Tobacco Use And Public Health: Federal Efforts to Prevent and Reduce Tobacco Use among Youth
Published: 2003-11-21T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Tobacco use is the leading cause of preventable death in the United States. The Centers for Disease Control and Prevention (CDC) reported that, on average, over 440,000 deaths and $76 billion in medical expenditures were attributable to cigarette smoking each year from 1995 through 1999. Reducing tobacco-related deaths and the incidence of disease, along with the associated costs, represents a significant public health challenge for the federal government. Most adults who use tobacco started using it between the ages of 10 and 18. According to a Surgeon General's report, if children and adolescents can be prevented from using tobacco products before they become adults, they are likely to remain tobacco-free for the rest of their lives. GAO was asked to provide information on federal efforts to prevent and reduce youth smoking. Specifically, this report describes (1) federal programs, research, and activities that aim to prevent and reduce tobacco use among youth, (2) the efforts of federal departments and agencies to monitor their programs, and (3) the coordination among federal departments and agencies in efforts to prevent and reduce tobacco use among youth.
section_title: What GAO Found
paragraphs: Some federal programs, research, and activities that aim to address tobacco use among youth focus only on tobacco while others aim to address tobacco use as part of broader efforts to address unhealthy behaviors such as substance abuse and violence. Two federal programs within the Department of Health and Human Services (HHS) focus only on tobacco use. CDC's National Tobacco Control Program (NTCP) focuses on preventing and reducing tobacco use among the general population and explicitly targets youth. The Substance Abuse and Mental Health Services Administration's program to oversee implementation of a provision of federal law, commonly referred as the Synar Amendment, focuses only on tobacco use among youth. The Synar Amendment requires states to enact and enforce laws prohibiting the sale of tobacco products to minors. In addition to these tobacco-focused programs, HHS, and the Departments of Defense (DOD), Justice (DOJ), and Education sponsor programs that include tobacco use as part of broader efforts to address unhealthy behaviors among youth, such as substance abuse and violence. For example, Education's Safe and Drug-Free Schools and Communities program is designed to prevent substance abuse and violence. HHS agencies, such as the National Institutes of Health, conduct research on tobacco use and nicotine addiction among youth and its health effects on youth. HHS agencies and other federal departments also support activities to prevent and reduce tobacco use among youth, such as education and outreach efforts. HHS and its component agencies coordinate tobacco-related efforts with other federal, state, and local government agencies and nongovernmental entities. Federal departments and agencies collect a variety of information to monitor how programs that aim to address tobacco use among youth are being implemented by grantees and the effectiveness of grantee efforts in meeting program goals. The information is collected through various means, including grant applications, progress reports, periodic site visits, and program evaluations. For example, to monitor NTCP, CDC requires states to submit biannual reports on the implementation of state NTCP-supported tobacco control programs. The information that federal departments and agencies collect on these programs is also used to provide training and technical assistance to grantees on topics such as conducting program evaluation. In commenting on a draft of this report, HHS stated that the report was very informative but it did not include programs like Medicaid that are a substantial element of HHS tobacco prevention efforts. Including programs that finance health insurance such as Medicaid, however, was beyond the scope of our review. Also, HHS noted that we did not include information about the challenges other federal agencies face in coordinating tobaccorelated issues but DOD, DOJ, and Education did not describe such challenges. DOD and DOJ had no comments on the report and HHS and Education provided technical comments that we incorporated as appropriate.

section_title: Letter
paragraphs: Tobacco use is the leading cause of preventable death in the United States.  In its most recent estimates of selected health consequences of cigarette  smoking, the Centers for Disease Control and Prevention (CDC) reported  that, on average, over 440,000 deaths and $76 billion in medical  expenditures were attributable to cigarette smoking each year from 1995  through 1999. Reducing the number of tobacco-related deaths, along with  the associated costs, represents a significant public health challenge for  the federal government. The first Surgeon General’s report to the Congress  that specifically focused on tobacco use among youth concluded that  preventing youth from starting to use tobacco is key to reducing the  deaths and incidence of disease attributable to tobacco use. Most adults  who use tobacco started using it between the ages of 10 and 18. According  to the report, if children and adolescents can be encouraged to abstain  from using tobacco before they become adults, they are less likely to use  tobacco for the rest of their lives. Although smoking rates (defined as  smoking one or more cigarettes in the previous 30 days) among 12th grade  students have declined from a rate of about 37 percent in 1997, in 2002,  about 27 percent of 12th grade students reported that they smoked. In  1992, the Congress passed legislation, commonly referred to as the Synar  Amendment, designed to prohibit the sale and distribution of tobacco  products to minors.
Given the harmful effects of tobacco use and the rates of smoking among  youth, you asked us to provide information on federal efforts to prevent  and reduce youth smoking. We focused our review on describing   (1) programs, research, and activities that aim to prevent and reduce  tobacco use among youth, (2) the efforts of federal departments and  agencies to monitor their programs, and (3) the coordination among  federal departments and agencies in their efforts to prevent and reduce  tobacco use among youth.
