Local Health Agency Exploratory Research Literature Review

Local Health Agency Exploratory Research
Literature Review
December 2006
Submitted to:
Colorado State Tobacco Education & Prevention Partnership
Colorado Department of Public Health & Environment
Prevention Services Division

Submitted by:
One Park Square
75 Washington Avenue
Portland, Maine 04101
Phone 207-767-6440
Fax 207-767-8158
Center for Health Policy, Planning and Research
716 Stevens Ave
Portland, ME 04101

TABLE OF CONTENTS
OVERVIEW AND PURPOSE ................................................................................................................ 1
NATIONAL GUIDANCE FOR STATE AND LOCAL HEALTH AGENCY ROLES....................................... 5
The Guide to Community Preventive Services................................................................... 5
NIH State of the Science Conference Statement on Tobacco Use: Prevention, Cessation,
and Control.......................................................................................................................... 6
Promising Practices in Chronic Disease Prevention and Control: A Public Health
Framework for Action......................................................................................................... 6
Best Practices for Comprehensive Tobacco Control Programs for Comprehensive
Tobacco Control Programs ................................................................................................. 7
The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST).......... 7
ROLES OF STATES AND LOCAL AGENCIES IN STATES WITH CLEAN INDOOR AIR LAWS .................. 9
Youth Focused Efforts ...................................................................................................... 10
Peer-Mentor Programs...................................................................................................... 10
Media/Counter-Marketing Campaigns ............................................................................. 11
Quit Lines.......................................................................................................................... 14
Physician Education Efforts.............................................................................................. 18
ENFORCEMENT............................................................................................................................... 19
Smokefree Policies............................................................................................................ 19
Broadening Protection from Environmental Tobacco Smoke .......................................... 21
Youth Access Restrictions ................................................................................................ 22
ELIMINATING DISPARITIES IN TOBACCO USE................................................................................. 24
STATE ROLES OF SURVEILLANCE AND TECHNICAL ASSISTANCE ................................................... 26
Surveillance....................................................................................................................... 26
Evaluation ......................................................................................................................... 27
THE CLEAN AIR STATES: APPROACHES TO FUNDING, ADMINISTRATION AND MANAGEMENT OF
LOCAL HEALTH AGENCIES AND TOBACCO PROGRAMS.................................................................. 29
REFERENCES .................................................................................................................................. 36

