tobacco industry sponsorship of public and 

private events | | | | | | $$$$◊

1.9.6 Proportion of jurisdictions with policies that regulate 

tobacco industry sponsorship of public events | | | | | | $$$†

1.9.7 Extent of tobacco advertising on school property, at 

school events, and near schools | | | | | | $$$

1.9.8 Extent of tobacco advertising in print media | | | | | | $$$

1.9.9 Amount and quality of news media stories about tobacco 

industry practices and political lobbying | | | | | | $$$

1.9.10 Number and type of Master Settlement Agreement 

violations by tobacco companies | | | | | |† $$$$◊

1.9.11 Extent of tobacco industry contributions to institutions 

and groups | | | | | | $

◊ †

1.9.12 Amount of tobacco industry campaign contributions 

to local and state politicians | | | | | |† $

◊

†�Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this indicator were within one 

point of each other (see Appendix B for an explanation).

◊�Denotes that the experts’ rating was modified (see Appendix B for an explanation).

Denotes no data.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

75
Indicator 1.9.1�

Extent and Type of Retail Tobacco Advertising and Promotions�

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 9 Reduced tobacco industry influences

What to measure� The level and type of tobacco advertising and promotion in and around retail stores and 

the extent of indoor and outdoor advertisements including promotions, price reductions, 

and strategic product placement

Why this indicator

is useful

Retail stores have become the industry’s primary communication channel to smokers 

and potential smokers. As a result, all shoppers, regardless of age or smoking status, are 

exposed to pro-tobacco messages.1,2 Some studies show that young people who approve 

of tobacco advertising and identify with the image portrayed in the advertisements are 

more likely to start smoking.3,4 Moreover, frequent (at least weekly) exposure to retail 

tobacco marketing among middle-school students is associated with a 50% increase in 

the odds of their ever smoking a cigarette, even after controlling for other known risk 

factors (e.g., parent smokes or friend smokes).5

Example data �

source(s)�

▲

▲

Environmental scan of tobacco advertising and promotional practices 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

Population group(s) Not applicable. This indicator is best measured by observation.

Example survey Not applicable

question(s)

Comments Note that in Lorillard v. Reilly (533 U.S. 525 [2001]), the U.S. Supreme Court held that 

most regulations regarding cigarette advertising are preempted by the Federal Cigarette 

Labeling and Advertising Act, which makes it difficult for states and localities to regulate 

the extent and amount of retail tobacco advertising and promotion. 

Evaluators may choose to gather and report their findings by type of retailer 

(e.g., grocery store, convenience store, or gas station).

States can track the price of tobacco products independently by collecting scanner 

data (obtained from scanning product bar codes), which provide information on brand 

and promotions. However, the cost of this type of data collection can be prohibitive.

Rating Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

| | | | | | $$$$◊

better

◊ Denotes that the experts’ rating was modified (see Appendix B for an explanation).

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

76
GOAL AREA 1 

▲Outcome 9

References

1. �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.

2. �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.

3. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

4. �Schooler C, Feighery E, Flora JA. Seventh graders’ self-reported exposure to cigarette marketing and its relationship 

to their smoking behavior. American Journal of Public Health. 1996;86(9):1216–21.

5. �Henriksen L, Feighery EC, Wang Y, Fortmann SP. Association of retail tobacco marketing with adolescent smoking. 

American Journal of Public Health. 2004;94(12):2081–3.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

77
Indicator 1.9.2�

Proportion of Jurisdictions with Policies That Regulate the 

Extent and Type of Retail Tobacco Advertising and Promotions

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 9 Reduced tobacco industry influences

What to measure The proportion of local jurisdictions that have public policies that in some way regulate 

retail advertising and promotion of tobacco

Why this indicator� The tobacco industry is increasingly shifting its advertising focus to retailer incentives

is useful� including offering financial and trade benefits to retailers that sell and display tobacco 

products. Regulating retail advertising and promotions may significantly reduce young 

people’s exposure to tobacco advertising.1

Example data Policy tracking system

source(s)

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey Not applicable

question(s)

Comments� Note that in Lorillard v. Reilly (533 U.S. 525 [2001]), the U.S. Supreme Court held that 

most regulations regarding cigarette advertising are preempted by the Federal Cigarette 

Labeling and Advertising Act, which makes it difficult for states and localities to regulate 

the extent and amount of retail tobacco advertising and promotion. 

Evaluators may also choose to gather data on the size and demographics of the 

population affected by the relevant laws or ordinances.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$

better

Reference

1. �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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

78
GOAL AREA 1 

▲Outcome 9

Indicator 1.9.3

Extent of Tobacco Advertising Outside of Stores

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure The level and type of tobacco advertising on the exteriors of retail stores

Why this indicator� Tobacco advertisements appear frequently outside U.S. stores. They can be on stores’

is useful� outside walls and windows, in parking lots, or on the street.1

 The strategies for reducing 

tobacco advertising on the exteriors of retail establishments are often different from the 

strategies for reducing advertising and promotions inside stores.2

Example data �

source(s)�

▲

▲

Environmental scan of tobacco advertising and promotional practices 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

Population group(s) Not applicable. This indicator is best measured by observation.

Example survey 

question(s)

Not applicable

Comments None

Rating Overall quality

low high

Resources 

needed

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

| | | | | | $$$$◊

better

◊ Denotes that the experts’ rating was modified (see Appendix B for an explanation).

References

1. �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.

2. �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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

79
Indicator 1.9.4�

Proportion of Jurisdictions with Policies That Regulate 

the Extent of Tobacco Advertising Outside of Stores

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 9 Reduced tobacco industry influences

What to measure� The proportion of local jurisdictions that have public policies that in some way regulate 

tobacco advertising on the exteriors of retail outlets (for example, some jurisdictions limit 

the percentage of store windows that may be covered with advertisements)1

Why this indicator Reducing exterior tobacco-related retail signs and displays will reduce young people’s

is useful exposure to tobacco advertising.2

Example data Policy tracking system

source(s)

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey Not applicable

question(s)

Comments� Note that in Lorillard v. Reilly (533 U.S. 525 [2001]), the U.S. Supreme Court held that 

most regulations regarding cigarette advertising are preempted by the Federal Cigarette 

Labeling and Advertising Act, which makes it difficult for states and localities to regulate 

the extent and amount of retail tobacco advertising and promotion. 

Evaluators may also choose to gather data on the size and demographics of the 

population affected by the relevant laws or ordinances. 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | † $$$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �Rogers T, Feighery EC, Tencati EM, Butler JL, Weiner L. Community mobilizations to reduce point-of-purchase 

advertising of tobacco products. Health Economics Quarterly. 1995;22(4);427–42.

2. �Jason LA, Pokorny SB, Mikulski K, Schoeny ME. Assessing storefront tobacco advertising after the billboard ban. 

