18

Section A: State and Community Interventions

I. State and Community Interventions 

Justification 

The history of successful public health practice 

has demonstrated that the active and coordinated involvement of a wide range of societal and 

community resources must be the foundation of 

sustained solutions to pervasive problems like 

tobacco use.1–8 In a review of evidence of population-wide tobacco prevention and control efforts, 

the Task Force on Community Preventive Services confirmed the importance of coordinated 

and combined intervention efforts.9 The strongest 

evidence demonstrating the effectiveness of many 

of the population-wide approaches that are most 

highly recommended by the Task Force on Community Preventive Services comes from studies in 

which specific strategies for smoking cessation, 

preventing tobacco use initiation, and eliminating 

exposure to secondhand smoke are combined with 

mass-media campaigns and efforts to mobilize 

communities and to integrate these strategies into 

synergistic and multicomponent efforts.9

Additionally, research has demonstrated the 

importance of community support and involvement 

at the grassroots level in implementing several 

of the most highly effective policy interventions, 

including increasing the unit price of tobacco 

products and creating smokefree public and private 

environments.3,4,6,10–12 Although knowledge is critical, 

communities must reinforce and support health.13

Example program and policy recommendations 

from the Task Force on Community Preventive 

Services, as well as the Healthy People 2020

policy goals for the nation, are provided in 

Appendix B. In addition, recommendations for 

tobacco-free living from the National Prevention 

Council are provided in Appendix C.

The policies, partnerships, and intervention 

activities that occur at the state and community 

levels will ultimately lead to social norm 

and behavior change nationwide. State and 

community coalitions are essential partnerships. 

For example, they can keep tobacco issues 

before the public, combat the tobacco industry, 

enhance community involvement and promote 

community buy-in and support, educate policy 

makers, and help to inform policy change. 

Social norm change influences behavior 

indirectly by creating social and legal climates in 

which harmful products and conduct become less 

desirable, acceptable, and attainable. The health 

impact pyramid provides a five-tier framework to 

improve health through different types of public 

health interventions, with greater improvements 

coming from activities focused on policy change 

that create a context in which the healthy options 

are easy to attain.6

 This community intervention 

model has now become a core element of statewide 

comprehensive tobacco control programs.3,4,10,14–16

Since the establishment of the California 

Tobacco Control Program in 1989, California has 

achieved an almost 50% decline in the prevalence 

of smoking among adults, from 22.7% in 1988 to 

11.9% in 2010; nearly one million lives saved from a 

combination of smokers who quit and young people who chose not to start; and improved health 

outcomes for Californians, with lung cancer declining nearly four times faster than in the rest of the 

nation.17 During fiscal years 1989–2008, the California Tobacco Control Program cost $2.4 billion 

and led to cumulative health care expenditure 

savings of $134 billion.18 The program uses a socialnorm-change approach to reduce the uptake and 

continued use of tobacco products. For example, 

the statewide media campaign frames the message, 

community-level projects provide education on evidence-based tobacco control policy interventions, 

and statewide projects build the capacity of community-level projects. The tobacco control program’s 

technical assistance is the engine powering social 

change across California by playing a key role in the 

education of evidence-based policy approaches to 

reduce tobacco use.19 State comprehensive tobacco 

control programs nationwide have the tools to 

match and even exceed California’s achievements. 

Tobacco control interventions can counter 

the aggressive and often misleading information 

spread by tobacco companies, which have been 

found in federal court to have deliberately deceived 

the public about the health effects of tobacco.20

In this context, it is particularly important that 

comprehensive statewide tobacco control programs 

coordinate community-level interventions that 

counter tobacco industry marketing and focus on:
19

Section A: State and Community Interventions

 Preventing initiation among youth and 

young adults 

 Promoting quitting among adults and youth

 Eliminating exposure to secondhand smoke

 Identifying and eliminating tobacco-related 

disparities among population groups

Reducing tobacco use is particularly challenging 

because tobacco products are so heavily marketed. 