OVERVIEW AND PURPOSE
In March 2006, the State of Colorado passed a new clean indoor air act prohibiting smoking in
most indoor areas throughout the state. This ban, affecting restaurants, bars, and other
businesses, went into effect in July 2006. Before the state-wide law came into effect, state and
local governments in Colorado had largely been focusing their work around tobacco control on
passing ordinances or laws to ban indoor smoking at the state and local level. Now, under the
new law, there is a need for a shift in focus of the work of these organizations and refocus on
other needed issue areas associated with freedom from second-hand smoke, smoking prevention
and cessation programs.
The purpose of this document is to examine the potential implementation, administration,
enforcement and surveillance roles of local health agencies in a state with a state-wide smoking
ban and to explore the implications of the state-wide ban on the role of local agencies in
developing and implementing evidence-based tobacco control programs and policies at the
community level. This report reviews the applicable literature and includes a discussion of
comparable activities occurring throughout the United States, with a focus on states that have
enacted clean indoor air acts similar to the new Colorado law. State tobacco program evaluation
and planning reports developed by those states with state-wide smoking bans, as well as
important national publications on the topic were included in this document.
Surgeon General: Secondhand Smoke a National Priority
The Surgeon General first acknowledged the issue of involuntary exposure to tobacco smoke
(also referred to as secondhand smoke or environmental tobacco smoke) in 1972, and, by 1986
concluded that involuntary smoking caused lung cancer in lifetime nonsmoking adults and
adverse effects on respiratory health in children and that separating smokers and nonsmokers in
the same airspace reduced but did not eliminate the exposure to secondhand smoke (US
Department of Health and Human Services, 1986).
The 1986 Surgeon General findings, supported by reports released in 1986 by the International
Agency for Research on Cancer of the World Health Organization (International Agency for
Research on Cancer, 1986) and the National Research Council (1986) provided an important
impetus to a growing movement in California and other states to restrict smoking in public
places and workplaces. And, since 1986, the evidence regarding the adverse health effects of
secondhand smoke and burden on health continued to mount, with the release of additional
reports from federal, state, and international agencies (US EPA, 1992), (California EPA, 1997),
(CDC, 2002), (World Health Organization, 1999). In response, many local and state
governments have enacted policies to prohibit smoking in restaurants, bars, and workplaces.
Colorado’s legislation is one of the most recent of those policies.
In June 2006, shortly after the Colorado clean indoor air legislation was passed, the US Surgeon
General released a report on the Health Consequences of Involuntary Exposure to Tobacco
Smoke. This report evaluated new evidence on the subject of “second hand smoke” or
“environmental tobacco smoke” exposures and updated prior Surgeon General findings on the
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subject (US Department of Health and Human Services, 2006). It made the following
conclusions:
• Secondhand smoke causes premature death and disease in children and in adults who do
not smoke.
• Children exposed to secondhand smoke are at an increased risk for sudden infant death
syndrome (SIDS), acute respiratory infections, ear problems, and even more severe
asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their
children.
• Exposure of adults to secondhand smoke has immediate adverse effects on the
cardiovascular system and causes coronary heart disease and lung cancer.
• There is no risk-free level of exposure to secondhand smoke
• Many millions of Americans, both children and adults, are still exposed to secondhand
smoke in their homes and workplaces despite substantial progress in tobacco control.
• Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to
secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and
ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.
The 2006 report, which stated that there was massive and conclusive scientific evidence
documenting the adverse effects of secondhand smoke and calling the issue an important
national priority, was the climax of many years of mounting evidence regarding secondhand
smoke and gives further weight to the importance of the new Colorado legislation.
The recommendations of the Surgeon General, World Health Organization and others represent a
dramatic shift from the previous emphasis on direct interventions to address behavioral risk
factors to intermediate outcomes in the “causal pathway between a determinant and the final
health outcome” which include quality-of-life, social, and environmental effects beyond the
intended health outcomes. This approach places a new importance on second hand smoke for
both practitioners and policymakers at state and local levels (Truman, 2000).
This shift toward environmental effects is evident in the Healthy People 2010 initiative; as well
as internationally in the Ottawa Charter; and various Canadian, European, and World Health
Organization initiatives in health promotion and population health. (Green, 2000).
States with Clean Indoor Air Acts
According to the 2006 Surgeon General’s report, most of the progress in adopting laws making
public places and workplaces smoke-free has occurred at the local level and, more recently, at
the state level. Local initiatives originally led the way because local governments tended to be
more responsive to public sentiment on this issue. The progress in implementing local
ordinances in hundreds of communities across the US, including high profile cities such as New
York and Boston, has demonstrated that ordinances are popular, can be implemented with little
difficulty, and are met with high levels of compliance. They also substantially reduce exposure
to secondhand smoke (Picket et al., 2006). Laws also have been shown to not have a negative
economic impact on restaurants and bars and may even increase revenues (Cowling and Bond,
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2005). Progress has also been helped by the growing tendency to view smoke-free laws as a
protection for workers, particularly hospitality workers.
Table 1 presents the states with relevant clean indoor air acts banning smoking in restaurants,
bars, and/or workplaces and the date when the smoking ban went into effect or is expected to go
into effect. Workplace bans include both public and private non-hospitality workplaces,
including but not limited to offices, factories, and retail stores. Restaurant bans include any
attached bar in the restaurants. Bar bans include all freestanding bars without separately
ventilated rooms (American Nonsmokers’ Rights Foundation, 2006). The first state-wide
smoking ban that included restaurants came into effect in California and Utah in 1995.
California began its smoking ban in bars in 1998. In the past five years, many other states
followed.
Table 1: States with Smoking Bans in Bars, Restaurants, and Workplaces*
State
Extent of Ban and Effective Date
Restaurants Bars Workplaces
California Jan 1995 Jan 1998
Utah Jan 1995 Jan 2009 May 2006
South Dakota July 2002
Delaware Nov 2002 Nov 2002 Nov 2002
Florida July 2003 July 2003
New York July 2003 July 2003 July 2003
Connecticut Oct 2003 April 2004
Maine Jan 2004 Jan 2004
Idaho July 2004
Massachusetts July 2005 July 2005 July 2005
Rhode Island March 2005 March 2005 March 2005
North Dakota Aug 2005
Vermont Sept 2005 Sept 2005
Montana Oct 2005 Sept 2009 Oct 2005
Washington Dec 2005 Dec 2005 Dec 2005
New Jersey April 2006 April 2006 April 2006
Colorado July 2006 July 2006
Hawaii Nov 2006 Nov 2006 Nov 2006
Louisiana Jan 2007 Jan 2007
* The District of Columbia and Puerto Rico have both passed bans. DC banned smoking in workplaces
as of April 2006 and in restaurants and bars as of January 2007. Puerto Rico banned smoking in
workplaces as of March 2007.
Many of the states that have passed smoking bans are in the first year or two of implementation,
therefore the experience of local governments during implementation has not been widely
documented in the peer reviewed literature. Additional information on this subject likely will
become available as time goes by and additional states have a longer history of smoking bans
and additional documentation of their experiences. In the meantime, much of the literature on
the implementation and after-effects of a state-wide ban comes from states like California, where
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many years of a smoking ban have produced some lessons learned that may be useful to
Colorado. Other states, such as New Jersey for example, offer limited, preliminary information
on implementing a state-wide indoor air act, although they are still in the early years of the ban.
New York was the third state to go smokefree (after California and Delaware), and brought
legitimacy to the struggle for clean indoor air legislation in other states because of its
comprehensive approach, diversity, geographic size and population (Stoner and Foley, 2005).
Once evidence came in showing that New York’s law was working, many other states followed
suit. Although many states are in the early stages of a ban, there is ample evidence available
from states like California and New York on best practices for controlling smoking and
promoting cessation after a ban is in place. This information may be useful to state and local
tobacco policymakers in Colorado and elsewhere as they continue their work on this issue. It is
important to note that most states credit the groundwork done by local health agencies at the
community level for laying the necessary foundation for the statewide ban. In addition, most see
the ban as part of a comprehensive tobacco control program. Thus, comprehensive, statewide
smoking bans are generally a success attributable to the collaboration between state-wide
agencies and interests with the local health agencies and community organizations. These
ongoing collaborative efforts, both before and after enactment of the statewide laws, are the
focus of this report.
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NATIONAL GUIDANCE FOR STATE AND LOCAL HEALTH AGENCY ROLES
The CDC recommends a statewide strategy that emphasizes the number of organizations and
individuals involved in education and training programs at the community level. Although
statewide policies are critical to the success of tobacco control goals, they must be reinforced by
community-based strategies, which are capable of influencing social norms and behaviors in the
population.
Clean indoor air acts have been shown to be an effective method of reducing tobacco exposure.
However, acts like the Colorado Clean Indoor Air Act are only one component of a
comprehensive state tobacco control program. A comprehensive state program typically
includes community-level activities and advocacy, school-based education, cessation programs,
and policies that restrict youth access to tobacco products and increase the price for products and
media campaigns to counteract tobacco advertising.
The Centers for Disease Control and the National Institutes for Health have issued reports on the
best practices for statewide policy and community-based strategy in tobacco control. There is
clear evidence that state programs make a difference and prevent deaths due to tobacco use
(National Cancer Policy Board, 2000), however the role of local health agencies has also been
shown to have a critical role, and the best practice to address tobacco use and second hand smoke
exposure is a statewide policy that works with local agencies for community based
implementation (Zaza, 2005).
The Guide to Community Preventive Services
The Guide to Community Preventive Services (Community Guide), developed by the Task Force
on Community Preventive Services (TFCPS), provides recommendations to states and
communities regarding population-based interventions to promote health and prevent disease
based on systematic reviews of topics. With respect to tobacco, the Community Guide addresses
the effectiveness of community based interventions to reduce youth tobacco initiation, reduce
environmental tobacco smoke, and enable smoking cessation through population-based strategies
(Tobacco Guide to Preventive Services, 2005).
In order to reduce youth initiation, TFPCS strongly recommends two, primarily state-level
activities; increasing the unit price for tobacco products, particularly through raising state and
federal excise taxes and developing extensive and extended mass media campaigns particularly
as centerpieces combined with other, local-level strategies. To decrease the effects of ETS, the
TFCPS strongly recommends developing laws and regulations to restrict or ban tobacco
consumption in workplaces and general areas used by the public. Addressing smoking cessation
from a population orientation, the TFCPS turns to community-level activities, strongly
recommending the use of broadcast and print media, provider education and implementation of
self-reminder systems to ensure that the issue is raised during clinical exams and telephone
counseling and support services. At the state level, increasing the unit price for tobacco products
is also strongly recommended.
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Community level data, gained through information systems developed and distributed by the
state health department as part of its technical assistance program, should inform collaborative
efforts between state agencies and county and city health departments. The collaborative effort
should then focus on the application of guideline practices specific to each community setting,
making use of the local expertise of local health agencies. In this way, state-wide policy can be
tailored to local needs, and, with the assistance of the evidence found in the Community Guide, a
state and local collaborative effort will “weave together a locally responsive yet comprehensive
statewide approach” (Wasserman, 2000).
NIH State of the Science Conference Statement on Tobacco Use: Prevention,
Cessation, and Control
The June 2006 National Institutes for Health State of the Science Conference Statement on
Tobacco Use: Prevention, Cessation, and Control provided general consensus and guidance to
State and local governments in Colorado on key issues around tobacco prevention, cessation, and
control (NIH, 2006). Three general approaches to preventing tobacco use specifically in young
adults were promoted, including: 1) taxation of tobacco products to increase their prices; 2)
passage of laws and regulations that prevent young people from gaining access to tobacco
products, reduce their exposure to tobacco smoke, or restrict industry advertising; and 3) mass
media campaigns. While school-based interventions have also been shown to be effective in the
short term, the conference concluded that there is a need to develop school-based strategies that
lead to sustained reduction in starting to use tobacco.
NIH concluded that the most effective cessation strategies were: mass media campaigns;
telephone smoking cessation support that gives advice to stop smoking (e.g., quit line); an
increase in the unit price for tobacco products, and a reduction in out-of-pocket costs for
cessation therapies.
Specifically at the community level, NIH concluded that local media campaigns, communitylevel
quit lines, increases in tobacco pricing and taxation, and community-based cessation
services were effective strategies. Community-based self help materials alone were not proven
to be effective.
Promising Practices in Chronic Disease Prevention and Control: A Public Health
Framework for Action
Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for
Action (2003) provides additional guidance from the Centers for Disease Control and Prevention
(CDC) for tobacco control programs at the local level, with examples of how state and local
health departments can develop evidence-based programs, leverage their limited resources, and
coordinate the efforts with stakeholder groups. CDC emphasizes the utility of partnering with
local and community groups, suggesting that state tobacco programs should partner with any
group that has overlapping interests, from national nongovernmental health organizations (e.g.,
American Cancer Society, to NIH or CDC, to groups representing specific local constituencies.
Local groups can help state officials design interventions that target local residents appropriately.
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Best Practices for Comprehensive Tobacco Control Programs for Comprehensive
Tobacco Control Programs
Earlier CDC guidance on evidence-based interventions at the local level is available in Best
Practices for Comprehensive Tobacco Control Programs for Comprehensive Tobacco Control
Programs (1999). This document encouraged state programs to include the following programs
at the local level: community programs to reduce tobacco use, school programs in coordination
with local community coalitions, enforcement activities aided by local organizations, technical
assistance to local programs, surveillance and evaluation efforts that measure local and statewide
progress, and administration and management in collaboration with state and local
agencies.
The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST)
The National Cancer Institute (NCI), in collaboration with the American Cancer Society (ACS),
produced The American Stop Smoking Intervention Study for Cancer Prevention, or ASSIST.
ASSIST focused on four policy areas: (1) eliminating exposure to environmental tobacco smoke,
(2) promoting higher taxes for tobacco, (3) limiting tobacco advertising and promotions, and (4)
reducing minors’ access to tobacco products. Seventeen state health departments (Colorado,
Indiana, Maine, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New Mexico, New
York, North Carolina, Rhode Island, South Carolina, Virginia, West Virginia, Washington, and
Wisconsin) participated in the ASSIST project. The ASSIST states implemented the project in
two phases: a 2-year planning phase (1991-1993) and a 6-year implementation phase (1993-
1999). This project represented the first major nationwide effort to create state-level tobacco
control infrastructures.
The ASSIST project required states to develop strategic alliances with a variety of organizations
and agencies, including national, state, and local agencies and organizations. At the state level,
each health department was required to establish a comprehensive tobacco control program,
build a coalition for tobacco control and provide leadership for community level coalitions
(ASSIST, 2005). At the end of the intervention period, the ASSIST states had statistically
significantly lower adult smoking prevalence than non-ASSIST states. The real focus of the
ASSIST project, however, was on policy change, which was assessed with an “initial outcomes
index” (IOI), measuring the percentage of workers in 100% smoke-free workplaces, the price of
cigarettes including tax, and a rating of local and state clean-indoor air policies. Increases in IOI
scores were associated with proportional decreases in per capita cigarette consumption,
regardless of the starting IOI score. Thus, the ASSIST project demonstrated a causal relationship
between tobacco control policy change and per capita tobacco consumption.
ASSIST states were associated with improvements in policy environment (i.e., increased IOI
score) only during the first years of the intervention. By 1994, three years into the ASSIST
project, the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation
and others were implementing programs in both ASSIST and non-ASSIST states, making it
difficult to identify differences between ASSIST and non-ASSIST states. The differences
attributable to policy changes held throughout this period however, and states with higher
capacity and tobacco control infrastructure had statistically significantly lower per capita
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consumption rates than states with lower capacity, regardless of their ASSIST status (Stillman,
2003).
In summary, national guidance on best practices for state tobacco control programs indicates
that state programs will be most effective if they partner with local and community groups to
design interventions that appropriately target local residents and tailor community-based
interventions to local populations. A comprehensive strategy for tobacco control at the
community level would include, at a minimum:
• An increase in the unit price for tobacco products,
• Mass media education campaigns,
• Cessation support (quit lines).
Other interventions may include cessation services in community settings, a reduction in out-ofpocket
costs for cessation therapies, and school-based interventions. There may be
opportunities to partner with local groups to carry out a variety of aspects of a tobacco control
program, from development of school programs to enforcement to surveillance and evaluation.
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ROLES OF STATES AND LOCAL AGENCIES IN STATES WITH CLEAN INDOOR AIR
LAWS
In general, local health agencies have had demonstrated success in tackling tobacco control
issues throughout the country. And, in states where local agencies were instrumental in
developing support for the enactment of smokefree laws, in most cases, they have also been an
ally in the development of programs and policies to move the state forward.
According to the 2006 Surgeon General’s Report, early local progress in enacting smokefree
laws, or clean indoor air policies, was furthered by support by state tobacco control programs
and other state organizations to develop and maintain a network of local coalitions (US
Department of Health and Human Services, 2006). By backing and funding local changes, state
programs were able to strengthen the work of community groups and local health agencies,
helping them to achieve progress on evidence-based approaches by giving support through
training and technical assistance. Some had extensive experience with local smoke-free
ordinances at the community level before implementing a state-wide law (Maine, Massachusetts
and New York). This prior local-level experience made it easier to transition to state-wide
legislation. Other states, like Connecticut, faced a more frustrating path with a state law that
regulated smoking in a limited array of venues (municipal and state-owned buildings, grocery
stores, and hospitals) and that contained a clause pre-empting municipalities from passing
additional local laws to regulate smoking (Blumenthal, 2002).
After initial passage of state smokefree laws, existing community coalitions that may have been
integral in achieving the passage of these laws, ideally should be supported by the state to
continue to achieve further successes in controlling tobacco. The concentration of efforts at the
city and county level has been noted as one of the highlights of California’s program and the
reason for its success (Green et al., 2006). Additionally, a study on ten state tobacco control
programs found that every state identified either community programs or counter marketing as
the highest priority. Community programs were high priority because states felt that changes in
policies and social norms are most likely to occur at the community level (Mueller et al., 2006).
Most states with comprehensive smokefree laws have continued their work in this area, focusing
on smokefree homes and cars, as well as drifting smoke in public outdoor areas and shared
housing (California Department of Health Services, Tobacco Control Section, 2003). These
efforts are often led by local jurisdictions, working with housing unit owners or disseminating
information on smokefree homes and cars throughout the community. Local jurisdictions have
also been active in passing additional smoke-free ordinances, making areas such as beaches and
parks smokefree.
In this section we explore the roles of states and local agencies in developing and implementing
specific programs, with particular attention to states with existing indoor air laws. The evidence
is strongly that state-wide comprehensive tobacco control programming, when combined with
strong local policies, has an effect beyond that predicted by either programs or policies alone
(Hyland et al., 2006). Further, statewide projects can increase the capacity of local programs by
providing technical assistance on program evaluation, media advocacy, implementation of smoke
9

