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. 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.) 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Table 2 lists selected federal grant programs that may be used to address tobacco use among youth. The list includes programs from four departments. In addition to the person named above, contributors to this report were Alice London, Donna Bulvin, Krister Friday, and Lawrence Solomon.

Summary: 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. 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.