In 2011, tobacco companies spent more than $8 

billion, or nearly $23 million per day, to market 

cigarettes in the United States, mostly at the point 

of sale.21 In addition to these tobacco advertising 

and promotion efforts, both adults and youth 

have been, and continue to be, heavily exposed 

to images of smoking in the movies, other massmedia, social marketing, and digital and mobile 

technologies.22–26 For example, 35% of U.S. youth 

reported having seen tobacco advertisements on 

the Internet in 2008.7 Research has shown that there 

is a causal relationship between advertising and 

promotional efforts of the tobacco companies and 

the initiation and progression of tobacco use among 

young people;7 approximately one-third of underage 

experimentation with smoking can be attributed 

to tobacco industry advertising and promotion.7

As cigarette use declines, new tobacco 

products, such as noncombustible products, and 

nicotine delivery products, such as e-cigarettes, are 

also being introduced and marketed. Approximately 

one of five current smokers has used e-cigarettes.27

Additionally, e-cigarette experimentation and recent 

use doubled among U.S. middle and high school 

students during 2011–2012, resulting in an estimated 

1.78 million students having ever used e-cigarettes 

as of 2012.28 Coordinated implementation of a broad 

range of statewide and community programs and 

policies is important to ensuring that the continued 

marketing of cigarettes and other combustible 

products, as well as the new marketing and sale 

of emerging non-combustible products, does not 

prolong the harms caused by smoking. These 

programs and policies are best implemented along 

with mass media campaigns to influence societal 

organizations, systems, and networks that encourage 

and support individuals to make behavior choices 

consistent with tobacco-free norms.3,4,14,29,30

Community engagement is essential for 

meaningful change to occur in the way that tobacco 

products are marketed, sold, and used. The National 

Association of County and City Health Officials 

has developed guidelines for comprehensive local 

tobacco control programs (Appendix D).31 The 

CDC-recommended community-based model to 

produce durable changes in social norms is based 

on evidence that approaches with the greatest span 

(economic, regulatory, and comprehensive) and 

jurisdictional reach (number of people covered) 

will have the greatest population impact.3,4,14,29,30

Interventions to prevent tobacco use initiation 

and to encourage cessation among youth and 

young adults can reshape the environment so that 

it supports tobacco-free norms. Nearly 9 of 10 

smokers in the United States start smoking by the 

time they are 18 years old, and 99% start by the age 

of 26.7 Thus, intervening during adolescence and 

young adulthood is critical.32 Research has shown 

that increasing the unit price of tobacco products, 

comprehensive smokefree air laws, and state 

tobacco control programs are effective strategies 

for curbing youth and adult smoking.32 Community 

programs and school and college policies and 

interventions should be part of a comprehensive 

effort—coordinated and implemented in 

conjunction with efforts to create tobacco-free social 

norms, including increasing the unit price of tobacco 

products, sustaining anti-tobacco media campaigns, 

and making environments smokefree.7,9,22,33

Recommendations for Preventing 

Tobacco Use Among Youth9,34

 Increase the unit price of tobacco products.

 Conduct mass-media education campaigns in 

combination with other community interventions.

 Mobilize the community to restrict minors’ 

access to tobacco products in combination 

with additional interventions (stronger 

local laws directed at retailers, active 

enforcement of retailer sales laws, and 

retailer education with reinforcement). 

Most states fund community and statewide 

organizations to develop and maintain an 

infrastructure and to implement populationwide and specific programs. To achieve lasting 

changes, community and statewide organizations 

require funding to hire diverse staff, provide 

operating expenses, purchase or develop 

education materials and resources, conduct 

education and training programs, carry out 

communication and media advocacy campaigns, 

and recruit and maintain local partnerships.31
20

Section A: State and Community Interventions

Statewide Programs 

Statewide programs can deliver statewide programming such as mass media campaigns and 

enforcement efforts, and provide leadership and 

coordination of efforts related to state policies, 

laws, and regulations. Statewide programs also 

can provide the skills, resources, and information 

needed for coordinated and strategic implementation of effective community programs. For 

example, training local community coalitions about 

the legal and technical aspects of comprehensive 

smokefree policies and enforcement can be provided most efficiently through statewide partners 

who have experience in administering these services. In states where comprehensive smokefree 

policies have already been implemented, efforts 

to promote smokefree private environments, such 

as multiunit housing, may be considered. Direct 

funding provided to statewide organizations can 

be used to mobilize their organizational assets to 

strengthen statewide initiatives and community 

resources. 

