9

Introduction 

Burden of Tobacco Use

Tobacco use is the single most preventable cause 

of disease and death in the United States.1 The 

health consequences of tobacco use include 

heart disease, multiple types of cancer, pulmonary disease, adverse reproductive effects, and the 

exacerbation of chronic health conditions.1 Nearly 

one-half million Americans still die prematurely 

from tobacco use each year, and economic costs 

attributable to smoking and exposure to secondhand smoke now approach $300 billion annually.2

Despite these known health and financial burdens, 

approximately one in four American adults currently use some form of tobacco, with one in five 

smoking cigarettes.3,4

This public health problem is compounded 

by the fact that the harmful effects of tobacco use 

do not end with the user. Although substantial 

progress has been made in the adoption of 

comprehensive smokefree policies that prohibit 

smoking in all indoor areas of workplaces and 

public places, millions of Americans not protected 

by such policies remain susceptible to involuntary 

secondhand smoke exposure in these areas, as 

well as private settings such as multiunit housing.5,6

There is no risk-free level of secondhand smoke, 

and exposure can cause premature death and 

disease in nonsmoking adults and children.7,8

Nearly 90% of adult smokers begin smoking 

by the time they are 18 years of age.9

 Although 

the prevalence of cigarette smoking among 

youth decreased significantly from the late 

1990s to 2003, the rate of decline has slowed in 

recent years.10 In 2012, approximately 6.7% of 

middle school students and 23.3% of high school 

students reported using a tobacco product within 

the past 30 days.11 Several factors may have 

contributed to this lack of continued decline, 

including smaller annual increases in the retail 

price of cigarettes, decreased exposure among 

youth to effective mass media tobacco control 

campaigns, and less funding for comprehensive 

statewide tobacco control programs.12

Additionally, actions by the tobacco industry, 

including substantial increases in expenditures 

on advertising and promotion at the point of sale, 

may also have played a role, especially given the 

industry’s history of deceptive advertising. In the 

2006 final opinion in United States v. Philip Morris, 

U.S. District Judge Gladys Kessler concluded that the 

major tobacco companies are adjudicated racketeers 

that had “mounted a coordinated, well-financed, 

sophisticated public relations campaign to attack 

and distort the scientific evidence demonstrating 

the relationship between smoking and disease.”13

Goals of Comprehensive 

Tobacco Control Programs

In 2007, the Institute of Medicine (IOM) released 

the report, Ending the Tobacco Problem: A Blueprint for the Nation, which outlined a two-pronged 

strategy for eliminating the burden of tobacco use 

in the United States.14 This strategy included: 1) 

strengthening and fully implementing traditional 

tobacco control measures; and 2) changing the regulatory landscape to permit policy innovations. 

The IOM Committee specifically concluded that 

there was compelling evidence that comprehensive state tobacco programs can achieve substantial 

reductions in tobacco use.14

The mission of comprehensive tobacco control 

programs is to reduce disease, disability, and 

death related to tobacco use. A comprehensive 

approach — one that optimizes synergy 

from applying a mix of educational, clinical, 

regulatory, economic, and social strategies — is 

the guiding principle for eliminating the health 

and economic burden of tobacco use.15,16

Goals for Comprehensive 

Tobacco Control Programs

 Prevent initiation among youth and young adults. 

 Promote quitting among adults and youth. 

 Eliminate exposure to secondhand smoke. 

 Identify and eliminate tobacco-related disparities 

among population groups. 
10

Introduction

Impact of Comprehensive 

Tobacco Control Programs

States that have made larger investments in comprehensive tobacco control programs have seen 

larger declines in cigarettes sales than the United 

States as a whole, and the prevalence of smoking among adults and youth has declined faster 

as spending for tobacco control programs has 

increased.17–19 For example, during 1998–2003, 

a comprehensive prevention program in Florida 

anchored by an aggressive youth-oriented health 

communications campaign reduced the prevalence of smoking among middle and high school 

students by 50% and 35%, respectively.20 Similarly, 

during 2001–2010, the New York State Tobacco 

Control Program reported declines in the prevalence of smoking among adults and youth in the 

state that outpaced declines nationally. As a result, 

smoking-attributable personal health care expenditures in New York in 2010 were $4.1 billion less 