Evaluation and the Health Professions. 2004;27(1):22–33. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

80
GOAL AREA 1 

▲Outcome 9

Indicator 1.9.5

Extent of Tobacco Industry Sponsorship of Public and Private Events

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure The extent of tobacco industry sponsorship of public and private events (e.g., sports, 

recreation, music, family, or work-related events)

Why this indicator The tobacco industry spends considerable resources sponsoring visible public events.1

is useful This sponsorship increases exposure to advertisements for tobacco product advertising 

and buys legitimacy for the tobacco industry.1,2

Example data �

source(s)�

▲

▲

Event sponsorship tracking system�

California Tobacco Industry Monitoring Evaluation: Project SMART Money 

Information available at: http://www.ttac.org/enews/mailer09-30-03full.html#LinkF

Population group(s) Not applicable. This indicator is best measured by observation.�

Example survey Not applicable

question(s)

Comments Evaluators may want to assess the types of events that are being sponsored and the 

numbers of attendees.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$$◊

better

◊ Denotes that the experts’ rating was modified (see Appendix B for an explanation).

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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

81
Indicator 1.9.6�

Proportion of Jurisdictions with Policies That Regulate 

Tobacco Industry Sponsorship of Public Events

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 9 Reduced tobacco industry influences

What to measure The proportion of local jurisdictions with public policies that regulate tobacco industry 

sponsorship of public events

Why this indicator The tobacco industry spends considerable resources to sponsor highly publicized events.1

is useful This sponsorship increases exposure to tobacco-product advertising and buys legitimacy 

for the tobacco industry.1,2

Example data Policy tracking system

source(s)

Population group(s) Not applicable. This indicator is best measured by tracking and monitoring pertinent 

local tobacco laws, ordinances, or regulations.

Example survey Not applicable

question(s)

Comments Evaluators may also choose to gather data on the size and demographics of the �

population affected by the relevant laws or ordinances. �

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | † $$$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

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. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

82
GOAL AREA 1 

▲Outcome 9

Indicator 1.9.7

Extent of Tobacco Advertising on School Property,

at School Events, and Near Schools

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 9 Reduced tobacco industry influences

What to measure The extent of tobacco advertising on school property, at school events off campus, and 

within a designated distance from schools

Why this indicator

is useful

Findings from a California study of retail tobacco advertising showed that stores near 

schools (within 1,000 feet) had significantly more tobacco advertising and promotional 

materials overall and more advertising on their exteriors than stores not near schools.1

Stores near schools also had a significantly higher probability of having tobacco advertising or promotions near candy and low to the ground (at the eye level of children) than 

stores not near schools.1

Example data �

source(s)�

▲

▲

▲

CDC School Health Profiles: School Principal Questionnaire (Profiles), 2002

Environmental scan of tobacco advertising and promotional practices 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

Population group(s) School principals

Example survey From Profiles

question(s) Is tobacco advertising prohibited in each of the following locations? 

(Mark yes or no for each location.) Yes

• In the school building

• On school grounds, including on the outside of the building,

on playing fields, or other areas of the campus 

• On school buses or other vehicles used to transport students

• In school publications (e.g., newsletters, newspapers, websites,

in other school publications)

No

Is tobacco advertising through sponsorship of school events prohibited?

Yes No

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$

better

Reference

1. �Roeseler A, Rogers T, Feighery E, Gehrman J. Operation storefront: youth against tobacco advertising and promotion.

Sacramento, CA: California Department of Health Services; 2003. pp. 1–4.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

83
Indicator 1.9.8�

Extent of Tobacco Advertising in Print Media

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure The extent of tobacco advertisement in print media (e.g., magazines or newspapers)�

Why this indicator� The Master Settlement Agreement (MSA) regulated aspects of tobacco advertising in

is useful� print media. However, one study found that after the MSA, the combined advertising 

expenditures of the four major tobacco companies increased in 19 magazines that have 

a youth focus.1 Another study found that 54% of teenagers’ favorite magazines had 

cigarette advertisements.2

Example data �

source(s)�

▲

▲

Media Tracking Service (e.g., clipping service)�

TNS Media Intelligence Competitive Media Reporting (CMR)�

Information available at: http://www.tnsmi-cmr.com/products/index.html�

Population group(s) Not applicable. This indicator is best measured by tracking tobacco advertisements 

in print media.

Example survey Not applicable

question(s)

Comments� Evaluators may want to assess tobacco advertising by type of print media (e.g., 

magazines targeted to adults or magazines targeted to adolescents). 

Quantitative studies involve counting articles, measuring column-inches, or noting 

article placement. Qualitative studies require detailed content analyses to detect article 

themes.3,4

More information on how to collect data on this indicator is in reference 5 below.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$

better

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. �Schooler C, Feighery E, Flora JA. Seventh graders’ self-reported exposure to cigarette marketing and its relationship to 

their smoking behavior. American Journal of Public Health. 1996;86(9):1216–21. 

3. �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. 

4. �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. 

5. �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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

84
GOAL AREA 1 

▲Outcome 9

Indicator 1.9.9

Amount and Quality of News Media Stories About �

Tobacco Industry Practices and Political Lobbying�

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure Media coverage of tobacco industry practices and political lobbying

Why this indicator� Demonstrating the negative aspects of tobacco industry practices may influence young

is useful� people’s behavior.1–3 For example, being aware that the tobacco industry is trying to 

manipulate behavior may reduce young people’s susceptibility to tobacco marketing 

and increase overall support for anti-tobacco policies, laws, or regulations.4

Example data Media Tracking Service (e.g., clipping service)

source(s)

Population group(s) Not applicable. This indicator is best measured by monitoring and tracking pertinent 

media coverage of tobacco industry practices. 

Example survey Not applicable

question(s)

Comments� Quantitative studies involve counting articles, measuring column-inches, or noting 

article placement. Qualitative studies require detailed content analyses to detect article 

themes.2,3

More information on how to collect data on this indicator is in reference 5 below.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$$

better

Denotes no data.

References

1. �Caburnay CA, Kreuter MW, Luke DA, Logan RA, Jacobsen HA, Reddy VC, Vempaty AR, Zayed HR. The news on health 

behavior: coverage of diet, activity, and tobacco in local newspapers. Health Education & Behavior. 2003;30(6):709–722.

2. �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. 

3. �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. 

4. �Hicks JJ. Crispin, Porter & Bogusky. The strategy behind Florida’s truth campaign. Miami, FL: Truth Campaign; 2001. 

Online publication. Available from: http://www.tobaccofreedom.org/msa/articles/truth_review.html.

5. �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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

85
Indicator 1.9.10�

Number and Type of Master Settlement Agreement Violations by Tobacco Companies

Goal area 1� Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure The number and type of Master Settlement Agreement (MSA) violations 

by tobacco companies

Why this indicator� In 2000, all of the major tobacco manufacturers failed to comply with the MSA, which

is useful� bans the tobacco companies from targeting young people through magazine advertisements. The companies are selectively increasing their magazine advertisements targeted 

to young people.1

 Tracking these and other violations of the MSA will aid in the MSA’s 

enforcement.2,3

Example data �

source(s)�

▲

▲

Tobacco industry monitoring system�

California Tobacco Industry Monitoring Evaluation: Project SMART Money 

Information available at: http://www.ttac.org/enews/mailer09-30-03full.html#LinkF

Population group(s) Not applicable. This indicator is best measured by monitoring and tracking tobacco 

industry practices.

Example survey Not applicable

question(s)

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $$$$◊

better

† �Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

◊� Denotes that the experts’ rating was modified (see Appendix B for an explanation).

References

1. �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 youth-targeting ban in magazine ads by the 

three top U.S. tobacco companies. Health Affairs. 2002;21(2):254–63.

2. �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.

3. �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. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

86
GOAL AREA 1 

▲Outcome 9

Indicator 1.9.11

Extent of Tobacco Industry Contributions to Institutions and Groups

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure The amount of funds contributed by the tobacco industry to institutions and groups 

(e.g., the hospitality industry, movie industry, sports organizations, and civic groups)

Why this indicator� Studies show that the tobacco industry has a history of collaborating with businesses

is useful� and community organizations. The amount of the tobacco industry’s influence on these 

groups is directly related to the amount it contributes.1–4 Tracking this indicator will help 

to understand tobacco industry influence.

Example data � ▲

▲

▲

Public records of political contributions�

source(s) 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 Not applicable

question(s)

Comments� Evaluators may want to categorize their findings by type of business or organization 

(e.g., the hospitality industry, movie industry, sports organizations, or civic groups) 

that received funds from the tobacco industry.

More information on how to collect data on this indicator is in reference 5 below. 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $◊

better

† �Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

◊�Denotes that the experts’ rating was modified (see Appendix B for an explanation).

Denotes no data.

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. �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. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

87
Indicator 1.9.12�

Amount of Tobacco Industry Campaign Contributions to Local and State Politicians

Goal area 1� Preventing initiation of tobacco use among young people

Outcome 9 Reduced tobacco industry influences

What to measure The amount of funds contributed to local and state politicians by the tobacco industry�

Why this indicator� Studies show an association between political contributions from the tobacco industry

is useful� and pro-tobacco legislation.1–3 Tobacco industry contributions are a significant predictor 

of the industry’s political influence, including its influence on votes for tobacco-related 

legislation.1,2 Tracking this indicator may help states counter the influence of the tobacco 

industry.

Example data � ▲

▲

▲

Public records of political contributions�

source(s) 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 Not applicable

question(s)

Comments More information on how to collect data on this indicator is in references 4 and 5 below.�

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

† | | | | | | $ ◊

better

† �Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

◊�Denotes that the experts’ rating was modified (see Appendix B for an explanation).

Denotes no data.

References

1. �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.

2. �Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legislative behavior? American 

Journal of Public Health. 1998;88(6):918–23.

3. �Luke DA, Krauss M. Where there’s smoking there’s money: tobacco industry campaign contributions and U.S. 

Congressional voting. American Journal of Preventive Medicine. 2004;27(5):363–72.

4. �Givel MS, Glantz SA. Tobacco lobby political influence on U.S. state legislatures in the 1990s. Tobacco Control.

2001;10(2):124–34.

5. �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;11:102–9.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

88
GOAL AREA 1 

Outcome 10

Outcome 10

▲

Reduced Susceptibility to Experimentation with Tobacco Products

Susceptibility to smoking is defined as the intention to smoke or the absence of a 

strong intention not to smoke.1 Studies show that susceptibility to experimentation 

is a valid and reliable predictor of future smoking behavior.1 Studies also 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

 Furthermore, 

recent evidence suggests that even low levels of smoking experimentation (two 

to four cigarettes smoked by age 10 years) substantially increase the likelihood of 

daily smoking in late adolescence.2

 To reduce the percentage of young people who 

take up smoking, it is therefore necessary to prevent young people from becoming 

susceptible to experimenting with tobacco.3

 In addition to tobacco industry influences, tobacco use by peers is strongly associated with early tobacco experimentation 

among children.4

 Parental involvement in young people’s decision making about 

tobacco use is also an important contributor to reduced susceptibility to tobacco 

use.5–7

Listed below are the indicators associated with this outcome:

▲

▲

▲

▲

▲

1.10.1� Proportion of young people who think that smoking is cool and 

helps them fit in

1.10.2� Proportion of young people who think that young people who smoke 

have more friends

1.10.3� Proportion of young people who report that their parents have discussed

not smoking with them

1.10.4 � Proportion of parents who report that they have discussed not smoking 

with their children

1.10.5� Proportion of young people who are susceptible never-smokers

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):355–361.

2. �Jackson C, Dickinson D. Cigarette consumption during childhood and persistence of smoking through adolescence. Archives of Pediatrics & Adolescent Medicine.

2004;158:1050–1056.

3. �U.S. Department of Health and Human Services. Preventing tobacco use among 

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

4. �Jackson C. Initial and experimental stages of tobacco and alcohol use during late 

childhood: relation to peer, parent, and personal risk factors. Addictive Behaviors.

1997;22(5):685–98.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

89
5. �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.

6. �Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, 

and smoking onset among children. Addictive Behaviors. 1997;22(1):107–14.

7. �Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents 

from becoming established smokers? Pediatrics. 2001;108(6):1256–62.

For Further Reading

Bidell MP, Furlong MJ, Dunn DM, Koegler JE. Case study of attempts to enact 

self-service tobacco display ordinances: a tale of three communities. Tobacco 

Control. 2000;9(1):71–7.

Centers for Disease Control and Prevention. Estimates of retailers willing to sell 

tobacco to minors: California, August–September 1995 and June–July 1996. Morbidity 

and Mortality Weekly Report. 1996;45(50):1095–9.

Feighery E, Altman DG, Shaffer G. The effects of combining education and enforcement to reduce tobacco sales to minors: a study of four northern California communities. Journal of the American Medical Association. 1991;266(22):3168–71.

Forster JL, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The 

effects of community policies to reduce youth access to tobacco. American Journal of 

Public Health. 1998;88(8):1193–8. 

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 L, Billows W, Schnopp-Wyatt D, King C. Reducing the illegal sales of cigarettes 

to minors: analysis of alternative enforcement schedules. Journal of Applied Behavior 

Analysis. 1996;29(3):333–44.