For example, the New York Tobacco Control 

Program runs statewide media campaigns, 

develops and executes policy and regulatory 

initiatives, implements enforcement efforts, and 

funds organizations across the state to work 

in five modalities: community partnerships for 

tobacco control, youth action programs, school 

policy programs, cessation centers, and colleges 

for change programs. Community programs 

are structured in such a way that every county 

falls within the coverage area of a community 

partnership, a cessation center, and a school policy 

program. All community programs are charged 

with bringing about environmental change in 

multiple settings, including worksites, schools, 

licensed tobacco retailers, multiunit housing, and 

public spaces such as parks and beaches. These 

community actions complement and reinforce 

similar statewide action through three types of 

activities: use of paid and earned media to raise 

awareness and educate the community and key 

community members about the tobacco epidemic; 

education of government policy makers about the 

tobacco epidemic to build support for tobacco 

control policies; and education of organizational 

decision makers, including tobacco retailers, health 

care organizations, school boards, and community 

organizations, for policy changes and resolutions.35

It is important to note that careful attention 

must be paid to ensuring that public funds are 

appropriately used. Tracking and reporting on 

funding sources by activity is integral to ensure that 

public funds are not used for prohibited activities. 

CDC’s National Center for Chronic Disease 

Prevention and Health Promotion has developed 

four domains that can provide a framework for 

state tobacco prevention and control programs 

to collaborate with other state and community 

programs to address diseases for which tobacco 

is a major cause, including multiple cancers, 

heart disease and stroke, and chronic lung 

and respiratory diseases (See Figure 1).36
21

Section A: State and Community Interventions

Figure 1. Key domains for transforming the nation’s health and providing individuals with 

equitable opportunities to take charge of their health. 

Domain 1

Epidemiology and surveillance to gather, analyze, and disseminate 

data and information and conduct evaluation to inform, prioritize, 

deliver, and monitor programs and population health. 

Domain 3

Health system interventions to improve the effective delivery and use of 

clinical and other preventive services in order to prevent disease, detect diseases 

early, and reduce or eliminate risk factors and mitigate or manage complications. 

Domain 2

Environmental approaches that promote health and support 

and reinforce healthful behaviors statewide and in communities. 

Domain 4

Strategies to improve community-clinical linkages ensuring 

that communities support and clinics refer patients to programs 

that improve management of chronic conditions. 

Addressing evidence-based tobacco control strategies in the broader context of tobacco-related 

diseases is beneficial for four reasons:

 It is critical that interventions are 

implemented to alleviate the existing 

burden of tobacco-related disease.

 The incorporation of tobacco prevention 

and cessation messages into broader 

public health activities ensures wider 

dissemination of tobacco control strategies.

 Tobacco use in conjunction with other 

diseases and risk factors, such as sedentary 

lifestyle, poor diet, and diabetes, poses a 

greater combined risk and poorer prognosis 

for many chronic diseases than the sum 

of each individual degree of risk. 

 Educating the public about the broader context 

of tobacco-related diseases helps mobilize 

public support and action for tobacco control.

Each state’s financial, social, and 

demographic characteristics have a significant 

role in tobacco prevention and control efforts. 

Examples are provided in the following box.
22

Section A: State and Community Interventions

 Supporting and/or facilitating tobacco prevention 

and control partnership and coalition development, 

as well as links to other related partnerships and 

coalitions (e.g., cancer control, cardiovascular disease, 

diabetes, asthma).

 Establishing a strategic plan for comprehensive 

tobacco control with appropriate partners at the 

state and community levels.