than they would have been had the prevalence of 

smoking remained at 2001 levels.21

In addition to the beneficial impact of larger 

investments in comprehensive tobacco control 

programs on smoking rates, research also shows 

that the longer states invest in such programs, the 

greater and quicker the impact.16 For example, in 

California, the nation’s first and longest-running 

comprehensive state tobacco control program, 

the prevalence of smoking among adults declined 

from 22.7% in 1988 to 11.9% in 2010.22 Decreases in 

lung cancer incidence and the correlation between 

lung cancer incidence and quit ratios also provide 

compelling evidence of the value of sustained 

tobacco control efforts. Since 1998, lung cancer 

incidence in California has been declining four 

times faster than in the rest of the United States.23

National Initiatives to 

Support Comprehensive 

Tobacco Control Programs

A comprehensive approach to tobacco prevention 

and control requires coordination and collaboration across the federal government, across the 

nation, and within each state. The federal government has undertaken a number of important 

activities that provide a foundation for state action. 

For example, in 1999, the National Tobacco Control Program (NTCP) was launched, combining 

initiatives from the National Cancer Institute (NCI) 

and the Centers for Disease Control and Prevention (CDC) into one coordinated national program 

that CDC funds and manages.24 CDC funding is 

designed to support and leverage state funding for 

evidence-based interventions and to help states 

evaluate their program efforts. NTCP provides 

technical assistance and limited funding to all 50 

states, the District of Columbia, and seven territories, as well as Tribal Support Centers and National 

Networks of specific populations. 

Similarly, The National Network of Tobacco 

Cessation Quitlines was developed through 

a partnership among CDC, the NCI Cancer 

Information Service, the North American 

Quitline Consortium, and the states.25 This 

system provides callers from across the nation 

with a single, toll-free access point (1-800-QUIT 

NOW) that automatically routes them to their 

state’s telephone-based cessation services. 

In addition to these activities, several major 

advances were made in recent years through the 

enactment of national tobacco control legislation. 

Specifically, the 2009 Family Smoking Prevention 

and Tobacco Control Act gives the Food and 

Drug Administration authority to regulate the 

manufacture, distribution, and marketing of tobacco 

products.26 In addition, the Patient Protection 

and Affordable Care Act, as amended by the 

Health Care and Education Reconciliation Act and 

referred to collectively as the Affordable Care Act, 

provides expanded coverage for recommended 

clinical preventive services, including evidencebased smoking-cessation treatments, for many 

persons in the United States.27 Finally, the Children’s 

Health Insurance Program Reauthorization Act 

of 2009 raised the federal tax rate for cigarettes 

from $0.39 to $1.01 per pack.28 Increasing the 

price of tobacco products is the single most 

effective way to prevent initiation among 

nonsmokers and to reduce consumption.15,29

Scientific data about the extent of tobacco use, 

its impact, and effective interventions to reduce 

its use have been generated and disseminated 

by several federal agencies, including CDC, 

the National Institutes of Health (NIH), the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA), and the Agency for 

Healthcare Research and Quality. The federal 

government has also supported several national 

and state tobacco use surveys among adults 

and youth through the CDC (e.g. Behavioral 

Risk Factor Surveillance System, National 
11

Introduction

Health Interview Survey, Youth Risk Behavior 

Surveillance System, national and state Adult 

Tobacco Surveys, national and state Youth Tobacco 

Surveys), NIH (e.g. Tobacco Use Supplement to 

the Current Population Survey and Monitoring 

the Future), and SAMHSA (e.g. National Survey 

on Drug Use and Health). These surveys provide 

complementary data from various populations 

that are critical for surveillance and evaluation.

National partner organizations and many 

academic and research partners also play a 

critical role in tobacco prevention and 

control efforts. For example: 