Jason LA, Pokorny SB, Schoeny ME. Evaluating the effects of enforcements and fines 

on youth smoking. Critical Public Health. 2003;13(1):33–45.

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.

Jason LA, Ji PY, Anes MD, Birkhead SH. Active enforcement of cigarette control 

laws in the prevention of cigarette sales to minors. Journal of the American Medical 

Association. 1991;266(22):3159–61.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

90
GOAL AREA 1 

Outcome 10 ▲

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.

Ma GX, Shive S, Tracy M. The effects of licensing and inspection enforcement to 

reduce tobacco sales to minors in greater Philadelphia, 1994–1998. Addictive Behaviors.

2001;26(5):677–87.

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;337:1044–51.

Siegel M, Biener L, Rigotti NA. The effect of local tobacco sales laws on adolescent 

smoking initiation. Preventive Medicine. 1999;29(5):334–42.

Stead LF, Lancaster T. A systematic review of interventions for preventing tobacco 

sales to minors. Tobacco Control. 2000;9(2):169–76.

Teall AM, Graham MC. Youth access to tobacco in two communities. Journal of 

Nursing Scholarship. 2001;33(2):175–8.

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

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

91
Outcome 10�

Reduced Susceptibility to Experimentation Indicator Rating

with Tobacco Products better

Number Indicator Overall quality Stren

evaluatio

Resources

Face v

needed

low high n evidence

gth of

Utility

alidity

practice

Accepted

1.10.1 Proportion of young people who think that smoking 

is cool and helps them fit in | | | | | | $$†

1.10.2 Proportion of young people who think that young 

people who smoke have more friends | | | | | | $$

1.10.3 Proportion of young people who report that their 

parents have discussed not smoking with them | | | | | | $$

1.10.4 Proportion of parents who report that they have 

discussed not smoking with their children | | | | | | $$$

1.10.5 Proportion of young people who are susceptible 

never-smokers | | | | | | $$†

†�Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this indicator were within one 

point of each other (see Appendix B for an explanation).

Denotes no data.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

92
GOAL AREA 1 

▲Outcome 10

Indicator 1.10.1

Proportion of Young People Who Think That Smoking Is Cool and Helps Them Fit In

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 10 Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who believe that smoking cigarettes will improve their 

social standing

Why this indicator Data indicate that adolescent cigarette smokers are significantly more likely to believe

is useful that smokers are more socially adept than nonsmokers.1–5 These data can be used to 

estimate norms regarding the social desirability of smoking.

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years�

Example survey From YTS

question(s) Do you think smoking cigarettes makes young people look cool or fit in?

Definitely yes Probably yes Probably not Definitely not

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | † $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 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. �Distefan JM, Gilpin EA, Sargent JD, Pierce JP. Do movie stars encourage adolescents to start smoking? Evidence from 

California. Preventive Medicine. 1999;28(1):1–11.

5. �Tickle JJ, Sargent JD, Dalton MA, Beach ML, Heatherton TF. Favorite movie stars, their tobacco use in contemporary 

movies, and its association with adolescent smoking. Tobacco Control. 2001;10(1):16–22.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

93
Indicator 1.10.2�

Proportion of Young People Who Think That �

Young People Who Smoke Have More Friends�

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 10 Reduced susceptibility to experimentation with tobacco products�

What to measure Proportion of young people who believe that those who smoke have more friends than 

those who do not smoke

Why this indicator Data indicate that cigarette smokers are significantly more likely to believe that those

is useful who smoke have more friends than those who do not smoke.1–5 These data can be used 

as an estimate of norms concerning the social desirability of smoking.

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years�

Example survey From YTS

question(s) Do you think young people who smoke cigarettes have more friends?

Definitely yes Probably yes Probably not Definitely not

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 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. �Distefan JM, Gilpin EA, Sargent JD, Pierce JP. Do movie stars encourage adolescents to start smoking? Evidence from 

California. Preventive Medicine. 1999;28(1):1–11.

5. �Tickle JJ, Sargent JD, Dalton MA, Beach ML, Heatherton TF. Favorite movie stars, their tobacco use in contemporary 

movies, and its association with adolescent smoking. Tobacco Control. 2001;10(1):16–22.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

94
GOAL AREA 1 

▲Outcome 10

Indicator 1.10.3

Proportion of Young People Who Report That 

Their Parents Have Discussed Not Smoking with Them

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 10 Reduced susceptibility to experimentation with tobacco products�

What to measure Proportion of young people who report that their parents have discussed the dangers of 

tobacco use with them in the past 12 months

Why this indicator� Parental involvement in their children’s smoking decisions is a predictor of whether their

is useful� children take up smoking.1–3 Teenagers who report that their parents are unconcerned 

about smoking or do not talk to them about it are more likely than other teenagers to take 

up smoking and to become regular smokers.1–4

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years�

Example survey From YTS

question(s) In the past 12 months, how often have your parents or guardians discussed the 

dangers of tobacco use with you?

Never Rarely Sometimes Often Very often

Comments� Evaluators may want to ask young people questions about parental rules about 

smoking and the perceived consequences of being caught smoking.

Evaluators may also want to ask young people if their parents have discussed the 

dangers of tobacco use (not just smoking) with them.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

References

1. �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.

2. �Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, and smoking onset among children. 

Addictive Behaviors. 1997;22(1):107–14.

3. �Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers? 

Pediatrics. 2001;108(6):1256–62.

4. �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. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

95
Indicator 1.10.4�

Proportion of Parents Who Report That 

They Have Discussed Not Smoking with Their Children

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 10 Reduced susceptibility to experimentation with tobacco products�

What to measure Proportion of parents who report that they talked to their children at least once in the 

previous 6 months about what their children may or may not do regarding tobacco use

Why this indicator Parental involvement in their children’s smoking decisions is a predictor of whether their

is useful children take up smoking.1–3 In addition, asking parents about their children and smoking 

sensitizes parents to the importance of discussing tobacco use with their children.1–4

Example data Adult Tobacco Survey (ATS): CDC Recommended Questions: Supplemental Section G:

source(s) Parental Involvement, 2003

Population group(s) Parents of children aged less than 18 years�

Example survey 

question(s)

From ATS

During the last 6 months, how many times have you talked to your child about 

what he/she can or cannot do when it comes to tobacco?

Never Once Twice 

Three or more times Don’t know/Not sure Refused

During the last 6 months, how many times have you told your child he/she 

cannot use tobacco?

Never Once Twice 

Three or more times Don’t know/Not sure Refused

Comments None

Rating Overall quality

low high

Resources 

needed

$$$

Strength of 

evaluation 

evidence

Utility Face validity Accepted 

practice

better

| | | | | |

Denotes no data.

References

1. �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.

2. �Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, and smoking onset among children. 

Addictive Behaviors. 1997;22(1):107–14.

3. �Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers? 