To identify federal programs, research, and activities that aim to address  tobacco use among youth, we reviewed the Catalog of Federal Domestic  Assistance, which is a database of federal grant programs, and other  pertinent documents. In addition, we interviewed program officials in  multiple federal agencies. As a result, we focused on four federal  departments that support programs and other efforts to prevent and  reduce tobacco use among youth: the Department of Health and Human  Services (HHS) and its component agencies—CDC, Substance Abuse and  Mental Health and Services Administration (SAMHSA), National Institutes  of Health (NIH), and Health Resources and Services Administration  (HRSA); the Department of Defense (DOD); the Department of Justice  (DOJ); and the Department of Education (Education). Where available, we  also obtained fiscal year 2002 funding information on the federal programs  and research that we identified. To identify how federal departments and  agencies monitor their programs, we reviewed agency strategic plans,  annual performance plans and reports, program guidance documents, and  program evaluations. To determine how federal departments and agencies  coordinate their efforts, we reviewed their strategic plans and annual  performance plans and reports and also descriptions of coordination  efforts. In addition, we interviewed agency officials about their program  monitoring and coordination efforts and asked them to describe any  coordination challenges they faced. (For additional information on our  methodology, see app. I.) We conducted our work from January 2003  through October 2003 in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: From 1991 through 2002, smoking rates among youth fluctuated and  reached their highest points around 1997. The estimated rate of current  smoking among youth (defined as smoking one or more cigarettes during  the previous 30 days) varied according to grade level (see fig.1). For  example, the rate among 8th grade students peaked at about 21 percent in  1996 before declining to about 11 percent in 2002. For 10th grade students,  the smoking rate peaked at 30 percent in 1996 before declining to 18  percent in 2002. Similarly, smoking among 12th grade students peaked at  about 37 percent in 1997, before declining to about 27 percent in 2002.
HHS serves as the lead federal department for addressing the nation’s  public health issues, including tobacco use. HHS is responsible for  informing the public of the dangers of tobacco use and coordinating  federal efforts to address tobacco use issues. Within HHS, CDC’s Office on  Smoking and Health has been delegated the lead for all policy and  programmatic issues related to the prevention and reduction of tobacco  use and has primary responsibility within the federal government for  tobacco use prevention efforts. Also within HHS, the Surgeon General  serves as the nation’s spokesperson on matters of public health and  reports on issues such as the health effects of tobacco use. Other HHS  agencies, such as SAMHSA, NIH, and HRSA, support efforts to prevent and  reduce tobacco use. Education, DOD, and DOJ also support programs and  activities that aim to address tobacco use among youth.
Several studies have highlighted the importance of addressing tobacco use  among youth. In 1994, the Surgeon General released a report that focused  on the use of tobacco among youth. The report highlighted several factors  that increase the likelihood that youth will begin using tobacco. These  factors include engaging in other unhealthy behaviors, like substance  abuse and violence; peer pressure to smoke; and cigarette advertising and  promotion. In addition, the Surgeon General, CDC, NIH, and the Institute  of Medicine have reported on approaches that can help prevent youth  from starting to use tobacco and help existing users quit. For instance,  they have reported on the demonstrated benefits of interventions such as  implementing counter-marketing campaigns, using school-based  educational programs in combination with providing youth with  alternatives to the illicit use of tobacco, deglamorizing tobacco use, and  restricting minors’ access to tobacco. According to the Surgeon General’s  1994 report, strategies for preventing and reducing tobacco use among  youth should be multifaceted and involve collaborations among those that  can influence the behavior and attitudes of youth, such as family members  and educators.
HHS led federal, state, and local agencies and nongovernmental  organizations in developing a 10-year national plan, the Healthy People  2010 initiative, that includes goals for addressing tobacco use. The Healthy  People 2010 initiative has identified tobacco use as one of 10 leading  health indicators for the nation. Healthy People 2010 objectives related to  tobacco use among youth include, among other objectives, reducing the  percentage of adolescents who smoked cigarettes in the past month and  increasing the percentage of adolescents who try to quit smoking.
section_title: Some Federal Programs, Research, and Activities Focus Only on Tobacco Use, While Others Address Tobacco Use Along with Other Unhealthy Behaviors
paragraphs: Two HHS agencies, CDC and SAMHSA, administer programs that focus  only on tobacco use. CDC’s NTCP targets youth within a broader mission  of preventing and reducing tobacco use among the general population.  SAMHSA oversees implementation of the Synar Amendment that requires  states to enact and enforce tobacco control laws prohibiting the sale of  tobacco products to minors. Other programs and activities administered  by HHS, DOD, DOJ, Education, and the Office of National Drug Control  Policy (ONDCP) address tobacco use as part of a broader focus on  unhealthy behaviors, such as substance abuse and violence. (See app. II  for examples of federal programs that can address tobacco prevention and  reduction among youth.)