 Educating state leaders, decision-makers, and 

the public about the burden of tobacco use and 

evidence-based policy and other strategies to 

reduce this burden.

 Engaging stakeholders and partners on 

approaches, such as message development 

and messengers, to reach populations with 

the greatest disparities in tobacco use.

 Collecting, disseminating, and analyzing state 

and community-specific data; developing and 

implementing culturally appropriate interventions 

with appropriate multicultural involvement; and 

making program adjustments as indicated.

 Sponsoring community, regional, and statewide 

trainings, conferences, and technical assistance on 

best practices for effective tobacco use prevention 

and cessation programs.

 Monitoring pro-tobacco influences to facilitate public 

discussion and debate among partners, decision 

makers, and other stakeholders at the state and 

community level.

 Supporting community-level innovations in tobacco 

control that may enhance the public health impact 

of current state-level policies and disseminating 

successful interventions across communities.

Examples of Statewide Efforts for Tobacco Prevention and Control 

Community Programs 

A “community” encompasses a diverse set of entities that reach across multiple sectors, including 

voluntary health agencies; civic, social, and recreational organizations; businesses and business 

associations; city and county governments; public health organizations; labor groups; health care 

systems and providers; health care professionals’ 

societies; schools and universities; faith organizations; and organizations for racial and ethnic 

minority groups.1–5,8,10

To counter aggressive pro-tobacco influences, 

communities are encouraged to change the 

knowledge, attitudes, and practices of tobacco 

users and nonusers and also engage in strategies to 

address the manner in which tobacco is promoted, 

the time, manner, and place in which tobacco is 

sold, and how and where tobacco is used.4,5,7

State and local governments play an 

integral role in achieving the goals of the Family 

Smoking Prevention and Tobacco Control Act 

(FSPTCA), which granted the Food and Drug 

Administration (FDA) the authority to regulate 

tobacco products.37 The FSPTCA permits states 

and local governments to impose specific bans or 

restrictions on the time, place, and manner—but 

not the content—of cigarette advertisements. 

States may adopt or continue to enforce 

requirements pertaining to tobacco products that 

are in addition to, or more stringent than, many 

requirements of the law. However, although the 

law preserves a substantial amount of the states’ 

authority to regulate tobacco products, some 

state and local requirements are preempted.37

Effective community programs involve and 

influence people in their daily environment.1,3–5,8,38

Therefore, community engagement and 

mobilization are essential to programs addressing 

tobacco control.39,40 Implementing strategies 

that can impact societal organizations, systems, 

and networks necessitates the involvement of 

community partners.1,2,4,7 Decreasing disparities in 

tobacco use occurs largely through engagement 

in evidence-based community interventions.
23

Section A: State and Community Interventions

 Providing funding to community-based organizations 

in order to strengthen the capacity of these groups to 

positively inform social norms regarding tobacco use 

and to build relationships among multiple sectors of 

the community, such as housing, education, business, 

planning, and transport.

 Empowering local agencies to build community 

coalitions and partnerships that facilitate 

collaboration among programs in local governments, 

voluntary and civic organizations, and diverse 

community-based organizations.

 Collaborating with partners and other programs to 

implement evidence-based interventions and build 

and sustain capacity through technical assistance 

and training.

 Supporting community strategies or efforts to 

educate the public and media, not only about 

the health effects of tobacco use and exposure 

to secondhand smoke, but also about available 

cessation services.

 Promoting public discussion among partners, decision 

makers, and other stakeholders about tobacco-related 

health issues and pro-tobacco influences.

 Establishing a community strategic plan of action that 

is consistent with the statewide strategic plan.

 Ensuring that funding formulas for the local public 

health infrastructure provide grantees (e.g., local 

and county health departments, tribal organizations, 

nonprofit organizations) operating expenses 

commensurate with tobacco control program and 

evaluation efforts.

 Ensuring that community grantees measure and 

evaluate social norm change outcomes (e.g., policy 

adoption, increased compliance) resulting from their 

interventions.

 Ensuring that partners receiving funding for tobacco 

control from various entities work collaboratively. 