free policies, and reduction of minor’s access to tobacco. With the passage of indoor air
legislation in Colorado, the state may now find new ways to utilize existing infrastructure and
resources at the local level to continue to improve tobacco control and to increase the
effectiveness of local and community programming.
Youth Focused Efforts
Since the vast majority of smokers initiate during adolescence and addiction begins during the
first few years of use, early interventions appear to offer a sensible approach. A study based on
interviews of tobacco control representatives from Oregon, California, Mississippi, and
Massachusetts found that the best return on investment in a tobacco control program is to reach
youth through a youth prevention program before they begin smoking (Gleckler et al., 2001).
The CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction
(Centers for Disease Control and Prevention, 1994) presents a range of strategies that have been
demonstrated to be effective in preventing tobacco use among youth. The CDC defines tobaccofree
school environments as those with policies that prohibit smoking and tobacco use in all
areas inside and outside the school building, and applies to all tobacco products; all students,
staff and visitors must adhere to this policy, and it is in effect 24 hours a day. (Centers for
Disease Control and Prevention, 2006). Schools are encouraged to:
• Develop and enforce a school policy on tobacco use
• Provide instruction about short- and long-term negative physiologic and social
consequences of tobacco use, social influences and peer norms regarding tobacco use,
and refusal skills.
• Provide tobacco-use prevention education in grades K-12, with intensive instruction in
middle school that is reinforced in high school.
• Provide program-specific training for teachers.
• Involve families in support of school-based programs to prevent tobacco use.
• Support cessation efforts among students and all school staff who use tobacco.
• Routinely assess the tobacco-use prevention program in schools.
Peer-Mentor Programs
Youth-led community groups or “youth empowerment groups” are widely used in state tobacco
control programs as a presence in the community that works to change norms about tobacco
through peer influence. Florida was the first state to develop a youth movement against tobacco;
when youth smoking rates declined in Florida, other states followed (O’Riordan et al., 2005).
The “Truth” program fostered community partnerships with all 67 Florida counties, school based
initiatives, an education and training initiative, enhanced enforcement of youth tobacco access
laws, and a law that penalized youth for possession of tobacco (Wakefield and Chaloupka,
2000). Due to the “Truth” program, a higher level of anti-tobacco awareness exist in Florida
than in other states across the nation (Niederdepp, 2004).
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A similar program in Hawaii, the REAL: Hawaii Youth Movement Against the Tobacco
Industry, has more than 2,500 members statewide. This program provides youth-run, youth, led
initiatives aimed at raising awareness about tobacco prevention and the tobacco industry’s media
campaigns, empowering youth, and developing advocacy and leadership skills. Partnerships
have been developed with the state tobacco program, the American Cancer Society, the
Department of Education’s Peer Education Program, and the Coalition for a Tobacco Free
Hawaii (O’Riordan et al., 2005). In addition, Maine’s Partnership for A Tobacco Free Maine
funds 31 local programs throughout the state to design and conduct community- and schoolbased
programs. Each local grantee is responsible for the development of a Youth Advocacy
Program.
At the university level, similar youth empowerment programs have been shown to be effective.
For example, the Student Tobacco Reform Initiative: Knowledge for Eternity (STRIKE) was
implemented to target university students and engage students as advocates for deconstruct
tobacco’s role on college campuses. This program was piloted on nine Florida campuses with
funding given to the universities to implement the program (Morrison and Talbott, 2005).
Teacher-focused interventions and anti-tobacco school policies also appear to increase the
motivation, confidence and effectiveness of teachers in providing anti-tobacco education to
students (Soza-Vento and Tubman, 2004). In addition, many states have funded the teaching of
anti-tobacco curricula. Vermont’s Department of Education and Department of Health have
partnered to give grants to school districts to teach research-based curricula on prevention,
following the CDC Guidelines for school-based tobacco reduction. These funds also support
cessation services for teens and peer leadership and youth empowerment programs (State of
Vermont, 2006). In Washington State, funding is given to Educational Service districts to help
schools improve and enforce tobacco-free policies, establish stop-smoking programs for
students, deliver research-based curricula, train teachers and staff, and provide information to
families (Washington State Department of Health, 2005). In Massachusetts, the state
Department of Public Health has traditionally contracted with school health services to
implement cessation services and health curricula. These school-based activities have
complemented community-based programs and activities of local health departments (Koh,
2005).
Media/Counter-Marketing Campaigns
Mass media campaigns to inform and motivate individuals to stay tobacco-free have been shown
to be effective, particularly when used in combination with other interventions such as increases
in costs of tobacco products and school-based education programs. Mass media social marketing
campaigns are designed to provide an alternative perspective to tobacco industry marketing.
Campaigns are often developed at the state level, sometimes in conjunction with local and
community groups. Local entities often help in the dissemination at the local level and, in some
states, have developed their own smaller media campaigns.
The CDC provides justification and evidence in support of counter-marketing activities to
promote smoking cessation, decrease the likelihood of initiation, and influence public support for
11

tobacco control interventions and community- and school-based efforts. Using paid media
placement, rather than relying on public service announcements and other free or low-cost
methods, is necessary to ensure adequate levels of exposure. Counter-marketing efforts should
be used in combination to address prevention, cessation, and protection from second hand
smoke, and they should target both young people and adults, addressing individual behaviors and
public policies. Counter marketing strategies work best when they include grassroots
promotions and work in conjunction with community programs. Rather than repeating a single
message, campaigns should maximize the number, variety, and novelty of messages. In addition,
messages should be more collegial than authoritarian in nature (CDC, 1999).
SmokeFreeColorado’s Outreach Implementation SubCommittee Key Informant Interviews
(2006) found that local agencies were key in the development of community-specific messages.
Advertisements have been found to be a frequently mentioned source of help among recent
quitters (Beiner et al., 2006). Thus, counter-advertising can increase demand for local resources,
and those responsible for the provision of local resources should be aware of marketing
campaigns that may affect demand for their services. In Massachusetts, for example, counteradvertising
campaigns disseminate messages that focus public attention on the tobacco problem,
while the statewide resource center concurrently forges partnerships to drive change at the
community level (Koh et al., 2005).
In New York, the New York State Tobacco Control Program’s (NYSTCP) media plan utilizes
community and local groups extensively in message development. This program is cited as one
of the most extensive uses of community groups to conduct media and counter-advertising
campaigns. Community Partnerships are provided with $6 million to collaboratively run
statewide media with the State Department of Health. Although this program functioned
effectively, there were occasions where the work of Community Partnerships had to be stopped
and restarted when contracts were discontinued and funding was lost for certain periods of time.
The evaluation of the program recommended that the functioning of the program could have
been better if the contract renewal process were improved so that swings in activity from
grantees were reduced. The evaluation also recommended that Community Partnerships be
better used to consistently cultivate relationships with media outlets to fully utilize opportunities
for donated advertising time (RTI, 2006).
In cases where the Community Partnership ads were used to promote clean indoor air
regulations, these ads were rated as low impact because they lacked emotional appeals and
intense images. This does not necessarily mean that they are poorly developed ads, but the
objectives associated with clean indoor air are of an educational nature and are not necessarily
suited to high impact images. Secondhand smoke ads highlighting health impacts that used more
emotional appeals tended to have a higher impact, particularly those that encouraged adults to
not smoke in the presence of children (RTI, 2006). This finding aligns with other findings on the
efficacy of ads. Advertisements that evoke strong emotion and portray the serious consequences
of smoking generally have been found to be more effective (Koh et al., 2005; Biener, 2004).
When properly coordinated, media campaigns can enable and support community level
initiatives (Siegel, 2002). In Texas, rates of smoking reduction among adults in areas that
received high-intensity anti-smoking media campaigns along with community-level programs
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and cessation services were three times higher than in areas that received no services or media
messages. Smoking reduction rates in areas that received media messages alone, without
community programs or cessation services, were twice as high as areas that received no
interventions (McAlister, 2004).
Vermont has also used state and local collaboration to develop “common theme campaigns” that
deliver messages from multiple sources – statewide media, community coalitions, local schoolbased
tobacco coordinators, and local hospital-based cessation coordinators. State and local
activities are coordinated during three specific times of the year. Common theme campaigns
were focused around: 1) youth prevention, targeted toward age 10-17, 2) smoking cessation,
linking adults to cessation resources around the Great American Smokeout in November and
New Years Day, and 3) secondhand smoke, encouraging people not to smoke in homes or cars
(State of Vermont, 2006).
Successful anti-smoking campaigns specifically targeted toward youth are often based on
aggressive advertising educating youths on corporate marketing practices of the tobacco
industry. In Florida, youths who viewed advertisements about tobacco industry manipulation of
youths were substantially less likely to begin smoking (Siegel, 2002), (Niederdeppe, 2004).
Many states have used this tactic, some in conjunction with community partners. For example,
New Jersey, which just began implementation of an indoor air law in 2006, has had a youth-led
anti-tobacco movement since 2000 called Reaching Everyone by Exposing Lies (REBEL).
REBEL has trained high school graduates and college students to develop anti-tobacco
initiatives. REBEL rallied youth to launch the Not For Sale advertising campaign in the state
(New Jersey Comprehensive Tobacco Program, 2001).
Among adolescents, reductions in tobacco use have been highest when intensive media
campaigns and comprehensive community programs are combined. Intensive media campaigns
combined with enhanced school programs achieve slightly lower, but significant reductions in
tobacco use. These patterns are also demonstrated to reduce smoking intentions among youth
(Mesack, 2004).
While media campaigns generally tend to be expensive, there are ways to lower the budget in
states with limited funds for tobacco control. In 1997, several years after Utah’s smokefree
restaurant law went into effect, the state began a low-budget media campaign to target youth
smoking, conducting interviews with other states that had already developed intensive media
campaigns. Focus groups were conducted with youth who used tobacco and did not use tobacco
to identify the most effective ads from various states, according to Utah teens. Given financial
limitations, the process of interviewing other states and drawing from their experiences, as well
as conducting focus groups was a useful way to develop messages at low cost (Murphy, 2000).
Counter-advertising also does not have to take the form of a mass media campaign. Gains can be
made by using community and local groups to help advocate against the tobacco industry in their
area. In California, passage of city ordinances in San Francisco, Los Angeles, and San Diego
have also effectively restricted advertising near the schools (Green et al., 2006). Additionally,
several California Partnerships for Priority Populations have engaged in efforts to combat
tobacco industry advertising and sponsorship in their communities. Some activities they have
engaged in include: working with organizations in their communities to adopt policies that
13