Pediatrics. 2001;108(6):1256–62.

4. �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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

96
GOAL AREA 1 

▲Outcome 10

Indicator 1.10.5

Proportion of Young People Who Are Susceptible Never-smokers

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 10 Reduced susceptibility to experimentation with tobacco products

What to measure Proportion of young people who have never tried a cigarette but have not made 

a firm decision not to smoke

Why this indicator Studies show that susceptible young people (those who have not made a firm decision 

is useful not to smoke) are more likely than other young people to experiment with smoking.1

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years

Example survey 

question(s)

From YTS 

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

Comments Evaluators should ask all four example questions to create a susceptibility index.1

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | † $$

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Reference

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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

97
Outcome 11�

Decreased Access to Tobacco Products 

As noted in the discussion of logic model component 8 (increased restriction and

increased enforcement of restrictions on tobacco sales to minors), adopting and enforcing strong laws that restrict young people’s access to tobacco can reduce the proportion of retailers that illegally sell tobacco products to minors. As also noted in that

discussion, reductions in illegal sales to minors may not automatically translate into

reductions in minors’ self-reported access to tobacco products through commercial

sources. In addition, reductions in illegal sales to young people would not be expected

to affect minors’ access to tobacco products through noncommercial (social) sources.

More importantly, it is unclear whether reductions in retail tobacco sales to minors

result in reductions in the actual rate of tobacco use by young people. Although some

studies indicate that this is the case, other studies fail to support such a link.1–3 The

data suggest that to be successful in reducing young people’s tobacco use, efforts to

reduce commercial access must achieve high levels of retailer compliance (perhaps

as high as 90% or more).2 In practice, these levels may not always be attainable.

According to the Guide to Community Preventive Services, the most effective approach 

to preventing young people from gaining access to tobacco (as measured by minors’ 

self-reported tobacco purchase or use behaviors) includes a combination of strong 

local and state laws, vigorous and sustained enforcement of these laws, retailer 

education, and—most importantly—community mobilization to generate community support for efforts to reduce youth access to tobacco products.4

 The Guide 

to Community Preventive Services notes that none of these interventions has 

been shown to be effective when implemented in isolation, in particular when 

implemented without a strong link to community mobilization initiatives.4,5

The Guide to Community Preventive Services and Reducing Tobacco Use: A Report of the 

Surgeon General also underscore the importance of taking a comprehensive approach 

to reducing tobacco use among young people.4,5 Such an approach includes interventions to reduce the appeal of, and demand for, tobacco products among young 

people, as well as to restrict their access to these products. In addition, because young 

people are influenced by the social norms and environmental cues that they observe 

in adult society, efforts to reduce their tobacco use should be integrated into the 

broader framework of a comprehensive tobacco control program that also addresses 

tobacco use by adults.

Listed below are the indicators associated with this outcome:

1.11.1 ▲Proportion of successful attempts to purchase tobacco products by 

young people

1.11.2 ▲Proportion of young people reporting that they have been sold tobacco 

products by a retailer

1.11.3 ▲Proportion of young people reporting that they have been unsuccessful 

in purchasing tobacco products from a retailer

1.11.4 ▲Proportion of young people reporting that they have received tobacco 

products from a social source

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

98
GOAL AREA 1 

Outcome 11 ▲

▲

▲

1.11.5� Proportion of young people reporting that they purchased cigarettes 

from a vending machine

1.11.6NR Proportion of young people who believe that it is easy to obtain 

tobacco products

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;337:1044–51.

2. �National Cancer Institute. Smoking and Tobacco Control Monograph, No. 14. 

Changing adolescent smoking prevalence: where it is and why. Bethesda, MD: National 

Cancer Institute; 2001. NIH Publication No. 02–5086.

3. �Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth 

smoking. Pediatrics. 2002;109(6):1088–92.

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

the Surgeon General. 2000.

5. �Fielding JE, Briss PA, Carande-Kulis VG, Hopkins DP, Husten CG, Pechacek TF, 

et al. Tobacco. In: Briss PA, Zaza S, Harris KW, editors. The guide to community 

preventive services. New York: Oxford University Press: [In 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.

Altman DG, Levine DW, Coeytaux R, Slade J, Jaffe R. Tobacco promotion and susceptibility to tobacco use among adolescents aged 12 through 17 years in a nationally 

representative sample. American Journal of Public Health. 1996;86(11):1590–3.

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. Morbidity and Mortality Weekly Report CDC Surveillance Summaries.

2001;50(SS-4):1–84.

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.

Forster JL, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The 

effects of community policies to reduce youth access to tobacco. American Journal of 

Public Health. 1998;88(8):1193–8.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

99
Gilpin EA, Pierce JP, Rosbrook B. Are adolescents receptive to current sales promotion 

practices of the tobacco industry? Preventive Medicine. 1997;26(1):14–21.

Jackson C, Henriksen L. Do as I say: parent smoking, antismoking socialization, 

and smoking onset among children. Addictive Behaviors. 1997;22(1):107–14.

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.

Jason LA, Ji PY, Anes MD, Birkhead SH. Active enforcement of cigarette control 

laws in the prevention of cigarette sales to minors. Journal of the American Medical 

Association. 1991;266(22):3159–61.

Jason LA, Pokorny SB, Schoeny M.E. 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.

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, Beach M, Bernhardt A, Heatherton T, Stevens M. Effect of 

cigarette promotions on smoking uptake among adolescents. Preventive Medicine.

2000;30(4):320–7.

Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents 

from becoming established smokers? Pediatrics. 2001;108(6):1256–62.

Schooler C, Feighery E, Flora JA. Seventh graders’ self-reported exposure to cigarette 

marketing and its relationship to their smoking behavior. American Journal of Public 

Health. 1996;86(9):1216–21.

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.

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

people: a report of the Surgeon General. Atlanta, GA: Centers for Disease Control and 

Prevention; 1994.

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.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

100
GOAL AREA 1 

▲Outcome 11

Outcome 11

Decreased Access to Tobacco Products Indicator Rating

better

Number Indicator Overall quality Stren

evaluatio

Resources

Face v

needed

low high n evidence

gth of

Utility

alidity

practice

Accepted

1.11.1 Proportion of successful attempts to purchase tobacco 

products by young people | | | | | |† $$$† †

1.11.2 Proportion of young people reporting that they have 

been sold tobacco products by a retailer | | | | | | $$

1.11.3 Proportion of young people reporting that they have 

been unsuccessful in purchasing tobacco products from 

a retailer

| | | | | |† $$ †

1.11.4 Proportion of young people reporting that they have 

received tobacco products from a social source | | | | | | $$

1.11.5 Proportion of young people reporting that they 

purchased cigarettes from a vending machine | | | | | | $$

1.11.6NR Proportion of young people who believe that it is easy 

to obtain tobacco products | | | | | |

†�Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this indicator were within one 

point of each other (see Appendix B for an explanation).