subsections: section_title: Some Federal Programs Only Address Tobacco Use
paragraphs: We identified two federal programs that focus only on tobacco use. The  first, CDC’s NTCP, focuses on preventing and reducing tobacco use  among the general population, but it also explicitly targets tobacco use  among youth. NTCP provides funds through cooperative agreements to all  states. In fiscal year 2002, NTCP provided about $58 million to states to  address NTCP’s four goals. NTCP’s four goals are to (1) prevent youth  from starting to smoke, (2) help youth and adults quit smoking, (3)  minimize the public’s exposure to secondhand smoke, and (4) identify and  mitigate the factors that make some populations more likely to use  tobacco than others. NTCP cooperative agreements specify the terms  under which federal funds are provided to the states.
Under NTCP, CDC encourages states to use multiple types of interventions  in their efforts to prevent and reduce tobacco use. CDC has developed  guidance intended to assist states in designing, implementing, and  evaluating their individual tobacco control programs. For instance, CDC  recommends that states establish comprehensive tobacco control  programs that include certain components, such as    community-based programs to reduce tobacco use that include a wide  range of prevention activities, such as engaging youth in developing and  implementing tobacco control interventions, conducting educational  programs for young people, parents, school personnel, and others, and  restricting access to tobacco products;    school programs to implement school health policies that consist of  tobacco-free policies, evidence-based curricula, teacher training, parental  involvement, cessation services, and links between school and other  community efforts and state media and educational campaigns;    marketing campaigns to counter protobacco influences and increase  prohealth messages and influences, including paid television, radio,  billboard, and print media campaigns;    cessation services to help people quit smoking;    enforcement of tobacco control policies by restricting minors’ access to  tobacco and restricting smoking in public places; and    statewide efforts to provide localities with technical assistance on how to  evaluate tobacco programs, promote media advocacy, implement smoke- free policies, and reduce minors’ access to tobacco.
CDC officials told us that CDC also provides training and technical  assistance to states in designing, implementing, and evaluating their  tobacco control programs. For example, in fiscal year 2000, CDC  conducted three regional workshops for state health departments and  education agencies aimed at helping such agencies develop coordinated  plans to prevent youth from starting to use tobacco. According to CDC,  representatives from 33 states participated in these workshops.
The second federal program that focuses only on tobacco and aims to  prevent tobacco use among youth is SAMHSA’s program to oversee state  implementation of legislation commonly referred to as the Synar  Amendment. This program is the only one we identified that focuses solely  on tobacco use among youth. The Synar Amendment and its implementing  regulation require states to enact and enforce laws that prohibit the sale of  tobacco products to minors, conduct random inspections of tobacco retail  or distribution outlets and estimate the percentage of retailers that illegally  sell tobacco to minors, and report the results of their efforts to the  Secretary of HHS. States are also required to report enforcement actions  taken against those who violate state laws in order to receive certain  federal grants. By the end of fiscal year 2003, states may have no more  than 20 percent of retail tobacco outlets in violation of state laws that  prohibit the sale of tobacco products to minors. To oversee states’ efforts  to accomplish this, SAMHSA and the states negotiated interim annual  target rates that states should meet. States may use a portion of their  Substance Abuse Prevention and Treatment block grant to help fund the  design and implementation of their inspection programs. For fiscal year  2002, the states reported that they planned to expend more than $5.4  million in block grant funds on Synar-related activities.
section_title: Other Federal Programs Address Tobacco Use Along with Other Unhealthy Behaviors
paragraphs: Other federal programs aim to address tobacco use among youth as part of  a broader focus on unhealthy behaviors. For example, CDC’s Coordinated  School Health program provides grants to states to implement school  health programs to prevent a range of unhealthy behaviors or conditions,  such as drug, alcohol, and tobacco use; physical inactivity; poor nutrition,  and obesity. In fiscal year 2002, CDC awarded grants to 22 states, with  each state receiving approximately $400,000. CDC helps state education  and health departments identify and implement health education curricula  to provide youth with information and the decision-making,  communication, and peer-resistance skills needed to avoid unhealthy  behaviors. In addition, CDC provides guidance to state and local health  education agencies on tobacco prevention programs in schools that covers  policies, programs, and a tobacco-free environment. CDC periodically  surveys the states, school districts, and schools on the health curricula  they offer and on school health policies relating to tobacco prevention and  reduction efforts. According to CDC, the information obtained through  these survey efforts is used to assess trends in school health education  programs.
Education’s Safe and Drug-Free Schools and Communities program aims  to prevent violence and drug, alcohol, and tobacco use in the nation’s  schools. Under this program in fiscal year 2002, Education awarded more  than $472 million in grants to state education departments and governors’  offices. Similarly, the Safe Schools/Healthy Students program, which is  funded by Education, HHS, and DOJ, provides local education agencies  with grants that support a variety of services designed to promote healthy  childhood development and prevent substance abuse (which can include  the use of tobacco) and violence. These services target preschoolers,  school-aged children, and adolescents. The Safe Schools/Healthy Students  program’s activities totaled about $172 million for fiscal year 2002.