prohibit tobacco industry sponsorship; conduct educational campaigns about sponsorship issues,
opposing donations, and reducing public display of products that use American Indian images
(Toward a Tobacco-Free California, 2006).
Community Partnerships in New York also advocated for the elimination of tobacco
advertisement and offered incentives for eliminating or reducing tobacco advertising by sending
mass mailings to store owners. Community Partnerships had realistic objectives, targeting one
or two retailers in their area – often those with lower levels of advertising – which was a good
start in this area. The evaluators of this program suggested concentrating on mass
merchandisers, large grocery stores, and pharmacies because these retailers are less likely to
participate in tobacco industry programs and rely less on tobacco revenue. Pharmacies and large
grocery stores – particularly local chains – may be more concerned about their image and more
likely to change. Challenges in these efforts were difficulty contacting store owners,
nonresponse to letters, store managers indicating that placement of tobacco advertisements
cannot be changed at the store level, store owners’ fear of loss of incentives from tobacco
companies or decrease in sales, and retailers’ lake of awareness of impact of tobacco ads on
tobacco smoking (RTI, 2006).
Quit Lines
Cessation services seem like an idea focus area for community organizations, running
decentralized cessation centers. However, the main focus for states in this area has been the Quit
Line, which tends to be an effective means of centralizing the cessation services and reaching
people throughout the state and connecting patients to local resources.
CDC’s Guide to Community Preventative Services recommends cessation programs such as a
Quit line as an effective intervention at the community level. Although Quit Lines may not be as
effective as face-to-face clinical contact, telephone counseling has been found to be effective
relative to interventions with no personal contact (Murphy and Aveyard, 2005). Quit Lines also
are more likely to be used than traditional counseling because they offer accessible counseling to
people throughout a state or region who may have limited mobility, because they are large
enough to offer counseling to a variety of ethnic groups and other populations with special
language needs, and because they can cover areas where other services are not available (CDC,
2004). Even those who are constrained by child care or transportation difficulties to participate
in local programs can use the Quit Line. Evaluation of the Massachusetts Quit Line services
have shown that a high percentage of callers are women, young people, and members of diverse
communities who may have had barriers to accessing other quit services (Koh et al., 2005). It
also is easier to promote than an array of separate local programs and saves money that can be
directed to other programs. The centralized nature of a Quit Line also makes it easier to have
extended Helpline hours. Other strengths are that clients are more candid when speaking over
the phone to people they will never see (California Department of Health Services, 2000).
Some states, like New York provide brief, on-the-spot one time counseling services to smokers
who call during operating hours. This minimal counseling approach enables the state to provide
services to a large number of callers. California, on the other hand, provides pro-active follow-
14

up sessions according to the probability of relapse (e.g., within 24 hours of quitting, at three
days, at one week, at two weeks, and at one month). Most states maintain lists of local programs
for referral (CDC, 2004).
In general, state Quit Line services have been offered to all those who initiate a call to the Quit
Line. Vermont, however, has in the past offered a free telephone support service specifically for
pregnant women smokers. Patients are referred from the Women, Infants, and Children program
and telephone contact is initiated by the telephone service representatives. This service resulted
in 25% self-reported abstinence from smoking at last telephone contact and 20% abstinence by
the postpartum visit at the Women, Infants, and Children program. The benefit of this program
is that it may succeed in reaching women who would not initiate a call to a Quit Line (Solomon
and Flynn, 2005).
CDC (2004) emphasizes that Quit Line community partnerships are essential. Partners can
increase referrals and supplement funding. Many community partners are also in need of referral
services that the Quit Line provides. Partnerships also promote closer coordination with county
and local control programs, and enable the Quit Line to act as the primary resource linking state
and local initiatives. For example, in New York, local coalitions feature the Quit Line in their
media campaigns and use the Quit Line as a referral resource to community-based programs.
Some states have also partnered with health plans. For example, Massachusetts negotiated with
all of its major health plans to adopt a universal system of fax referral and proactive telephone
counseling (CDC, 2004).
States can partner with community groups and with local tobacco control programs to get these
organizations to promote the Quit Line. In turn, the Quit Line can provide local referrals. In
New York State, Community Partnerships and Cessation Centers were used to promote the Quit
Line. They provided Quit Line information and giveaways at health care provider trainings and
presentations. They conducted mass media efforts promoting the Quit Line (e.g., tv, radio,
newspaper, billboards, etc.) They provided Quit Line information to cessation groups. They
increased spending in January to capitalize on New Year’s resolutions. However, there was a
lull in activities in late summer 2005 when Community Partnership contracts were not renewed
in time. For every 10% increase in expenditures on television ads for the Quit Line, call volume
increased by 5.3%; a 10% increase in radio or newspaper ads resulted in a 1.9% and 1.1%
increase in call volume, respectively (RTI, 2006).
The California Helpline began in August 1992. One of the Helpline’s interventions is to refer
clients to local programs. The program works with all of the local health departments across the
state to maintain up-to-date listings of legitimate (as determined at the local level) tobacco
cessation services in each county. Lists are updated twice a year. The Helpline is publicized as
a part of the California Tobacco Control Program’s media campaign, which advertises on
television, radio, billboards, bus signs, and local newspapers. Since 1996, the Helpline has also
been doing its own outreach to increase awareness among health care providers (by sending them
back thank you cards), sending promotional materials to high school tobacco educators, and
sending newsletters to county-level and regional, and local level partners (California Department
of Health Services, 2000).
15

Some Quit Lines, along with providing counseling and referrals, also provide training to health
care providers For example, Washington State’s Quit Line, funded by the state Department of
Health, provides residents with one-on-one counseling, quit kits, and referrals to local programs.
This Quit Line also trains healthcare system workers to effectively intervene with their patients
who are smokers (Washington State Department of Health, 2005). Massachusetts’ Quit Works
program links providers to the Quit Line, the Quit Net (an Internet-based service) and other
cessation services and promotes provider education (Koh et al., 2005).
Offering free or reduced price distribution of nicotine replacement therapy (NRT) may be an
effective strategy for getting people to call the Quit Line and increasing the success of their quit
attempt. This strategy, in conjunction with community partners, has been used effectively in
New York. The New York City Department of Health and Mental Hygiene, with the New York
State Department of Health, and the Roswell Park Cancer Institute distributed free nicotine
replacement therapy (NRT) to over 34,000 callers to the Quit Line in 2003. Of individuals
contacted after 6 months, more NRT recipients than comparison group members quit smoking
(33% vs. 6%). This program was begun at a time when new smoke-free legislation was coming
into effect and increased taxation of cigarettes also focused more attention on cessation. Those
who received at least one counseling call during that time also had a higher level of quitting. A
quit-line driven free NRT distribution program might help increase the success rate of quitting
among smokers who are seeking help (Miller et al., 2005). Maine’s Quit Line also offers free
NRT to eligible callers, with higher quit rates among those who received NRT, another
indication that tobacco medication access may be vital for states to maximize the impact of their
programs (Swartz et al., 2005). In other areas of New York, due to budget constraints, another
program sent a one-week or two-week supply of NRT to a smaller group of smokers instead of a
six-week supply (and in one area, participants got a voucher sent to their home for redemption of
a two-week supply at a local pharmacy). Lower quit rates (21%) were observed in areas where
only a one-week supply of patches was sent. However, the cost of an intervention with only a
one-week supply was far lower (Cummings et al., 2006).
Free medication may not only increase success of quit attempts but may also prompt smokers
who wish to quit to call the quitline (Cummings et al., 2006). Responses to a newspaper
advertisement promotion to call the Quit Line for a free 2-week supply of medication resulted in
a 25-fold increase in calls and a similar promotion of a Better Quit stop smoking aide that can be
used as a cigarette substitute resulted in a 2-fold increase in calls (Bauer et al., 2006). Programs
like these may work especially well in states when there is a climate in the state (e.g., a new
indoor air law, an increase in cigarette taxes) that prompts smokers to want to quit (Murphy and
Aveyard). Additional smokers may be trying to quit and be ready to take advantages of such free
NRT services and follow-up counseling offered by a Quit Line.
Additional localized programs services promoted by state tobacco control programs include:
• Vermont’s “Ready, Set… STOP” program, which supports a network of counselors in every
hospital in the state who coordinate and provide services at the local level, collaborating
with community partners, employers, and providers to promote services and administering
the QuitBucks program, which offers free or reduced price nicotine replacement therapy
(NRT) to those in counseling. NRT is also shipped from the Quit Line to clients enrolled in
16