Examples of State Program Involvement in Community-Level Interventions 

Achieving Equity to Eliminate 

Tobacco-Related Disparities 

Reducing tobacco-related disparities is a critical 

component of a comprehensive tobacco control 

program.10,41 Tobacco-related disparities are differences that exist among population groups with 

regard to key tobacco-related indicators, including patterns, prevention, and treatment of tobacco 

use; the risk, incidence, morbidity, mortality, and 

burden of tobacco-related illness; and capacity, 

infrastructure, and access to resources; and second-hand smoke exposure.42

Identifying and eliminating tobacco-related 

disparities among population groups is one of 

the four goals for comprehensive state tobacco 

control programs. To ultimately eliminate 

tobacco-related disparities, tobacco control 

programs and policies must be implemented in 

a way that achieves equitable benefits for all.

Activities focused on achieving equity and 

eliminating tobacco-related disparities can help 

accelerate the decline in the prevalence of tobacco 

use and access to effective cessation treatments, 

thus alleviating the disproportionate health 

and economic burden experienced by some 

population subgroups.10 Tobacco-related disparities 

can affect population subgroups on the basis of 

certain factors, including but not limited to:43,44

 Age

 Disability / limitation 

 Educational attainment

 Geographic location (e.g., rural/urban) 

 Income 

 Mental health status

 Occupation 

 Race / ethnicity

 Sex 

 Sexual orientation and gender identity 

 Substance abuse conditions 

 Veteran and military status

It is important to use surveillance systems 

and other data collection systems to measure these 

types of characteristics within states and communities 

to help identify populations with tobacco-related 

disparities,45 and to engage members of affected 

communities in reducing and preventing tobacco use. 
24

Section A: State and Community Interventions

 Conduct surveillance to identify populations 

disproportionately affected by tobacco use.

 Partner with population groups and communitybased organizations that serve these populations 

experiencing tobacco-related disparities.

 Ensure that health equity is an integral part of state 

and community tobacco control strategic plans.

 Mitigate barriers to effective implementation 

of tobacco control interventions, such as 

enhancing access to cessation services for 

low-income or other communities.

 Fund organizations that can effectively reach, 

educate, and involve populations experiencing 

tobacco-related disparities.

 Provide culturally competent technical assistance 

and training to grantees and partners.

Activities to Support Equity Achievement and Eliminate 

Tobacco-Related Disparities

In order to adequately identify and effectively 

eliminate tobacco-related disparities, state tobacco 

control programs must implement a number of 

tobacco prevention and control strategies, including establishing infrastructure and building 

capacity.42 These strategies are useful for guiding the development of policies and practices that 

reflect the principles of inclusion, cultural competency, and equity. Reaching the national goal of 

eliminating health disparities related to tobacco 

use will also require enhanced collection and 

This guidance is based upon information and 

experience derived from state practices, scientific studies, and input from external partners and 

experts in the field of tobacco control. The guidance highlights the presumed minimum capacity 

and infrastructure needed by state tobacco control 

programs to pursue a strategic plan with initiatives 

that will most effectively achieve equity in tobacco 

prevention and control through the identification 

and elimination of tobacco-related disparities.47

use of standardized data to correctly identify disparities in tobacco-related outcomes, including 

awareness and use of tobacco products, health 

outcomes, and program effectiveness.45,46 The 

use of oversampling, combining multiple years 

of data, and qualitative methods are often necessary to adequately assess these outcomes among 

some population groups.10 In addition, clear leadership, dedicated resources, and a commitment to 

inclusion are essential to develop and implement a 

strong strategic plan.42

Ending the Epidemic: A Tobacco Control 

Strategic Action Plan for the U.S. Department 

of Health and Human Services, which was 

published in 2010, called attention to the need 

to reduce tobacco-related disparities through 

specific interventions in locations serving high-risk 

populations, such as subsidized and public housing, 

substance abuse facilities, mental health facilities, 

correctional institutions, community health centers, 

federally qualified health centers, Ryan White 

clinics, rural health clinics, and critical 

access hospitals. 