DOJ and DOD support drug prevention programs that also aim to prevent  tobacco use among youth. For example, the Drug-Free Communities  Support program, which is administered by ONDCP and DOJ, is designed  to support the efforts of community coalitions that aim to prevent and  reduce young people’s use of drugs, alcohol, and tobacco. These coalitions  consist of youth, parents, health care professionals, educators, law  enforcement officials, and other community partners. In fiscal year 2002,  DOJ awarded about $46 million to community coalitions located in 50  states. Approximately $7 million was given in new awards to 70  community coalitions, and $39 million was given in renewed funding to  462 existing community coalitions. Another program, the Drug Education  for Youth program (DEFY), which is sponsored by DOD and DOJ, targets  youth aged 9 to 12 to improve awareness of the harmful effects of alcohol  and other drugs, including tobacco. According to agency officials, the  program aims to promote positive self-images and lifestyles. In fiscal year  2002, DOD funding totaled over $1 million for 55 local DEFY programs.  DOJ provided approximately $850,000 in funding to implement 111 local  DEFY programs.
section_title: HHS Agencies Support Research to Address Tobacco Use among Youth
paragraphs: In addition to supporting programs that aim to address tobacco use among  youth, HHS agencies conduct research on tobacco use and its health  effects. NIH’s National Cancer Institute (NCI) has identified tobacco use  among youth as one of its research priorities. In fiscal year 2002, NCI  funded more than 40 grants, totaling almost $30 million, for research on  ways to understand, prevent, reduce, and treat tobacco use among youth.  Similarly, NIH’s National Institute on Drug Abuse (NIDA) supports  research on effective tobacco use prevention and reduction interventions  for youth. For example, NIDA established and funds a teen tobacco  addiction treatment research center to examine methods of eliminating  dependence on nicotine and assess the effectiveness of these strategies.  The center is assessing the safe use and effectiveness of nicotine patches  and gum for adolescents. According to NIDA, in fiscal year 2002, funding  for its research projects that focused on substance abuse, including  tobacco use among youth, totaled about $124 million.
In fiscal year 1999, NCI and NIDA jointly established seven  Transdisciplinary Tobacco Use Research Centers (TTURCs) at academic  institutions in an effort to identify effective ways to prevent and reduce  tobacco use. According to HHS officials, additional information on ways  to reduce tobacco use among youth is needed because of the limited  knowledge available about cessation interventions that work best for  young people. The 5-year TTURCs research effort is designed to study new  ways of preventing tobacco use and nicotine addiction. According to HHS  officials, in fiscal year 2002, NCI and NIDA provided over $15 million to  TTURCs, which included funding for research on youth and adolescent  tobacco use and nicotine addiction at four of the seven centers. These four  centers are conducting studies on adolescent smoking. According to NCI,  one study found that students with high academic performance, perceived  academic competence, and involvement in school-related clubs and sports  teams were less likely to smoke.
CDC also supports research on health promotion and disease prevention  including research on tobacco use among youth, through its network of 28  research centers that are affiliated with schools of public health, medicine,  or osteopathy located throughout the country. According to CDC officials,  these research centers focus on identifying effective prevention strategies  that can be applied at the community level. One center is examining  factors that can influence youth and young adults to start using tobacco  and two other centers are conducting research that examines youth  cessation programs, according to CDC. HRSA is working with certain  federally supported community health centers on a multiyear initiative to  address health disparities among youth. HRSA officials said that the effort  would involve developing interventions to address the needs of high-risk  medical subpopulations, such as young people with asthma or  cardiovascular conditions for whom tobacco use can pose especially high  risks.
section_title: Federal Activities Also Aim to Address Tobacco Use among Youth
paragraphs: In addition to research, HHS and other federal departments conduct a  variety of tobacco-focused activities that aim to prevent and reduce  tobacco use among youth. For example, officials from HHS, Education,  and other federal departments, along with experts from national  organizations and professional associations, developed guidance to help  schools identify and implement strategies for preventing tobacco use  among youth. For example, the guidelines recommend that schools  develop and enforce a school policy on tobacco use, provide tobacco-use  prevention education from kindergarten through 12th grade, provide  instructions about the short- and long-term consequences of tobacco use,  and provide training for teachers. Similarly, in 1997, SAMHSA issued  guidance that describes strategies that communities can use to prevent  and reduce tobacco use among youth.