Medicare and Ladies first (a woman’s health program) and to uninsured Vermonters (State
of Vermont, 2006).
• Utah’s Ending Nicotine Dependence (END) program has served over 1,000 youth cited by
Utah courts for tobacco possession to help them quit. Most participants liked the END class
and would recommend it to friends who use tobacco (Utah Department of Health, 2006).
• New Jersey’s “Quitcenters”, 15 clinics at locations throughout the state that offer face-toface
counseling on a sliding-scale fee based on income (New Jersey Comprehensive
Tobacco Control Program, 2001).
• New York’s 19 Cessation Centers, established in late 2004 to increase the screening and
counseling of tobacco users by health care providers. These centers are working with 187
health care provider organizations and are targeting larger organizations because of their size
and reach and will use those relationships to facilitate future outreach to affiliated clinics and
medical practices. Cessation Centers advocate for policy change with provider
organizations, provide training to providers, and provide technical assistance.
Collaborations with provider organizations and activities have increased over time. Best
practices identified by the Cessation Centers for provider trainings were: provide training
on-site, provide incentives such as lunch, coordinate training with already scheduled
meetings, offer CME credits. In addition, providing mini-grants to targeted health care
providers appears to facilitate systems-level changes. Barriers were competing priorities,
financial barriers, and perceptions that existing systems sufficiently address cessation (RTI,
2006).
Use of cessation centers like those in New York to train providers to provide better smoking
cessation services, including motivational interviewing techniques may be another useful
intervention, complementing a Quit Line. However, follow-up trainings may need to be
organized to yield the full benefits of this type of intervention and, in some cases, competing
priorities will make it difficult for changes to be sustained (Velasquez et al., 2000). Working
with hospitals may be another opportunity, which is often missed currently. When patients are
hospitalized, this may be an opportune time to initiate smoking cessation interventions to
increase quit rates (Polednak, 2000).
Financial incentives, NRT, and competitions may also prompt smokers to quit. In New York
State, local tobacco coalitions partnered with the Roswell Park Cancer Institute to administer 11
“Quit and Win” competitions between November 2001 and March 2004. These competitions
were intended to motivate smokers to initiate quit attempts and provide incentives for abstinence
(e.g., cash prizes via a lottery) in the weeks immediately following the quit date when relapse is
likely. Across all eleven contests, 87-93% of participants reported actually making a quit
attempt and the average quit rate after one month was 21-49%. By comparison the average quit
rate across all New Yorkers was 21.5%. For 8 of the 11 programs, participants had a
significantly higher rate of quitting than the general population. Costs per attributable quit
ranged from $301 to $953 and were not related to market size (O’Connor et al., 2006). A survey
of adult smokers in Erie and Niagara Counties found that the offer of free nicotine patches/gum
17

or cash incentives were interventions that would be most likely to convince smokers to stop
smoking (Giardina et al., 2004).
Physician Education Efforts
The Agency for Health Care Policy and Research (AHCPR) has found that brief advice by
medical providers is effective, although less effective than intensive individual, group, and
telephone counseling interventions. FDA-approved pharmacotherapy can be effective,
particularly when combined with counseling.
The CDC recommends that statewide tobacco treatment include the following elements:
• Population-based counseling and treatment programs, such as cessation helplines
• Systemic changes that incorporate the AHCPR-sponsored cessation guideline
• Coverage for treatment for tobacco use under public and private insurance
• Elimination of cost barriers to treatment for underserved populations, particularly the
uninsured
The Community Guide’s Tobacco Review website (CDC, 2006) summarizes the results of 39
measurements, taken from 20 studies on the use of provider reminders prompting providers to
ask patients about their smoking status, and found that, although none were found to increase
provider knowledge, 15 resulted in the provider offering cessation advice, 7 resulted in patient
cessation attempts and 14 of the 39 measurements resulted in the cessation of patient smoking.
18

ENFORCEMENT
Both local entities and state governments benefit when states provide assistance to local
governments in enforcement with respect to secondhand smoke and use of tobacco by minors.
Most local governments do not have the resources or expertise in legal and enforcement issues
pertaining to tobacco control strategies, and most state-level lack knowledge of community
accessibility. It therefore is helpful to develop state-wide resources that can be accessed by local
governments and community groups for legal issues associated with enforcement of policies.
In California, the Technical Assistance Legal Center (TALC) is a statewide project which
provides legal technical assistance to California cities and counties that have questions relating to
tobacco control policies and strategies. TALC conducts legal research and develops print
resources – including model ordinances – and provides technical assistance on legal strategies to
reduce tobacco use, including preventing tobacco sponsorship, limiting youth access to tobacco,
regulating tobacco retailers, expanding secondhand smoke protections, etc. TALC’s legal staff
are lawyers with experience in public health, policy development, and municipal government.
TALC works on legal issues that are almost always generated by the community. Rather than
telling advocates or municipal legislators which issues to work on, TALC assists them in
developing the strongest and most defensible policy possible to achieve their goals. TALC
responds to approximately 750 requests for assistance each year. TALC employs a “train the
trainers” approach to educating community advocates, communicates with public officials via
written and oral presentations, and participates in statewide workgroups. TALC has been able to
work with local agencies because California’s tobacco control infrastructure enables this type of
collaboration. Without community-based agencies involved in the issue formally, TALC would
have had to work only at the state level (California Department of Health Services, 2002).
Similarly, Massachusetts has traditionally offered legal assistance to local entities through its
Community Assistance Statewide Team to help them create and enforce smoke-free laws (Koh et
al., 2005).
States generally will benefit if they can get local entities interested in working on enforcement
and policy development; however, providing some resources to help local groups conduct their
work will multiply their effectiveness.
Smokefree Policies
In general, there have been very low rates of infraction with secondhand smoke policies in most
industries. For example, a study of bars in Los Angeles County after the 1998 smoke-free law
passed showed that compliance with the law – initially at 45.7% -- climbed to 75.8% by 2002
(Weber et al., 2003). One month after the New York state smoke-free law went into effect, the
proportion of smoke-free restaurants, bars, and bowling alleys in the state climbed from 31 to 93
percent (New York State Department of Health, 2004). A preliminary assessment after the
Massachusetts statewide indoor air act came into effect found that 3.7% (n=1) of establishments
assessed had smoking in them. In this one establishment, there was only one smoker who put
out his cigarette when a peer asked him to (Connoly et. al, 2005). In Vermont, the Department
19

of Health is the lead agency for enforcement of the Clean Indoor Air Act, handling complaints
and sending out a Food and Lodging sanitarian to investigate, sometimes in coordination with
the Department of Liquor Control. The Department of Health has generally obtained voluntary
compliance through owner education and large fines for noncompliance (State of Vermont,
2006).
According to the 2006 Surgeon General’s Report, public education and public debate before the
adoption of the law, as well as in the period leading up to its implementation, can help
jurisdictions achieve high levels of compliance with the law. To be effective, the law also needs
to designate an appropriate enforcement agency and establish a public complaint mechanism and
make complaints received the driving force for enforcement (Jacobson and Wasserman, 1999).
Using local or community officials to help enforce tobacco control policies enhances their
efficacy both by deterring violations and by sending a message to the public that community
leadership supports the policy (Erikson, 2000).
BREATH, the California Smoke-free Bar Project, a statewide project of the American Lung
Association of Contra Costa and Solano Counties was initiated to ease the transition to the new
law for business owners, to activate public support for the law, and to defeat tobacco industry
efforts to undermine the law. As described by Kiser and Boschert (2001) BREATH included just
four full-time and one part-time staff members assigned to work with the county and local health
departments, the regions, ethnic networks, voluntary health groups, and various tobacco control
grantees throughout California. Some of the main activities they conducted, using local and
community resources included: working with local health departments to help ease the transition
to the new law; activating support for the law; developing a network of local experts to work
with on enforcement actions; and working with lobbyists for voluntary health organizations to
defeat attempts to undermine the law. The use of powerful community members to tell public
officials that they support smoke-free laws was an essential component of BREATH’s strategy.
In addition, grassroots organizing through voluntary health organizations (for heart disease, lung
disease, and cancer) proved to be indispensable in providing financial help and volunteer
advocates (Kiser and Boschert, 2001).
Local Lead Agencies (LLAs) in California played an important role in enforcement of the
Smoke-free law, developing local interventions based on local needs, including ethnic make-up
and language challenges. Using local officials helped because they were less visible to those
who opposed the law at a state level (Magzamen and Glanz, 2001). Grants were awarded to law
enforcement agencies at the local level to help fund these activities (Tobacco Education and
Research Oversight Committee, 2003). Activities included helping smooth the transition to the
new law and enforcement. For example, LLAs in Shasta and Riverside Counties hired law
enforcement officers or health educators to cite noncompliant bars throughout the country,
writing citations and educating local judges and court commissions. LLA members in San
Mateo County rode along with city police officers to witness citations of bars (California
Department of Health Services, 2001). Regional organizations also played a role in enforcement,
and the four Ethnic Tobacco Education Networks of the California Tobacco Control Program
have provided ethnic-specific technical assistance and training. The smoke-free workplace law
was implemented with equal fidelity in small and large workplaces (Green et al., 2006).
20