 The American Cancer Society, American Heart 

Association, and American Lung Association 

provide strong national, state, and local 

advocacy leadership on tobacco control 

policy issues as well as community support 

 The American Legacy Foundation’s truth® 

campaign reinforces state-based youth 

prevention efforts and has been independently 

associated with substantial declines in the 

prevalence of smoking among youth30

 The Americans for Nonsmokers’ Rights 

Foundation provides technical assistance to 

states and localities as they engage in the 

process of implementing smokefree policies 

 The Association of State and Territorial 

Health Officials, the National Association 

of County and City Health Officials, and 

the National Association of Local Boards of 

Health provide state and local health officials 

with support in developing and maintaining 

tobacco control policies and programs 

 The Campaign for Tobacco-Free Kids 

provides legal, media, and research 

support to assist in promoting and 

implementing tobacco control policies 

 The Robert Wood Johnson Foundation 

has supported research to document the 

effectiveness of policies and programs and also 

helps build tobacco control infrastructure 

 The Tobacco Control Legal Consortium, 

a network of legal programs supporting 

tobacco control policy change, works 

to assist communities and increase legal 

resources available for tobacco control 

 The Tobacco Technical Assistance 

Consortium supports the effectiveness of 

tobacco control programs by providing 

technical assistance to state and local 

programs, partners, and coalitions 

Although a number of critical efforts to curb 

tobacco use occur at the national level, state and 

local community action is essential to ensure the 

success of tobacco control interventions. Most 

funding for tobacco control interventions comes 

from the states.31 Furthermore, it is the policies, 

partnerships, and intervention activities that occur 

at the state and local levels that ultimately lead to 

social norm and behavior change. In acknowledging 

the essential and unique roles that states and 

communities play in tobacco control efforts, this 

report provides technical information and evidencebased benchmarks to assist states in designing 

comprehensive programs. Communities, in turn, 

support comprehensive programs by implementing 

evidence-based initiatives at the local level. 

For example, although the centralized quitline 

number and structure of the National Network 

of Tobacco Cessation Quitlines were established 

through partnerships at the national level, states 

still provide the foundation for this system by 

maintaining their quitline services and promoting 

their use through broadcast media. Communities 

can further promote this service through local 

channels, such as hospitals, health care systems, 

newspapers, and community organizations.

Implementing Best Practices 

for Comprehensive Tobacco 

Control Programs 

Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and 

accountable have been shown to reduce smoking rates as well as tobacco-related diseases and 

deaths. A comprehensive statewide tobacco control 

program is a coordinated effort to:

 Establish smokefree policies and social norms 

 Promote cessation and assist tobacco 

users to quit 

 Prevent initiation of tobacco use 

CDC’s Best Practices for Comprehensive 

Tobacco Control Programs — 2014 is an evidencebased guide to help states plan and establish 

comprehensive tobacco control programs. CDC 

has prepared this report to help states organize 

their tobacco control program efforts into an 

integrated and effective structure that uses and 
12

Introduction

maximizes interventions proven to be effective 

and to operate at the scale that would be required 

to reach the Healthy People 2020 objective of 

reducing smoking to 12% or less by the year 2020. 

In 1999, CDC first published Best Practices 

for Comprehensive Tobacco Control Programs.

That report outlined the elements of an evidencebased state tobacco control program and 

provided a recommended state funding range 

to substantially reduce tobacco-related disease, 

disability, and death.32 Best Practices — 1999

recommended that states invest a combined 

$1.6 to $4.2 billion annually in such programs. 

Subsequently, the recommendation was 

updated to $3.7 billion annually in 2007.16

After the 1999 report was published, overall 

funding for state tobacco control programs more 

than doubled, and states restructured their tobacco 

control programs to align with CDC’s goals and 

programmatic recommendations.16 To date, all 

50 states and the District of Columbia have state 

tobacco control programs that are funded through 

various revenue streams, including tobacco 

industry settlement payments, cigarette excise 

tax revenues, state general funds, the federal 

government, and nonprofit organizations.31

However, in 2011, only two states funded 

tobacco control programs at CDC-recommended 

levels, whereas 27 states funded at less than 25% of 

these levels.4

 Many state programs have experienced 

and are facing substantial state government cuts 

to tobacco control funding, resulting in the nearelimination of tobacco control programs in 

those states.31 In 2010, states appropriated only 

2.4% of their state tobacco revenues for tobacco 

control. Reaching the Best Practices — 2007

funding goal would have required an additional 

13.0% of tobacco revenues, or $3.1 billion of 

the $24 billion collected across all states.31

Investing in comprehensive tobacco control 

programs and implementing evidence-based 

interventions have been shown to reduce youth 

initiation, tobacco-related disease and death, 

and tobacco-related health care costs and lost 

productivity.14,16,32 These interventions include:

 Increasing the price of tobacco products

 Enacting comprehensive smokefree policies

 Funding hard hitting mass-media campaigns 

 Making cessation services fully 

accessible to tobacco users

Best Practices for Comprehensive Tobacco 

Control Programs — 2014 updates the guidance 

provided in 2007, reflecting additional state 

experiences in implementing comprehensive 

tobacco control programs, new scientific literature, 

and changes in state populations, inflation, 

and the national tobacco control landscape. 