In other activities, HHS agencies develop and promote educational  materials to prevent and reduce a range of unhealthy behaviors among  adolescents, including tobacco use. For example, Girl Power!, a national  public education campaign, is designed to prevent 9- to 13-year-old girls  from using tobacco, alcohol, and illegal drugs and includes a Web site that  offers articles, games, and quizzes that teach girls about the dangers of  tobacco use. Similarly, CDC’s Tobacco Information and Prevention Source  Web site offers a variety of educational materials for youth, such as tips on  how to quit using tobacco and information on the health consequences of  using tobacco. CDC also disseminates information for parents, such as a  kit that offers advice on ways to increase parental involvement in their  children’s lives and incorporate tobacco prevention messages into daily  activities. In addition, DOD sponsors Web sites that include information on  preventing and reducing tobacco use among youth and supports various  youth activities that address unhealthy behaviors, including tobacco use.  For example, one project identified was Smart Moves, which aims to  prevent tobacco, alcohol, and drug use by bolstering youths’ self-esteem  and their resistance to unhealthy behaviors.
HHS agencies also support activities that use various media, such as print,  radio, television, and videotapes, to counteract the impact of tobacco  product marketing. For example, CDC supports a variety of entertainment- related outreach activities that enlist celebrities as spokespersons to  deliver antismoking messages and to increase prohealth messages in  entertainment programming. CDC also supports the Media Campaign  Resource Center, a clearinghouse offering antitobacco media products  developed for television, radio, print, and outdoor advertising. In addition,  CDC and SAMHSA developed Media Sharp, a media literacy guide for  educators and community leaders who work with middle school and high  school age youth to dissuade youth from using tobacco.
section_title: Federal Departments and Agencies Collect a Variety of Information on Their Programs That Aim to Prevent Tobacco Use among Youth
paragraphs: To monitor federal programs that aim to prevent and reduce tobacco use  among youth, federal departments and agencies collect information on  how their programs are being implemented by grantees and the  effectiveness of grantees’ efforts in meeting national program goals.  Federal departments and agencies obtain this information from various  sources, such as grantee applications for federal funding, progress reports,  site visits, and program evaluations. According to federal officials, the  information is used to assist grantees in managing and evaluating their  programs.
subsections: section_title: CDC Collects Information on the States’ NTCP- Supported Tobacco Control Programs
paragraphs: To monitor the NTCP, CDC collects information on the design,  implementation, and effectiveness of state tobacco control programs. CDC  obtains this information through various sources, such as states’  applications for NTCP funding, state progress reports, periodic site visits,  surveys, and program evaluations conducted by various states. For  instance, the applications that states submit when applying for NTCP  funding must include strategic plans that provide information on the  design and implementation of their tobacco control programs. The plans  must also include information on how states will achieve NTCP’s goals.  According to CDC officials, other important sources of information are the  biannual reports that the agency requires states to submit on the progress  of their tobacco control programs. These reports provide CDC with  additional information, such as enforcement strategies used to prevent the  sale of tobacco products to minors, information campaigns to increase the  public’s awareness of the health consequences of using tobacco, and  efforts to promote tobacco-free schools and positive role models for  youth.
CDC also obtains information on state tobacco control programs through  other sources. For example, CDC officials said that NTCP project officers,  who are responsible for monitoring state tobacco control programs, visit  each of their assigned states approximately every 12 to 18 months. CDC  officials said that through these visits they obtain more in-depth  information about the design and implementation of the states’ programs,  and they gain a better understanding of the challenges that states may face  in achieving NTCP’s goals. In addition, these officials said that they  monitor the effects of state tobacco control programs through periodic  national and state youth tobacco surveys. Through these surveys, CDC  obtains information on changes in tobacco use among youth and their  knowledge, attitudes, and behaviors towards tobacco use. CDC officials  said that they work with the states to design the state surveys and to help  states interpret and use the survey data. CDC officials also said that they  have obtained useful information from evaluations that several states  completed on the effectiveness of their tobacco control programs.
According to CDC officials, the information they obtain has been used in  various ways. For example, in developing its best practice guidance for  comprehensive tobacco control programs, CDC used information from  analyses of tobacco control programs in California and Massachusetts and  CDC officials’ experience in providing technical assistance in other states.  CDC officials also said that the agency has provided a variety of training  and technical assistance to help states, among other things, adopt  evidence-based interventions for preventing tobacco use. In addition, CDC  developed guidance in 2001 on how states could evaluate their individual  tobacco control programs. The guidance includes information on  approaches for designing evaluations; measuring outcomes of specific  program components; and analyzing, interpreting, and using evaluation  results to improve operations and enhance the impact of tobacco control  programs.
In fiscal year 2003, CDC took action to collect additional information on  the design, implementation, and effectiveness of state tobacco control  programs. For instance, CDC now requires that states submit additional  information in their biannual reports. These officials said that the  expanded NTCP data collection effort should enable CDC to obtain a more  comprehensive picture of state tobacco control programs and the extent  to which program activities are consistent with NTCP’s goals. CDC  officials said that they anticipate that these changes, along with the  redesign of the NTCP information system, will facilitate more  comprehensive comparisons within and across states and regions on  progress towards reducing tobacco use. The changes should also enable  CDC to better identify state-specific or systemic issues, according to these  officials.