 Create partnerships to maximize resources 

and reach of interventions.

 Integrate efforts to eliminate tobacco-related 

disparities in all chronic disease prevention areas.

 Identify and develop culturally competent 

materials and interventions.

 Educate partners and key decision makers 

about tobacco-related disparities.

 Reduce exposure to targeted tobacco industry 

advertising, promotion, and sponsorship.

 Obtain comprehensive Medicaid coverage 

for tobacco dependence treatments.

 Evaluate intervention efficacy and 

refine efforts as appropriate.

Strategies to Achieve Equity and Eliminate Tobacco-Related Disparities 
25

Section A: State and Community Interventions

Reducing the prevalence of tobacco use 

requires greater attention to populations 

carrying a disproportionate burden of use and 

dependence. One way to reach such groups 

is through efforts that directly affect those 

populations, including tobacco-free policies, 

quitline promotion, and counseling and 

cessation services.48 Following are examples 

from select states that have made such efforts.

In 2006, the Massachusetts Medicaid program 

expanded its cessation benefit by providing 

comprehensive coverage of tobacco cessation 

medications.49 More than 75,000 (37%) Medicaid 

subscribers used the benefit in the first two and a 

half years. The prevalence of smoking among the 

Medicaid population decreased from 38% to 28% 

during this period. Use of a comprehensive tobacco 

cessation benefit that includes pharmacotherapy was 

associated with a significant decrease in claims for 

hospitalizations for heart attacks and acute coronary 

heart disease. Annualized hospitalizations for these 

cardiovascular conditions among Medicaid smokers 

who used the benefit declined by almost half. Every 

dollar spent on the benefit was associated with $3.12 

in medical savings for cardiovascular conditions.49

In California, the California Smoker’s Helpline 

and the Asian Smokers Quitline provide cessation 

services and culturally appropriate information in 

multiple languages for different audiences. These 

focused tobacco cessation interventions, along with 

other elements, have led to significant reductions 

in smoking across ethnic groups in California. 

For instance, during 1990-2005, smoking rates 

among Asian men dropped from 20% to less than 

15%; among Hispanic men, from 22% to 16%; and 

among African American men, from 28% to 21%.50

Adults with any mental illness have a high 

prevalence of cigarette smoking.51 Moreover, 

sociodemographic variations in the prevalence 

of current smoking among persons with any 

mental illness resemble patterns in the overall 

population, and adult smokers with mental illness 

are less likely to quit than those smokers without 

mental illness. Accordingly, enhanced prevention 

and cessation efforts among persons with mental 

illness can further reduce smoking-related death 

and disease. For example, the New York tobacco 

control program has identified populations with 

chemical addictions or mental illness for specific 

intervention. To reach these populations, the state 

used strategies that included integrating tobacco 

dependence treatment into treatment protocols 

for mental illness or chemical dependency, 

promoting tobacco-free campuses for substance 

abuse and mental health facilities, and partnering 

with agencies representing each group.52

In 2013, the following national networks jointly 

designed and sponsored a series of trainings in 

Texas to introduce specific populations to tobacco 

control: the National African American Tobacco 

Prevention Network (NAATPN), the National Latino 

Tobacco Control Network (NLTCN), and the Asian 

Pacific Partners for Empowerment, Advocacy and 

Leadership (APPEAL). Participants with long-term 

involvement in their communities were identified 

and recruited to attend these training opportunities. 

The trainings sought to increase specific population 

leadership, collaboration, and civic engagement at 

a grassroots level to address disparities in health 

that result from tobacco use and secondhand 

smoke exposure. The trainings addressed the 

importance of: building organizational capacity 

by connecting participants with local coalitions, 

including Community Transformation Grantees, or 

building a local coalition; mobilizing communities 

to address health disparities and implement tobacco 

control and health promotion policies; facilitating 

cross cultural collaboration among Latino, African 

American, and Asian American, Native Hawaiian, 

and Pacific Islander communities; increasing 

leadership knowledge and skills on health 

disparities among community advocates; increasing 

knowledge of the impact of tobacco use on chronic 

disease disparities; creating emerging promising 

practices on engaging priority populations; 