Broadening Protection from Environmental Tobacco Smoke
The states discussed in this report have all enacted smokefree legislation at the state level,
usually affecting workplaces, restaurants, and bars. Many states have continued their work on
environmental tobacco smoke, addressing smoke in homes, cars, and other public places. Most
of this work has been done in collaboration with local governments or community groups.
Some local public housing authorities and municipalities in California have adopted nonsmoking
policies in at least some sections of publicly-funded housing complexes for nonsmokers,
including Los Angeles, San Francisco, Santa Barbara, San Luis Obispo, Madera, Belmont,
Sebastopol, and Thousand Oaks (Toward a Tobacco-Free California, 2006). Smiliarly, Utah’s
Tobacco Control Program educates local municipalities and multi-unit housing owners and
tenants about policies that protect users of recreation venues and tenants about secondhand
smoke (Utah Department of Health, 2006).
A variety of local jurisdictions in Utah have also been active in banning smoking in countyowned
vehicles, in city parks, in assisted living facilities, at fairs and festivals, in playgrounds,
and on sports fields (Utah Department of Health, 2006). Local jurisdictions in California have
continued to enact ordinances to protect the public from smoke, including outdoor tobacco
smoke at beaches and parks, in shared spaces of multi-unit housing, in front of entryways to
private buildings open to the public, and at public events such as fairs and festivals. San Luis
Obispo also passed an ordinance to protect foster children, prohibiting foster parents from
allowing children in their care to smoke, prohibiting smoking in cars during and prior to
transporting foster children, and prohibiting smoking within 20 feet of children in foster care. In
addition, the Campuses Organized and United for Good Health (COUGH) campaign continued
its work to strengthen anti-smoking policies on the 23 campuses of the California State
University and has expanded to the University of California and community college systems
(Toward a Tobacco-Free California, 2006).
On a voluntary basis, the State of Vermont has also conducted a “Take it Outside” campaign to
encourage smoke-free policies in homes and cars for parents and caregivers (State of Vermont,
2006) New York set a goal to increase the percentage of adults and youth who live in
households where smoking is prohibited and ride in vehicles where smoking is prohibited. This
effort has been lead by Community Partners throughout NY state. They have used two broad
strategies: 1) paid media (including television, radio, billboard, print ads, website ads, and mass
mailings) and 2) community education (including information dissemination at community
events, planning and implementing smoke-free pledge campaigns, and identifying partners and
collaborators to gain access to targeted groups). Several partners worked through health care
providers or used materials from the US EPA. Others advocated with landlords and realtors
about smoke-free dwelling policies. Community Partners reported struggling with designing and
distributing materials and questioned the value of community education efforts. Data on trends
in smoke-free homes and cars showed that the efforts were not effective, indicating that either
the strategies have been ineffective or have not been sufficiently coordinated across the state.
The evaluators of this program suggested that community activities are less effective in
21

promoting home activities than paid media, indicating that a state-led effort would be more
effective than an effort led by the Community Partners (RTI International, 2006).
Youth Access Restrictions
Combined with mass media and educational programs, the restriction of tobacco sales to youth
may be an additional deterrent to initiation of smoking. This can be accomplished through the
passage of laws at the federal, state, or local level preventing sales to people under a certain age.
Laws can also require tobacco to only be held in a case behind the sales counter, not on the floor
of a retail shop. Sales to youth and others can also be restricted through a state or local tax on
tobacco, making it more difficult for people to afford to buy the products.
There is some debate whether laws should be enacted only on the federal or state level or if local
ordinances will be effective. In general, state laws restricting the availability of tobacco to
adolescents may be relatively weak and difficult to enforce because they do not target business
owners but instead target minors and employees. They can also include preemption clauses that
make it difficult for local jurisdictions to put in pace more restrictive measures. An advantage to
enacting laws at the local level to curb tobacco sales to minor is that such laws have the support
of local enforcement agencies and are, thus, more likely to be enforced. Local officials can also
tailor their policy response to local conditions because the tobacco industry has less influence
over local politics. And strong youth access laws implemented and enforced at the local level
have been showed to have both long- and short-term positive effects on youth smoking (Chen
and Forster, 2006). Fourteen local jurisdictions in California implemented or strengthened
tobacco retailer licensing with strong enforcement provisions and fees set high enough to fund
their programs effectively in the past three years. These efforts will help prohibit sales to minors
as well (Toward a Tobacco-Free California, 2006).
However, in New Jersey, where there was no state-wide law to discourage youth smoking, local
ordinances were rarely enforced, potentially because there was confusion about who was
responsible for enforcing ordinances and because penalties were not significant enough to deter
smoking. Laws from locality to locality appeared to be too heterogeneous and lacking in
cohesion to have a substantial impact on youth smoking rates in the state (Hrywna et al., 2004).
A study of Massachusetts towns with local youth access ordinances confirmed these results,
finding that there was little evidence that these ordinances reduced youth’s perceived access to
tobacco products (Thomson et al., 2004).
When state laws are passed, there is also the question of who should enforce them – state or local
governments. In New Jersey, enactment of the Tobacco Age of Sale Enforcement legislation in
1996, which mandated that enforcement of youth smoking laws be given to the state’s
Department of Health and Senior Services (New Jersey Comprehensive Tobacco Control
Program, 2001). In Vermont, enforcement is also done by the state. The Department of Liquor
Control has been working with the Department of Health to offer free training classes to retailers
because training in conjunction with enforcement leads to more successful compliance . The
Department of Liquor Control monitors retailers for compliance with laws related to the ban on
22

self-service displays and sales to minors, training 17-year old “youth buyers” (State of Vermont,
2006).
In other states, local and state governments work together to enforce the laws. Washington State
Department of Health works with the state Attorney General, the Liquor Control Board, and
local law enforcement to enforce state and federal laws that restrict sales and advertising to kids
(Washington State Department of Health, 2005).In California, youth access laws are enforced by
local and state enforcement agencies. The Stop Tobacco Access to Kids Enforcement (STAKE)
Act includes a state-wide media campaign that publicizes a toll-free number to report stores
suspected of selling tobacco to minors and an enforcement program that conducts approximately
2,000 compliance checks annually at tobacco retailers – less than 10% of retailers each year.
Local enforcement efforts complement state activity by conducting additional compliance
checks, providing community-specific sales rates that can be used to put pressure on local
retailers. The California experience indicates that, while an aggressive state enforcement
program (e.g., like that of the State of Vermont) might make local enforcement unnecessary, in
some states with less effective state programs local enforcement may be necessary for an
effective enforcement program (Howard et al., 2001).
A study of enforcement of state laws prohibiting the sale of tobacco to minors found that the
following practices had a higher level of compliance: a law enforcement strategy coordinated by
a state agency, state funding of test purchases for enforcement, prosecution of offenders with
penalties for violating the law, and effective merchant education. Meanwhile, the study found
that warnings in lieu of penalties for offenders, reliance upon nonfunded local enforcement, and
limitations placed on enforcement authority or the conduct of test purchases were less successful
(DiFranza, 2005).
23

ELIMINATING DISPARITIES IN TOBACCO USE
One of CDC’s goals is to eliminate disparities in tobacco use among population groups. In
response, most states have allocated a portion of their tobacco program funding to the
elimination of disparities, building capacity of organizations who work with priority groups and
funding community grantees to implement programs in this area. Several states have also
launched anti-tobacco marketing campaigns targeted toward specific groups.
In a study of 10 state tobacco programs, the populations most often identified as priorities for a
state program were: specific minorities (e.g., African Americans), low socioeconomic ranking
populations, youth, and pregnant women (Mueller et al., 2006). Colorado’s disparately affected
groups include Hispanic, African American, Native American, Asian American and Asian
Pacific Islander and the Gay, Lesbian, Bisexual and Trans-gendered (GLBTQ) population.
Health disparities and limited access to health care co-exist with higher rates of tobacco use
within specific segments of the population, including those associated with gender, race or
ethnicity, education or income, age, geographic location and sexual orientation. The most
effective approach to eliminating disparities are still being developed, and are likely to vary
according to group, region, community and other factors (DHHS, 2000).
Despite the complexity of the issue of disparate populations, some success stories are available.
Oregon successfully tailored their statewide tobacco control policy to the Native American
population in the state to address a smoking prevalence among Native Americans that was
almost twice the statewide rate (41%, compared to 21%). Youth advocates on Indian
Reservations placed articles in tribal newspapers and conducted outreach to tribal community
members regarding the marketing and positioning of tobacco products by tobacco companies on
Reservation lands. Interventions were informed by, and worked around the ceremonial and
religious use of tobacco by many Native American tribes, as well as the existing community
infrastructure, income, education and employment levels, access to health services, as well as the
mental health and substance abuse interventions that were already in place in the community.
Much of the success of the project was attributed to the role of an Indian organization in
planning and implementing the intervention and evaluation protocols (Lichtenstein, 1995).
Arizona’s tobacco prevention efforts have been successful in targeting low income populations.
From 1996 to 1999, smoking prevalence declined by 21 percent among adults and 24 percent
among young adults (18-24). Some of the largest declines in smoking, however, were among
residents in low income (31.2% to 22.8%) and low education (29.3% to 16.2%) categories,
reducing disparities in smoking rates (Campaign for Tobacco-Free Kids, 2006).
California has identified certain populations with disproportionately high rates of tobacco use:
immigrant communities, the Lesbian, Gay, Bisexual and Transgender community, the African
American community, the American Indian community, active-duty military, and individuals of
low socioeconomic status (Toward a Tobacco Free California, 2006). The state has been
targeting some campaigns toward these communities to help eliminate disparities. California has
been providing training and culturally appropriate technical assistance to a variety of groups to
24