In fiscal year 2003, CDC began requiring that each state dedicate staff to  evaluate the state’s tobacco control program. Each state was required to  submit detailed information with its NTCP funding application that  described how it intended to evaluate the program’s effectiveness. The  application had to include information on the specific performance  indicators the state intends to use and its methodologies for collecting and  analyzing data, projected time lines for completing evaluation efforts, and  plans for using evaluation results to improve its program. CDC officials  told us that they recognize that conducting program evaluations can  present financial and methodological challenges for state tobacco control  programs, but that CDC had instituted this requirement because evidence  on the impact of individual state programs has been generally limited.  These officials noted that while evaluations have been completed by eight  states, the results of these evaluations and other studies provide only a  limited picture of the impact of all states’ programs in achieving NTCP’s  goals.
section_title: SAMHSA Collects Information on States’ Progress in Prohibiting the Sale of Tobacco Products to Minors
paragraphs: To monitor state compliance with the requirements of the Synar  Amendment and its implementing regulation, SAMHSA collects data on  the design and implementation of state compliance efforts. The regulation  requires that each state report to SAMHSA information on the state’s  efforts to inspect retail tobacco outlets, including the state’s sampling  methodology, inspection protocol, and inspection results. SAMSHA  reviews the information to determine whether states have complied with  requirements for enforcing state laws and conducting random inspections  of retail tobacco outlets. In reviewing these data, SAMHSA determines  whether a state’s estimated retailer violation rate meets negotiated annual  targets and shows progress toward the 20 percent goal. Based on the latest  data available at the time of our review, 49 states met their negotiated  retailer violation rate targets for 2002.
section_title: Federal Departments and Agencies Collect Information on Their Programs That Address Unhealthy Behaviors among Youth
paragraphs: Federal agencies with programs that address tobacco use, along with  other unhealthy behaviors among youth, obtain information on grantees’  efforts to design and implement their programs. They obtain this  information by various means, such as periodic reports and visits to  grantee sites. For example, DOJ requires community antidrug coalitions  that participate in the Drug-Free Communities Support program to submit  annual progress reports on their programs. As part of this reporting  requirement, coalitions must report on certain measures of youth  behavior, such as the age youth first started to use tobacco, the frequency  of tobacco use in the past 30 days, and youths’ perceptions of tobacco- related risks. According to DOJ officials, the information obtained from  reports and site visits is used to provide grantees with training and  technical assistance. DOJ is also overseeing a 5-year evaluation of the  effectiveness of this federal grant program. The evaluation, which is  scheduled for completion in 2004, is designed to take into consideration  both the similarities and differences among the coalitions and their  communities and aims to assess the effectiveness of the coalitions’ efforts  to reduce the use of tobacco, alcohol, and illicit drugs among youth.
Similarly, to monitor their programs, DOJ and DOD contracted for  evaluations of the effectiveness of some DEFY components. For instance,  one study examined the effectiveness of the summer camp component in  1997 at 18 DOJ DEFY camps and 28 military DEFY camps. The study  included the use of pre- and postcamp questionnaires to assess youths’  attitudes towards smoking cigarettes and to determine how often they  smoked.
section_title: Federal Departments and Agencies Coordinate in Various Ways to Address Tobacco Use among Youth
paragraphs: HHS and other federal departments coordinate their efforts to prevent,  treat, and reduce tobacco use among youth by participating on various  committees and work groups and by collaborating on various programs,  research projects, and activities. Although HHS has the lead responsibility  for coordinating these efforts, some HHS officials stated that coordination  among HHS agencies presents challenges.
subsections: section_title: HHS Leads Coordination Efforts to Address Tobacco Use
paragraphs: HHS leads efforts among its agencies and others to develop strategies for  addressing tobacco use among youth in support of the Healthy People  initiative, which includes objectives to reduce tobacco use among youth.  As part of this initiative, representatives from various federal departments  and nongovernmental organizations participate in work groups that focus  on tobacco use objectives. For example, the Healthy People 2010 Tobacco  Use Work Group, chaired by CDC, includes representatives from other  HHS agencies as well as the Environmental Protection Agency (EPA), the  Federal Trade Commission, and nonfederal organizations. The work group  meets periodically to discuss strategies and challenges in addressing  issues related to tobacco use.
HHS also plays a leadership role in the Youth Tobacco Cessation  Collaborative. Established in 1998, the collaborative brings together CDC,  NCI, NICHD, NIDA, the National Heart, Lung, and Blood Institute (NHLBI),  and several nonfederal organizations to help ensure young tobacco users’  access to cessation interventions. In 2000, the collaborative published an  action plan to facilitate planning and priority-setting on the need for  tobacco cessation for youth. In addition, three members of the   collaborative—CDC, NCI, and the Robert Wood Johnson Foundation—are  working together on the Helping Young Smokers Quit initiative, a 4-year  project that aims to identify, characterize, and evaluate the effectiveness  of various youth cessation programs.