and developing materials and approaches, 

such as workers’ rights and social justice, that 

make secondhand smoke exposure relevant to 

populations with a high burden of exposure.
26

Section A: State and Community Interventions

Budget 

Linking state and community interventions creates 

synergistic effects, greatly increasing the effects 

of each comprehensive tobacco control component. Effective actions are those that reinforce one 

another, including: raising community awareness 

and mobilization efforts; developing health communication interventions; collecting, analyzing, 

and disseminating data; and providing cessation 

interventions. Evidence indicates that interventions 

that promote changes in social norms appear to 

be the most effective approach for sustained 

behavior change.9

Best Practices dictates allocating funds for 

establishing and sustaining internal capacity with 

experienced staff and developing an infrastructure 

with partner organizations and other programs to 

oversee and implement evidence-based programs. 

Most states fund local health departments, boards 

of health, or health-related nonprofit community 

organizations representing each county, multicounty 

region, or major metropolitan areas to develop 

and maintain local infrastructure and implement 

jurisdiction-wide and targeted programs. Best 

Practices recommends that funds be awarded 

directly to tribal health departments and tribalserving organizations to deliver tobacco control 

programming to tribes and tribal members, as 

well as to other organizations that serve specific 

populations, in order to implement evidence-based 

programs and activities with that population. Funds 

may also be distributed to different agencies to 

ensure compliance with tobacco prevention and 

control laws. These varied efforts remain integrated 

through effective communication, coalitions, and 

networks. It is important that states also take into 

account the special issues of different communities 

within their state, such as large variations in 

population size, differences in the prevalence of 

smoking among various populations, access to 

cessation services, and reach of the interventions. 

Recommendations for funding state and 

community interventions are based on the 1999 

funding formulas, which were updated in 2007 to 

include the following major components: statewide 

programs, community programs to reduce tobacco 

use, chronic disease programs to reduce the burden 

of tobacco-related diseases, school programs, 

and enforcement.47,53

The minimum and recommended funding levels 

are derived from the 2007 funding formulas and 

adjusted for population changes and inflation. The 

specific state-recommended level of investment 

is based on the relative complexity and cost of 

doing business in that state. Drawing from the 

experience of states that have implemented robust 

state and community interventions, funding levels 

were determined for each state. The minimum 

and recommended levels of investment were 

based primarily on each state’s current smoking 

prevalence, while also taking into account other 

factors 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.

For the 2014 update of Best Practices, the 

state and community interventions formula 

does not specifically include chronic disease 

programs to reduce the burden of tobacco-related 

diseases, school programs, and enforcement as 

major components. However, activities in these 

three areas may still be undertaken within the 

framework of state and community interventions. 

For example, chronic disease prevention and 

control programs are stakeholders and partners in 

tobacco control. Using evidence-based interventions 

and strategies to address state tobacco control 

priorities, as described in the state chronic disease 

plan, can support achieving the four National 

Tobacco Control Program goals. Similarly, there 

is little evidence of the long-term effectiveness 

of school-based programs to prevent smoking.7,54

However, they can be more efficacious when part 

of a comprehensive, multicomponent approach to 

tobacco use prevention that includes school policies, 

community-wide strategies, and mass media. 

Finally, active enforcement of youth access laws 

is part of broader community mobilization efforts 

that combine additional interventions, including 

stronger retailer laws and retailer education, with 

reinforcement. The FSPTCA authorizes FDA to 

contract with states, territories, and tribes for 

the purposes of conducting compliance check 

inspections of tobacco retailers. Some states have 

contracted with local public health organizations 

to assist with FDA’s rigorous enforcement efforts. 

For the last 15 years, states have implemented 

CDC’s recommendations, focusing their efforts 

on proven activities that have the greatest 

impact, while also expanding the evidencebase of effective tobacco control interventions 

and building on each other’s successes.7,9,10,33
27

Section A: State and Community Interventions

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