Denotes no data.� NR Denotes an indicator that is not rated (see Appendix B for an explanation).�

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

101
Indicator 1.11.1�

Proportion of Successful Attempts to Purchase Tobacco Products by Young People

Goal area 1� Preventing initiation of tobacco use among young people

Outcome 11 Decreased access to tobacco products

What to measure The proportion of retailers not in compliance with policies prohibiting the sale 

of tobacco products to minors

Why this indicator Decreasing the rate at which young people are successful in purchasing tobacco may

is useful contribute to a reduction in tobacco use by young people.1

Example data Substance Abuse and Mental Health Services Administration (SAMHSA) Compliance

source(s) Checks 

Information available at: http://prevention.samhsa.gov/tobacco/guidance.asp

Population group(s) Tobacco retailers

Example survey Not applicable

question(s)

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.2

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low

| | | | | |† † $$$ †

better

† Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

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;337:1044–51.

2. �DiFranza JR. Are the federal and state governments complying with the Synar Amendment? Archives of Pediatrics & 

Adolescent Medicine. 1999;153(10):1089–97. 

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

102
GOAL AREA 1 

▲Outcome 11

Indicator 1.11.2

Proportion of Young People Reporting That 

They Have Been Sold Tobacco Products by a Retailer

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 11 Decreased access to tobacco products

What to measure The proportion of young people who report having been sold tobacco products by a 

retailer in the previous 30 days

Why this indicator

is useful

Even if most retailers in a community comply with laws prohibiting the sale of tobacco 

to young people and only a few continue to sell tobacco products to minors, young 

people’s access to tobacco products through retail stores may remain unacceptably high. 

Young smokers will seek out the retailers that are willing to sell to them. Measuring this 

indicator helps determine the extent to which illegal sales of tobacco to young people are 

occurring.1

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003

Population group(s) Young people aged less than 18 years

Example survey From YTS

question(s) 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 drugstore 

during the past 30 days A vending machine

A gas station I bought them over the Internet

A convenience store Other _____________________

A grocery store

From YTS and YRBSS

During the past 30 days, how did you usually get your own cigarettes? 

I did not smoke cigarettes during I borrowed (or bummed) them from

the past 30 days someone else

I bought them in a store such as a A person 18 years or older gave them to me

convenience store, supermarket, I took them from a store or family member

discount store, or gas station I got them some other way

I bought them from a vending I gave someone else money to buy

machine them for me

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Reference

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;337:1044–51.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

103
Indicator 1.11.3�

Proportion of Young People Reporting That They Have Been 

Unsuccessful in Purchasing Tobacco Products from a Retailer

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 11 Decreased access to tobacco products

What to measure Proportion of young people who report that they were refused sale of cigarettes because 

of their age during the previous 30 days

Why this indicator Measuring this indicator helps determine the extent to which local and state policies and

is useful enforcement activities are reducing young people’s access to tobacco products.1

Example data Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

source(s)

Population group(s) Young people aged less than 18 years�

Example survey From YTS

question(s) 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, someone refused to sell me cigarettes because of my age

No, no one refused to sell me cigarettes because of my age

Comments Evaluators may also want to assess the type of retailer (e.g., gas station, convenience 

store, or grocery store) that sold tobacco to a minor.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | |† † $$

better

† �Denotes low agreement among reviewers: that is, fewer than 75% of the valid ratings for this 

indicator were within one point of each other (see Appendix B for an explanation).

Denotes no data.

Reference

1. �Jones SE, Sharp DJ, Husten CG, Crossett LS. Cigarette acquisition and proof of age among US high school students who 

smoke. Tobacco Control. 2002;11:20–5.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

104
GOAL AREA 1 

▲Outcome 11

Indicator 1.11.4

Proportion of Young People Reporting That They 

Have Received Tobacco Products from a Social Source

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 11 Decreased access to tobacco products

What to measure Proportion of young people who report getting their cigarettes from a social source such 

as a friend, family member, or schoolmate during the previous 30 days

Why this indicator Although increasing enforcement of laws prohibiting the sale of tobacco to minors

is useful reduces illegal sales, studies also suggest that more than half of high-school-aged 

smokers report obtaining cigarettes from social sources.1

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003

Population group(s) Young people aged less than 18 years

Example survey 

question(s)

From YTS and YRBSS

During the past 30 days, how did you usually get your own cigarettes? 

I did not smoke cigarettes during the past 30 days

I bought them in a store such as a convenience store, supermarket, 

discount store, or gas station

I bought them from a vending machine

I gave someone else money to buy them for me

I borrowed (or bummed) them from someone else

A person 18 years old or older gave them to me 

I took them from a store or family member

I got them some other way

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Reference

1. �Centers for Disease Control and Prevention. Tobacco use and usual source of cigarettes among high school students–

United States. Morbidity and Mortality Weekly Report. 1996;45(20);413–8.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

105
Indicator 1.11.5�

Proportion of Young People Reporting That They �

Purchased Cigarettes from a Vending Machine�

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 11 Decreased access to tobacco products

What to measure The proportion of young people who usually purchased their cigarettes from a vending 

machine during the previous 30 days

Why this indicator� Accessible vending machines provide virtually unrestricted access to cigarettes and can

is useful� be used by even the youngest children. As of 2004, 46 states and the District of Columbia 

restricted minors’ access to tobacco through vending machines, and 30 states and the 

District of Columbia banned vending machines in locations that are accessible to young 

people.1

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003

Population group(s) Young people aged less than 18 years

Example survey From YTS

question(s) 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 grocery store

during the past 30 days A drugstore

A gas station A vending machine

A convenience store I bought them over the Internet

From YTS and YRBSS

During the past 30 days, how did you usually get your own cigarettes? 

I did not smoke cigarettes during I borrowed (or bummed) them from

the past 30 days someone else

I bought them in a store such as a A person 18 years or older gave them to me

convenience store, supermarket, I took them from a store or family member

discount store, or gas station I got them some other way

I bought them from a vending I gave someone else money to buy

machine them for me

Comments None

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Denotes no data.

Reference

1. �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 from: http://www.cdc.gov/tobacco/statesystem. 

Accessed February 2005.

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GOAL AREA 1 

▲Outcome 11

Indicator 1.11.6NR

Proportion of Young People Who Believe That 

It Is Easy to Obtain Tobacco Products

Goal area 1 Preventing initiation of tobacco use among young people�

Outcome 11 Decreased access to tobacco products

What to measure The degree to which young people believe that it is easy or difficult to obtain 

tobacco products

Why this indicator� Changing the social norms regarding tobacco use by young people requires changing

is useful� the perception among young people that tobacco products are easily obtained. If young 

people perceive that obtaining tobacco products is difficult, they are less likely to try to 

obtain such products.1

Example data � California Youth Tobacco Survey (CA YTS), 1999

source(s)� Information available at: http://www.dhs.ca.gov/ps/cdic/ccb/TCS/html/

Evaluation_Resources.htm

Population group(s) Young people aged less than 18 years�

Example survey From CA YTS

question(s) Do you think it would be easy or hard for you to get cigarettes if you wanted some?