This report draws upon best practices 

determined by evidence-based analysis of state 

tobacco control programs and published evidence 

of effective tobacco control strategies. On the 

basis of this analysis, experience, and evidence, 

CDC recommends that states establish and sustain 

comprehensive tobacco control programs that 

contain the following overarching components. 

Overarching Components 

of Comprehensive Tobacco 

Control Programs 

 State and community interventions. 

 Mass-reach health communication interventions.

 Cessation interventions. 

 Surveillance and evaluation. 

 Infrastructure, administration, and management. 

This report describes an integrated budget 

structure for implementing interventions proven to 

be effective, and the minimum and recommended

state investment that would be required to reduce, 

and ultimately eliminate, tobacco use in each state. 

Information for each of these components includes:

 Justification for the program intervention

 Considerations for achieving equity to 

reduce tobacco-related disparities

 Budget recommendations for 

successful implementation

 References to assist with implementation
13

Introduction

As with the funding guidance published in 2007, 

annual funding levels can vary within the lower 

and upper estimate provided for each state.16 The 

levels of annual investment for state and community 

interventions factor in multiple state-specific 

variables, such as the proportion of individuals 

within the state living at or below 200% of the 

poverty level, the proportion of the population that 

is a racial/ethnic minority, average wage rates for 

implementing public health programs, geographic 

size, and the state’s infrastructure as reflected by 

the number of local governmental health units. 

The 2014 funding formulas are provided 

in Appendix A of this report. On the basis of 

these different factors, the annual investment 

needed to implement the recommended program 

components of a comprehensive tobacco 

control program has been estimated to range 

from $7.41 to $10.53 per capita for all 50 states 

and the District of Columbia combined. 

The minimum and recommended funding 

levels presented in this report reflect the annual 

investment that each state can make in order to 

fully fund and sustain a comprehensive tobacco 

control program. The minimum funding level 

represents the lowest annual investment for 

attaining a comprehensive tobacco control program. 

The recommended funding level represents the 

annual level of investment for ensuring a fully 

funded and sustained comprehensive tobacco 

control program with resources sufficient to most 

effectively reduce tobacco use. These funding 

investment recommendations reflect, in aggregate, 

a nationally realistic level of investment. States 

that invest resources above the recommended 

level will accelerate their progress in eliminating 

tobacco use and reducing tobacco-related 

morbidity and mortality, and associated costs. 

It is important to note that additional 

investments are also required at the societal level 

in order to most effectively reduce tobacco use. 

For example, the enactment of the Affordable Care 

Act has presented significant new opportunities 

to institutionalize tobacco use screening and 

interventions and to increase access to evidencebased cessation treatments through expanded 

insurance coverage. These costs are important to 

consider for the purposes of addressing tobacco 

use but are not necessarily within the purview of 

state tobacco control program funding parameters. 

In fact, the new opportunities realized through 

the Affordable Care Act, along with other factors, 

contributed to a decline in the recommended 

state funding levels for cessation interventions in 

Best Practices for Comprehensive Tobacco Control 

Programs — 2014.

Although each state’s analysis of their priorities 

can shape decisions about funding allocations 

for each recommended program component, it 

remains clear that more substantial investments 

in comprehensive state tobacco controls programs 

lead to quicker and greater declines in smoking 

rates and in smoking-related disease and death.17–19

This report provides evidence to support 

each of the five components of a comprehensive 

tobacco control program. While acknowledging the 

importance of the individual program components, 

it is critical to recognize why these individual 

components must work together to produce the 

synergistic effects of a comprehensive program. 

A comprehensive approach, with the combination 

and coordination of all five program components, 

has shown to be most effective at preventing 

tobacco use initiation and promoting cessation.33–35

Each day in the Unites States, the tobacco 

industry spends nearly $23 million to advertise 

and promote cigarettes.36 During the same period, 

more than 3,200 youth younger than 18 years of 

age smoke their first cigarette and another 2,100 

youth and young adults who are occasional smokers 

progress to become daily smokers.2

 However, 

the tobacco use epidemic can be stopped by 

implementing the interventions that we know 

work. Full implementation of comprehensive 

tobacco control policies and evidence-based 

interventions at CDC-recommended funding levels 

would result in a substantial reduction in tobaccorelated morbidity and mortality and billions of 

dollars in savings from averted medical costs 

and lost productivity in the United States.2,16
14

Introduction

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