assist in the development of Communities of Excellence in Tobacco Control. Targeted groups
include African Americans, American Indians, Asian and Pacific Islanders, Hispanics/Latinos,
the Lesbian, Gay, Bisexual, and Transgender community, labor groups, and people of low
socioeconomic status. Among other activities, the state focused on building the capacity of
organizations that work with these priority organizations to deliver tobacco control programs to
these communities, funding community grantees to do the work.
New Jersey launched a multicultural marketing and media campaign directed toward African-
American, Asian, and Hispanic communities to address disparities. Radio, billboard, bus, and
newspaper advertisements are in English and Spanish. Chinese and Korean materials are also
used. Twelve multicultural newspapers and eight radio stations have been targeted (New Jersey
Tobacco Control Program, 2001).
Vermont has also offered special services to certain populations. To reach low-income adults,
the state develops cessation outreach materials for those with lower literacy, conducts promotion
in blue-collar workplace settings, and uses venues such as the Vermont Food Bank and other
organizations that work with low-income adults to distribute materials. Cessation materials are
also designed for distribution through channels that reach the gay, lesbian, bisexual, transgender,
and queer community. In addition, outreach to women who smoke during pregnancy is another
area of focus (State of Vermont, 2006).
Utah has focused on providing counseling and medications to low-income smokers, funding
ethnic networks to educate people in the Hispanic, Native American, African American, and
Pacific Islander communities about tobacco use and to develop culturally appropriate messages
for media campaigns (Utah Department of Health, 2006).
Passage of a state-wide Smokefree Law may, in and of itself, eliminate some disparities. A
study of locations with local anti-smoking ordinances found that towns with higher levels of
education and income were more likely to pass such ordinances (Skeer et al., 2004). In New
York, 60% of the population was covered by a smokefree law prior to the passage of the state
law, and equity of protection for the remaining 40% was a campaign message of advocates of the
law (Stoner and Foley, 2005).
25

STATE ROLES OF SURVEILLANCE AND TECHNICAL ASSISTANCE
Surveillance
Large, local surveys can provide essential data to advocate for, plan, implement, and evaluate a
comprehensive tobacco control program (Mostashari et al., 2005). In most states, the Behavioral
Risk Factor Surveillance System (BRFSS)and Youth Risk Behavior Survey, which are
collaborative efforts between the states and the US Centers for Disease Control, are the most
widely used data for these functions. In some cases, the state health department also fills the
function of conducting surveys, and results are provided to local health authorities for program
development. For example, Hawaii conducts a cross-sectional mediator survey is conducted to
assess the mediators of change, such as stage, self-efficacy, perceived environment, attitude, and
subjective norm for the target behaviors. This information is used in conjunction with the
BRFSS and Youth Risk Behavioral Survey (Nigg et al., 2005).
More creative surveillance programs are also implemented by the states. For example,
surveillance on quit rates in NYC was conducted by the NY State Bureau of Epidemiology
Services by collecting data from 200 stores in NYC, approximately 30% of pharmacies in the
city. Weekly sales of over the counter brand name and generic nicotine patch and nicotine gum
products were collected between July 2001 and January 2004. This enabled the state to assess
changes in mean weekly sales of these products soon after the state tax increase in April 2002 (a
27% increase in nicotine patch sales; a 7% increase in nicotine gum sales), the city tax increase
in July 2002 (50% increase in patch sales; 10% increase in gum sales), and the New York City
smoke-free workplace law in 2003 (31% increase in patch sales, 8% increase in gum sales). This
surveillance system provided strong evidence that increased taxation and smoke-free legislation
are associated with increases in smoking cessation behaviors and that electronic retail data can
help to provide a rapid assessment of tobacco control initiatives (Metzger et al., 2005).
In general, there is not a lot of evidence in the published literature that local government
agencies or community groups have been conducting significant surveillance efforts for tobacco
control. In general, the more effective surveillance systems have been implemented by states or
by the federal government and shared with local programs to inform policy and program
development.
Although self-report measures of second-hand smoke exposure gathered through populationbased
surveys are generally considered acceptable, the reliability of these measures is
questionable (Hamilton, 2003). Observational studies to record compliance (i.e., patron smoking
behavior, non-smoking signage, employee exposure) with statewide laws present an ideal
activity for local community organizations. The measurement of respirable suspended particles
(RSPs) in public places is an effective and reliable monitoring tool when coordinated state-wide,
and may also be used to demonstrate the effectiveness of statewide comprehensive clean air
policies when compared to control locations in states with no comprehensive policy in place.
26

Evaluation
Evaluations of state programs typically focus on the effectiveness of tobacco control activities in
decreasing tobacco use. Some have also been evaluated on level of funding dedicated to tobacco
policy or, in certain cases, political and financial climates and measures of organizational
capacity (Krauss, 2004). Siegel (2002) asserts that process evaluation of state tobacco programs
is critical to accurately assess whether failures to observe an effect are due to flawed design or
inadequate implementation, while outcome evaluation is critical to see if the goals of changing
smoking behavior (and ultimately disease incidence and mortality) are met. However, most
programs are so new that even evaluations to determine behavioral outcomes are insufficient
(Seigel, 2002).
A workshop convened by the Institute for Global Tobacco Control at Johns Hopkins (2002)
made recommendations on appropriate evaluation of tobacco control interventions. This
workshop discussed the evaluation methods of the California Tobacco Program as one of its case
studies, finding that the program had been mainly evaluated using large triennial surveys and
smaller ongoing surveys. However, because the interventions in the program differ at the local
level – each community deciding for itself what was feasible – the evaluation was complex.
Evaluators were not able to link program components to outcomes. While changes in immediate
outcomes were noted (e.g., passage of new policies), more distal outcomes (e.g., declines in
smoking prevalence, reduced mortality) were more difficult to show; however, given the
longevity of the program, some of these links have been established. These findings indicate that
process evaluation may be any easier way for the state to evaluate programs implemented at the
local level and that, with more time, outcome evaluation may be feasible (Institute for Global
Tobacco Control, 2002).
In some states, community and local grantees are required by states to evaluate their programs,
using specific methods. For example, Hawaii requires grant awardees to submit periodic
progress reports, addressing progress, barriers, facilitators, and future action plans. The Hawaii
Outcomes Institute at the University of Hawaii identifies community needs and priorities and
assists individuals and communities in evaluating health outcomes. This has included the
development of community health profile indicators (Nigg et al., 2005).
Community-level evaluation, often focused more on process outcomes, should fit within a more
extensive state-level evaluation plan that will use longer-term outcome-oriented measures.
Montana requires its community-based contractors to develop and implement Action Plans based
on the state’s long-term, intermediate, and short-term objectives. Contractors are required to
develop Specific, Measurable, Appropriate, Realistic, and Time-bound (SMART) objectives and
evidence-based interventions with timelines. They report outputs on a quarterly basis to describe
interventions completed and pending. They complete a Service Area Profile to illustrate shortterm
changes in the community, which should include data, such as the number of schools that
provide evidence-based tobacco curricula and number of smoke-free businesses. The state
evaluators oversee longer term data collection to determine the effectiveness of interventions and
to determine impacts (Montana Tobacco Prevention Advisory Board, 2004).
Community partners may benefit from technical assistance for their evaluation. One example of
this is in California. The state requires that its school-based Tobacco Use Prevention Education
27

(TUPE) programs adhere to federal Principles of Effectiveness, which requires a needs
assessment, performance indicators, research-based prevention programs, and evaluation of
progress. TUPE programs utilize the California Kids Health Survey to assess progress, and the
state offers workshops each year to assist schools in analyzing their data (Tobacco Education and
Research Oversight Committee, 2003).
At the state level, some states, like Vermont and New York, use an independent evaluator to
evaluate the program. Others, like Washington State’s Tobacco Program collect and analyze
their own data on tobacco use for evaluation purposes (Washington State Department of Health,
2005).
Vermont’s process evaluation includes an assessment of the activities within each component of
the Tobacco Control program, using information from reporting forms from each of the
community coalitions and school-based programs. Outcome evaluation consists of measuring
changes over time with respect to awareness of program activities, utilization of services,
knowledge, perceptions and attitudes related to tobacco use, and behaviors. Data comes from
Vermont departments of Health, Education, and Liquor Control; key statewide data; and national
datasets (State of Vermont, 2006).
Evaluation of the Massachusetts Tobacco Control Program has been conducted on several levels.
The first was an overall evaluation by Abt Associates, an independent firm. The second was
monitoring of smoking behaviors through population-based surveys (e.g., Massachusetts Adult
Tobacco Survey, Massachusetts Behavioral Risk Factor Surveillance System). The third was
field initiated research demonstration projects (e.g., investigations of knowledge, attitudes, and
behaviors). The fourth was a Management Information System that tracks individual program
services and accomplishments (e.g., database of locally enacted programs). Because the program
is a comprehensive program, there are difficulties with any attempt to measure the effectiveness
of any given component of this program (Koh et al, 2005).
28