Other work groups focus on broader adolescent health issues that include  tobacco use among youth. For example, both the Healthy People 2010  Adolescent Health Work Group, cochaired by CDC and HRSA, and the  related National Initiative to Improve Adolescent Health by 2010 aim to  foster greater involvement by various professions to improve the overall  health of adolescents, in part by reducing their use of tobacco. According  to HRSA officials, members of the national initiative are trying to educate  health care and other professionals on the importance of screening for  tobacco use and other unhealthy behaviors during routine health care  visits, providing counseling on the benefits of quitting tobacco use, and  providing referrals for youth, their parents, and other family members to  tobacco cessation services. As part of the national initiative, CDC, HRSA,  and the American Academy of Pediatrics are collaborating on the  development of a prevention guide to help pediatricians address unhealthy  behaviors among youth, including tobacco use.
section_title: HHS Established the Interagency Committee on Smoking and Health to Coordinate Federal Efforts
paragraphs: In 1984, the Congress passed legislation requiring, among other things, that  HHS establish an interagency committee to coordinate the department’s  research, educational programs, and other smoking and health efforts with  similar efforts of other federal departments and nonfederal organizations.  As a result, in 1985, HHS established the Interagency Committee on  Smoking and Health. According to CDC officials, the committee brings  together representatives of federal agencies and nonfederal organizations  involved in tobacco use issues and serves as a forum for committee  members and the public to share information and discuss a variety of  tobacco-related issues and efforts. Committee meetings that have  specifically focused on tobacco use among youth have covered such  topics as the health effects of smoking on young people, the sale of  cigarettes to minors, and strategies for preventing tobacco use.
section_title: HHS and Other Federal Departments Coordinate Their Efforts by Jointly Administering Programs and Supporting Research and Activities
paragraphs: Federal departments also collaborate on efforts to prevent and reduce  tobacco use among youth by jointly administering programs, conducting  research, and supporting education and outreach activities. For example,  Education, DOJ, and HHS jointly administer the Safe Schools/Healthy  Students program. Through interagency agreements, Education handles  grants management activities, HHS provides technical advice and financial  assistance, and DOJ oversees program evaluation efforts. Similarly, for the  Drug-Free Communities Support program, ONDCP directs the program  and through an interagency agreement transfers funds to DOJ to cover  grant awards, grants management, and evaluation activities. Both ONDCP  and DOJ provide technical assistance to program grantees.
HHS agencies also coordinate on efforts to jointly support research on  tobacco use prevention and cessation. For example, in addition to the NCI-  and NIDA-supported TTURCs initiative, NCI led the creation of an NIH- wide Tobacco and Nicotine Research Interest Group in January 2003.  According to NCI officials, the group was established to leverage expertise  and resources across NIH for tobacco research. In addition to NCI,  representatives from other NIH institutes, such as NICHD, NIDA, NHLBI,  and the National Institute of Dental and Craniofacial Research (NIDCR)  have participated in the group. Representatives from CDC are also  participating in the group’s meetings.
Furthermore, HHS agencies, Education, ONDCP, and nonfederal  organizations collaborate on education and outreach activities aimed at  discouraging youth from starting to use tobacco and encouraging existing  users to quit. For example, CDC and Education collaborated on the  development and dissemination of a guide for parents on how to address  their children’s health needs, including preventing and reducing tobacco  use. Table 1 highlights various education and outreach activities aimed at  preventing and reducing tobacco use among youth that HHS and other  federal departments and agencies work on together.
section_title: HHS Officials Identified Several Challenges to Coordination within the Department
paragraphs: HHS officials said that coordinating on tobacco-related issues within HHS  presents challenges. They pointed out that, although multiple HHS  agencies have programs and other efforts to address the prevention and  reduction of tobacco use, the missions and funding priorities of the  agencies differ. For example, CDC officials told us that they had initiated  discussions in fiscal year 2003 with HRSA to collaborate on offering  tobacco prevention and cessation services to underserved populations  that obtain health care through HRSA’s network of community health  centers. However, this effort has been delayed largely due to HRSA’s  competing funding priorities and limited resources. In another instance,  NCI officials noted that NIDA and NIDCR decided to fund a proposal to  translate research findings on alcohol, tobacco, and other drug prevention  and treatment research to clinical dental practice settings. However,  according to an NCI official, NCI did not learn about the proposal in time  to consider it for fiscal year 2003 funding.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS, DOD, DOJ, and Education for  comment. DOD concurred with the report as written and DOJ did not have  comments. HHS and Education provided technical comments that we  incorporated as appropriate.
In written comments, HHS stated that the report was very informative and  provided a thorough overview of nicotine and tobacco activities related to  youth, but did not include programs within CMS that are a substantial  element of HHS tobacco prevention. Specifically, HHS stated that under  Medicaid, states are required to cover certain smoking cessation services  for children and adolescents. Including joint federal-state programs that  finance health insurance such Medicaid and the State Children’s Health  Insurance Program, was beyond the scope of our review. HHS also noted  that the report did not include information about the challenges other  federal agencies experienced in coordinating tobacco-related issues. We  discussed coordination of tobacco-related issues with officials from DOD,  DOJ, and Education. However, these officials did not cite any challenges  they had experienced with coordinating their tobacco-related efforts.