Easy Hard Don’t know/Not sure Refused

Comments This indicator was not rated by the panel of experts and, therefore, no rating information 

is available. See Appendix B for an explanation.

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | |

better

Denotes no data.

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

Reference

1. �Gilpin EA, Lee L, Pierce JP. Does adolescent perception of difficulty in getting cigarettes deter experimentation? Preventive 

Medicine. 2004;38(4):485–91. 

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

107
Outcome 12�

Increased Price of Tobacco Products

Studies show an inverse relationship between cigarette price and smoking prevalence 

by young people and adults. Increasing state or local excise taxes on cigarettes is 

an effective method of increasing the real price of cigarettes. However, maintaining 

higher real prices requires further tax increases to offset the effects of inflation and 

industry practices designed to control retail product prices.1,2 Recent efforts to offset 

industry pricing practices have focused on supporting minimum retail pricing laws.3

Econometric studies show price elasticity for tobacco use among adolescents of –0.76, 

which means that a 10% increase in price would result in a 7.6% decrease in tobacco 

use.4

 In addition, to directly motivate people to quit or not start tobacco use, price 

increases can indirectly reduce tobacco use if a portion of the excise tax revenue is 

dedicated to the state’s tobacco control program.4

Although young people usually start using tobacco by first experimenting with 

cigarettes, some begin by experimenting with other tobacco products such as 

spit tobacco (smokeless), bidis, small cigars, and loose tobacco (roll-your-own). 

All tobacco products are taxed. To prevent tobacco users from shifting to cheaper 

tobacco products, increasing taxes on all tobacco products is important.5

 Tax 

increases on tobacco products increase the real price of tobacco products and 

thus reduce young people’s demand for such products.

Listed below is the indicator associated with this outcome:

1.12.1 Amount of tobacco product excise tax

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among 

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

2. �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;12:184–8.

3. �Bloom PN. Role of slotting fees and trade promotions in shaping how tobacco 

is marketed in retail stores. Tobacco Control. 2001;10(4):340–4.

4. �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.

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

report of the Surgeon General. Atlanta, GA: Centers for Disease Control and 

Prevention; 2000.

▲

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GOAL AREA 1 

Outcome 12 ▲

For Further Reading

Gratias EJ, Krowchuk DP, Lawless MR, Durant RH. Middle school students’ sources 

of acquiring cigarettes and requests for proof of age. Journal of Adolescent Health.

1999;25(4):276–83.

Ringel J, Pacula RL, Wasserman J. Youth access to cigarettes: results from the 1999 

National Youth Tobacco Survey. Legacy First Look Report 10. Washington, DC: 

American Legacy Foundation; 2000.

U.S. Centers for Disease Control and Prevention. Responses to cigarette prices by 

race/ethnicity, income, and age groups—United States, 1976–1993. Morbidity and 

Mortality Weekly Report. 1998;47(29):605–9.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

109
1.12.1

c

Outcome 12�

Increased Price of Tobacco Products Indicator Rating

Number Indicator Overall quality

low high

Amount of tobacco product excise tax | | | | | | $

better

Resources

needed

Strength of

evaluation eviden e

Utility

Face validity

Accepted

practice

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GOAL AREA 1 

▲Outcome 12

Indicator 1.12.1

Amount of Tobacco Product Excise Tax

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 12 Increased price of tobacco products

What to measure (1) The state excise tax per pack of cigarettes and (2) the percentage of the total price 

of a pack of cigarettes that is attributable to tax

Why this indicator� Increasing tax on tobacco products reduces tobacco consumption and prevalence,

is useful� especially among the most price-sensitive populations (e.g., young people).1,2

Increasing cigarette excise taxes is an effective method of increasing the real price 

of cigarettes, although maintaining high prices requires further tax increases to 

offset the effects of inflation.1,2

Example data � ▲

▲

▲

CDC State Tobacco Activities Tracking and Evaluation (STATE) system �

source(s) Data available at: http://www.cdc.gov/tobacco/STATEsystem. Select “economics” 

and “cigarette sales.”

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 taxes on tobacco products.

Example survey Not applicable

question(s)

Comments� States can also independently track the price of tobacco products by collecting 

scanner data (obtained from product bar codes), which provide information 

on product price, brand, and promotions. However, the cost of this type of data 

collection can be prohibitive. 

To gather more complete data on tobacco price, evaluators can also collect data on 

other tobacco products such as spit tobacco (smokeless), bidis, small cigars, and loose 

tobacco (roll-your-own).

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $

better

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. 

Atlanta, GA: Centers for Disease Control and Prevention; 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.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

111
Outcome 13�

▲

▲

Reduced Initiation of Tobacco Use by Young People

Tobacco use begins primarily during adolescence, decades earlier than when the 

death and disability associated with tobacco use are likely to occur. Few people begin 

to use tobacco as adults; almost 90% of adult smokers began by age 18 years.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.1,2 Both the duration 

and amount of tobacco use are related to eventual chronic health problems, with 

duration posing the stronger risk.3,4 The processes of nicotine addiction further 

ensure that many of today’s adolescent smokers will use tobacco regularly when 

they are adults.1

Listed below are the indicators associated with this outcome:

1.13.1 Average age at which young people first smoked a whole cigarette

1.13.2 Proportion of young people who report never having tried a cigarette

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among 

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

2. �Jackson C, Dickinson D. Cigarette consumption during childhood and persistence of smoking through adolescence. Archives of Pediatrics & Adolescent Medicine.

2004;158:1050–6.

3. �Doll R, Peto R. Cigarette smoking and lung cancer: dose and time relationships 

among regular smokers and lifelong non-smokers. Journal of Epidemiology and 

Community Health. 1978;32(4):303–13.

4. �Flanders DW, Lally CA, Ahu BP, Henley J, Thun MJ. Lung cancer mortality in 

relation to age, duration of smoking, and daily cigarette consumption: results

from Cancer Prevention Study II. Cancer Research. 2003;63:6556–62.