As agreed with your office, unless you release its contents earlier, we plan  no further distribution of this report until 30 days after the issue date. At  that time, we will send copies of this report to the Secretary of Health and  Human Services, the Secretary of Defense, the Attorney General, the  Secretary of Education, appropriate congressional committees, and other  interested parties. We will also make copies available to others upon  request. In addition, the report is available at no charge on the GAO Web  site at http://www.gao.gov. If you or your staff have questions about this  report, please contact me at (202) 512-7101. An additional contact and staff  acknowledgments are provided in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To do our work, we obtained and reviewed program documents, strategic  and performance plans, pertinent program reports and special studies,  surveillance and other data, and federal Web sites from the Department of  Health and Human Services (HHS) including the Office of the Secretary,  the Office of the Assistant Secretary for Planning and Evaluation, Office of  Public Health and Science, Agency for Healthcare Research and Quality,  Centers for Disease Control and Prevention (CDC), Centers for Medicare  & Medicaid Services, Health Resources and Services Administration  (HRSA), Indian Health Service, National Institutes of Health (NIH), and  Substance Abuse and Mental Health Services Administration (SAMHSA);  the Departments of Defense (DOD), Justice (DOJ), and Education; the  Environmental Protection Agency; the Federal Trade Commission; and the  Office of National Drug Control Policy (ONDCP). We also reviewed the  relevant literature and documents prepared by federal interagency  committees and work groups that focused on the prevention and  reduction of tobacco use among youth and adults.
To identify federal programs that aim to prevent and reduce tobacco use  among youth (defined as children and adolescents under age 18), we  reviewed the Catalog of Federal Domestic Assistance, a database of  federal grant programs. We also reviewed pertinent documents and  federal Web sites. After identifying federal programs, we interviewed and  collected information from federal program officials to confirm that these  programs supported efforts to prevent and reduce tobacco use among  youth. As a result, we focused on four federal departments: HHS and its  component agencies—CDC, SAMHSA, NIH, and HRSA; Education; DOJ;  and DOD. We then obtained more detailed information on the programs  they fund. We interviewed officials in HHS, DOD, DOJ, and Education and  obtained information on program characteristics, including the purpose,  target audience, and program and financial requirements. We also  obtained information on research and activities that involve federal  departments and agencies, such as education and outreach efforts  intended to prevent the initiation of tobacco use among youth and help  youth quit tobacco use. In conducting this work, we also reviewed  strategic and annual performance plans, along with budgetary and other  pertinent documents, including national action plans and tobacco use  prevention and cessation guidance. Where available, we obtained fiscal  year 2002 funding information on the federal programs and research that  we identified. However, we were unable to determine the extent of  spending by federal agencies on efforts to prevent and reduce tobacco use  among youth because, in many instances, funding information covers  more than the prevention and reduction of tobacco use among youth. The  programs, research, and activities that we discuss in this report do not  represent an exhaustive list of all federal efforts to prevent and reduce  tobacco use among youth, but highlight a range of such efforts.
To determine how federal departments and agencies monitor programs  that aim to prevent and reduce tobacco use among youth and the types of  monitoring information that departments and agencies collect, we  obtained and reviewed descriptive information on federal departments  and agencies’ monitoring efforts. Specifically, we reviewed strategic plans,  annual performance plans and reports, performance monitoring reports,  program evaluation guidance, and copies of federal and state program  evaluation reports. We also interviewed program officials to obtain a more  detailed understanding of their monitoring efforts.
To determine how federal departments and agencies coordinate their  efforts to address youth tobacco use, we focused our attention on  identifying the key coordination mechanisms and the results of such  coordination. Specifically, we reviewed strategic and annual performance  plans and reports, interagency agreements, memorandums of  understanding, minutes of interagency meetings, and other pertinent  documents. We also interviewed federal program officials and obtained  information from these officials describing the characteristics of various  federal efforts, including information on purpose, federal agencies  involved, and the target audience. We also obtained their perspectives on  any factors presenting coordination challenges related to addressing youth  tobacco use.
We conducted our work from January 2003 through October 2003 in  accordance with generally accepted government auditing standards. Our  findings are limited to the select examples identified and thus do not  necessarily reflect the full scope of federal programs and other activities  related to preventing and reducing tobacco use among youth. We did not  assess the effectiveness of federal programs, monitoring efforts, or  coordination activities.
section_title: Appendix II: Selected Federal Programs That Address or Can Address Tobacco Prevention and Reduction among Youth
paragraphs: Table 2 lists selected federal grant programs that may be used to address  tobacco use among youth. The list includes programs from four  departments.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the person named above, contributors to this report were  Alice London, Donna Bulvin, Krister Friday, and Lawrence Solomon.