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GOAL AREA 1 

▲Outcome 13

Outcome 13

Reduced Initiation of Tobacco Use by Young People Indicator Rating

better

Number Indicator Overall quality Streng evaluatio

Resources

Face v

needed

low high n evidence

th of

Utility

alidity

practice

Accepted

1.13.1 Average age at which young people first smoked 

a whole cigarette | | | | | | $$

1.13.2 Proportion of young people who report never having 

tried a cigarette | | | | | | $$

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

113
Indicator 1.13.1�

Average Age at Which Young People First Smoked a Whole Cigarette

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 13 Reduced initiation of tobacco use by young people

What to measure The average age at which young smokers first smoked a whole cigarette

Why this indicator� The age at which someone first smokes a whole cigarette is significantly related to

is useful� that person’s long-term smoking habits. The younger people are when they start using 

tobacco, the more likely they are to use tobacco products as adults.1

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003

Population group(s) Young people aged less than 18 years

Example survey From YTS and YRBSS

question(s) 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

Comments� To gather more complete data on tobacco use, evaluators can also ask questions about 

the use of other tobacco products such as spit tobacco (smokeless), bidis, small cigars, 

and loose tobacco (roll-your-own). 

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Reference

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

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GOAL AREA 1 

▲Outcome 13

Indicator 1.13.2

Proportion of Young People Who Report Never Having Tried a Cigarette

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 13 Reduced initiation of tobacco use by young people

What to measure Proportion of young people who have never tried a cigarette, not even one or two puffs�

Why this indicator Reducing the number of minors who experiment with tobacco will decrease the number

is useful who become established smokers.1

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003

Population group(s) Young people aged less than 18 years

Example survey From YTS and YRBSS

question(s) Have you ever tried cigarette smoking, even one or two puffs?

Yes No

Comments� To gather more complete data on tobacco use, evaluators can also ask questions about 

the use of other tobacco products such as spit tobacco (smokeless), bidis, small cigars, 

and loose tobacco (roll-your-own).

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

Reference

1. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

115
Outcome 14�

▲

▲

Reduced Tobacco-use Prevalence Among Young People

Smoking by young people is associated with serious health problems, such as 

reduced lung capacity and physical fitness.1 Smoking by young people also increases 

the likelihood that they will continue to smoke through adulthood, increasing their 

risk of tobacco-related diseases such as lung and other cancers, heart disease, and 

emphysema.2,3 

Because the number of years of cigarette smoking produces a greater risk of disease 

than the number of cigarettes smoked per day, it is critically important to work on 

both preventing young people from starting to smoke and increasing the number 

and percentage of young smokers who quit.4,5

Listed below are the indicators associated with this outcome:

1.14.1 Prevalence of tobacco use among young people

1.14.2 Proportion of established young smokers

References

1. �U.S. Department of Health and Human Services. Preventing tobacco use among 

young people: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 1994.

2. �Jackson C, Dickinson D. Cigarette consumption during childhood and persistence of smoking through adolescence. Archives of Pediatrics & Adolescent Medicine.

2004;158(11):1050–6.

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

smoking: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 2004.

4. �Doll R, Peto R. Cigarette smoking and lung cancer: dose and time relationships 

among regular smokers and lifelong non-smokers. Journal of Epidemiology and 

Community Health. 1978;32(4):303–13.

5. �Flanders DW, Lally CA, Ahu BP, Henley J, Thun MJ. Lung cancer mortality in 

relation to age, duration of smoking, and daily cigarette consumption: results 

from Cancer Prevention Study II. Cancer Research. 2003;63(19):6556–62.

For Further Reading

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 from: http://www.cdc.gov/nccdphp/aag/aag_osh.htm. Accessed 

March 2005.

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GOAL AREA 1 

Outcome 14 ▲

Centers for Disease Control and Prevention. Projected smoking-related deaths among 

youth—United States. Morbidity and Mortality Weekly Report. 1996;45(44):971–4.

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

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

Public Health Service, Office of the Surgeon General; 2001.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

117
Outcome 14�

Reduced Tobacco-use Prevalence Among Young People Indicator Rating

better

Number Indicator Overall quality Streng

evaluatio

Resources

Face v

needed

low high n evidence

th of

Utility

alidity

practice

Accepted

1.14.1 Prevalence of tobacco use among young people | | | | | | $$

1.14.2 Proportion of established young smokers | | | | | | $$

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GOAL AREA 1 

▲Outcome 14

Indicator 1.14.1

Prevalence of Tobacco Use Among Young People

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 14 Reduced tobacco-use prevalence among young people

What to measure Proportion of young people who have smoked on at least 1 day during the 

previous 30 days1

Why this indicator Reducing tobacco use among young people decreases their chances of smoking

is useful as adults.2

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003

Population group(s) Young people aged less than 18 years

Example survey From YTS and YRBSS

question(s) 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

Comments� Evaluators may also want to collect data on young people who ever smoked a cigarette 

and young people who frequently smoke.

To gather more complete data on tobacco use, evaluators can also ask questions about the 

use of other tobacco products such as spit tobacco (smokeless), bidis, small cigars, and 

loose tobacco (roll-your-own).

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

References

1. �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.

2. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. 

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

C H A P T E R 2 ▲Goal Area 1: Preventing Initiation of Tobacco Use Among Young People

119
Indicator 1.14.2�

Proportion of Established Young Smokers

Goal area 1 Preventing initiation of tobacco use among young people

Outcome 14 Reduced tobacco-use prevalence among young people

What to measure Proportion of young people who smoked 100 cigarettes or more during their lifetimes1

Why this indicator Young people who are established smokers are at high risk of becoming addicted

is useful to cigarettes and continuing to smoke as adults.2

Example data �

source(s)�

▲

▲

Youth Tobacco Survey (YTS): CDC Recommended Questions: Core, 2004

CDC Youth Risk Behavior Surveillance System (YRBSS), 2003 

Population group(s) Young people aged less than 18 years

Example survey From YTS and YRBSS

question(s) During the past 30 days, on how many days did you smoke cigarettes?

0 days 10 to 19 days

1 or 2 days 20 to 29 days

3 to 5 days All 30 days

6 to 9 days

During the past 30 days, what brand of cigarettes did you usually smoke? 

(CHOOSE ONLY ONE ANSWER)

I did not smoke cigarettes Newport

during the past 30 days Virginia Slims

I do not have a usual brand GPC, Basic, or Doral

Camel Some other brand

Marlboro

About how many cigarettes have you smoked in your entire life?

None

1 or more puffs but never a whole cigarette

1 cigarette

2 to 5 cigarettes

6 to 15 cigarettes (about half 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)

Comments� To gather more complete data on tobacco use, evaluators can also ask questions about the 

use of other tobacco products such as spit tobacco (smokeless), bidis, small cigars, and 

loose tobacco (roll-your-own).

Rating� Overall quality Resources Strength of Utility Face validity Accepted 

high needed evaluation � practice

evidence

low 

| | | | | | $$

better

References

1. �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. 

2. �U.S. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General.

Atlanta, GA: Centers for Disease Control and Prevention; 1994.

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