THE CLEAN AIR STATES: APPROACHES TO FUNDING, ADMINISTRATION AND
MANAGEMENT OF LOCAL HEALTH AGENCIES AND TOBACCO PROGRAMS
One of the single most critical factors in program success is funding level, as more fully funded
programs can increase expenditures on both mass media campaigns and community initiatives
(Wakefield and Chaloupka, 2000), which are essential components to a successful anti-tobacco
strategy. States vary in the level of funding available for work in the area of tobacco, and their
approach inevitably is impacted by that.
Louisiana, for example, has traditionally had a very limited operating budget. Opportunities
were created by partnerships with schools and the American Lung Association (Thomas et al.,
2002), but the state has traditionally had difficulty conducting large-scale media campaigns or to
fund extensive school-based or community initiatives, whereas in states like California or New
York media campaigns are more likely to be undertaken. In some states, collaboration is more
extensive and distributed more broadly throughout the state. For example, in New Jersey, the
Local Information Network Communication Center administers state grants to New Jersey’s 114
local health departments to support their work with Communities Against Tobacco (CAT)
coalitions to reduce environmental tobacco smoke in municipalities and to evaluate progress
(New Jersey Comprehensive Tobacco Control Program, 2001).
Some state tobacco control budgets have extensive budgets but may be under funded on a per
capita basis. For example, in California, the budget was $80 million in 2006; New York
budgeted $45 million. Both states only budgeted about half the recommended CDC Best
Practices Minimum State Spending Requirement for state tobacco programs; however, both
states still have made gains in tobacco control because their operating budget, overall, was large.
Meanwhile, Maine ($15 million) and Delaware ($10 million) exceeded the CDC per capita
minimum (American Lung Association, 2005), though their total spending was far lower than
California or New York. On the low end of the scale, Connecticut appropriated only about 1.2
million dollars, approximately 5% of the recommended per capita level.
Because a comprehensive state tobacco control program involves multiple state and local
agencies and many voluntary and community agencies, program management and administration
is vital (Eriksen, 2000). Coordinating and integrating statewide programs with local program
efforts requires adequate staffing and communication systems, and funding local partners
requires Requests for Proposals to be well-designed, assistance to grant applicants, a wellmanaged
review system, and technical assistance to improve local project performance and
management (CDC, 1999). A study of ten state tobacco control programs concluded that lead
state agencies tend to be familiar with Best Practices; however, dissemination efforts are
essential to ensure that other program partners gain familiarity with the guidelines. This will
allow resources to be better leveraged by community groups (Mueller et al., 2006).
The public health presence of a local government or local health department can take a variety of
forms and local-level health departments of the various states with clean indoor air acts are
organized in a variety of ways. The National Association of County and City Health Officials
(NACCHO) has stated that functional local health departments should meet certain standards,
29

including having the capacity to monitor health status, developing public health policies and
plans, enforcing public health laws and regulations, helping people receive health services, and
evaluating interventions (NACCHO, 2005). Many states use their local health entities to carry
out these functions and others with respect to tobacco control.
The general organizational structure of several tobacco programs and interactions with local or
community-level organizations in several states with smokefree laws are presented here:
• California: The comprehensive tobacco control program in California, with thousands of
saved lives, has probably had the greatest effect on the public’s health of any US program,
even at a national level (Siegel, 2002), and because it is the largest and longest running
tobacco control program, more has been written about it than any other state’s programs. In
California, county and city health departments are responsible for conducting local tobacco
control programs within their health jurisdiction and involving a community coalition in
mobilization activities. These agencies take the lead on local community policy
development, facilitate enforcement of laws, and provide local cessation services. The state
program also funds Competitive Grantees, which include nonprofits and community-based
organizations, as well as universities. Priority Populations Partnerships work to address the
tobacco control needs of specific racial, ethnic, socioeconomic, cultural, sexual orientation,
and occupational groups.
California is making an effort to maintain and expand its smokefree workplace protections;
increase enforcement of public policies promoting smoke-free environments; and implement
a campaign for smoke-free shared spaces, including all indoor and outdoor public spaces and
common areas of multi-unit residential housing. Further, the state’s Tobacco Education,
Research and Oversight Committee (TEROC) has recommended local health agencies work
toward reducing and eliminating all exposure to drifting secondhand smoke.
• Delaware: As a result of Delaware’s Clean Indoor Air Act, carcinogens in indoor public
areas have been reduced by 90%. Delaware offers mini-grants to help community
organizations conduct tobacco prevention programs and events. They use both CDC and
Master Settlement funding to award mini-grants to community-based organizations to fund
implementation of tobacco prevention and control programs. Funding has also fueled
activities and programs through contracts with organizations such as the American Lung
Association, American Cancer Society, the Boys and Girls Clubs, and various other
community groups. They also provide incentives to community organizations to implement
effective programs, and are attempting to expand their youth-led and youth-involvement
programs. These include Teens Against Tobacco Use (TATU), the Delaware Kick Butts
Generation (KBG), and an annual Youth Tobacco Conference, currently sponsored by the
IMPACT Delaware Tobacco Prevention. In addition to their popular QuitLine, Delaware
also offers an online Quitnet service (State of Delaware, 2005).
• Florida: Florida has five Regional Tobacco Prevention Coordinators (RTPCs) that oversee
tobacco prevention and control programs across regions that range in size from seven to 16
counties. RTPCs are the point of contact for youth anti-tobacco advocates in the regions,
serve as resources for Students Working Against Tobacco (SWAT) chapters, and assist with
30

training youth leaders and adult SWAT advisors. The RTPC coordinators serve as
community tobacco prevention and control experts, liaisons with county health departments
and community organizations, and advocate for tobacco prevention on boards and councils
within their designated regions (State of Florida, 2005)
• Hawaii: County government has provided extensive support to Hawaii on tobacco issues.
Community-based coalitions have been mobilized in each county with additional efforts to
organize coalitions on the island of Molokai, part of Maui County, and Oahu.
• Louisiana: Louisiana’s Office of Public health Tobacco Control Program focuses on
providing community and statewide partnership grants and mini grants to communities to
coordinate community planning and capacity-building activities.
• Maine: Maine funds 31 local Health Maine Partnerships state to work to improve the health
of Maine residents through four programs: the Partnership for a Tobacco-Free Maine (PTM),
Maine Cardiovascular Health Program (MCVHP), the Community Health Program (CHP)
and the Coordinated School Health Programs (CSHP). The Healthy Maine Partnerships
facilitate the coordination of the state and local intervention activities funded by the tobacco
settlement and assures linkages with related program activities. Each Partnership works to
reduce tobacco-related chronic diseases by developing and implementing comprehensive
community-level interventions that promote and support tobacco use prevention, increased
physical activity and healthy eating, primarily through policy and environmental change
(State of Maine, 2004)
• Massachusetts: The Massachusetts Tobacco Control Program (MTCP) was launched when
Massachusetts became the second state (after California) to pass an initiative petition raising
cigarette excise taxes to fund the program. MTCP funds local tobacco control programs to
provide direct, community-based services, as well as several statewide programs that offer
technical training and assistance and educational materials to these local programs and other
grassroots efforts. Local programs are organized into six regional networks that meet
monthly. Each regional network is guided by a Steering Committee comprised of
representatives from local and regional programs; managers representing other segments of
the Department’s public health service system, such as substance abuse services; and
representatives from the American Cancer Society and the Department of Education
(Massachusetts Department of Health, 2002).
• Montana: The Montana Tobacco Use Prevention Program (MTUPP) was launched in 2000.
Montana apportions their efforts in tobacco control as approximately 30% to statewide
programs, 40% to Community-Based Programs, 20% to School-Based Programs and 10% on
Special Emphasis Populations which include Native Americans, low income populations, spit
tobacco users and women of childbearing age. The state funds 28 contracts that provide
community-based programs in 29 counties, on seven reservations, to the Little Shell Tribe
and five Urban Indian Centers. Montana’s statewide clean indoor air law restricts smoking
to designated areas in most public places, private workplaces, and restaurants. In general,
these laws consist of a requirement to post signs indicating where smoking is and is not
31

allowed. In April of 2001, the Montana Legislature mandated that all state-owned or leased
buildings be smoke-free. (Montana Tobacco Prevention Advisory Board, 2004).
• New Jersey: The New Jersey Department of Health and Senior Services, through the Local
Information Network Communication System (LINCS) administers grants to 114 local health
departments to support work with the Communities Against Tobacco (CAT) coalitions. The
Tobacco Program also awards money to the American Cancer Society to work with
community groups, to the Princeton Center for Leadership Training works with schools and
communities to coordinate the REBEL program, and to the NJ Higher Education Consortium
to decrease smoking on college campuses. New Jersey’s Smoke-Free Air Act was enacted in
April of 2006, making indoor public places and workplaces across the State smoke free.
(New Jersey Comprehensive Tobacco Control Program, 2001).
• New York: Both New York State and the city of New York implemented comprehensive
clean indoor air laws In 2003, making most enclosed workplaces and public places, including
restaurants and bars, smoke free. Both the state and the city have conducted thorough,
systematic evaluations of the impact of these laws, with technical assistance from US CDC.
The evaluations found high levels of public support for the laws and high levels of
compliance among restaurants, bars, and other workplaces. In addition, air quality in
hospitality venues has improved substantially, the level of particulate matter fell sharply in a
number of hospitality venues; and that worker secondhand smoke exposure has fallen
sharply. New York City has reported a sharp reduction in adult smoking prevalence since its
law took effect, although other factors, including an increase in the cigarette excise tax, a
media/public education campaign, and cessation initiatives, likely also contributed to this
outcome. The evaluation also examined the economic impact of the laws and found that
restaurant and bar business, as measured by business tax receipts, employment, and the
number of liquor licenses issued has not been adversely affected by the laws.
New York had the largest increase in funding in FY 2007 of any state, almost doubling the
state’s tobacco prevention and cessation program funding, and bringing the total program
budget to $85.5 million. The New York Tobacco Control Program (NYTCP) funds four
types of interventions to control tobacco at the community level: Community Partnerships,
Youth Action Programs, School Policy Partners, and Cessation Centers. Many of the state’s
programs focus on youth, including grants to local youth organizations with existing countywide
programming, an interactive web site, youth-focused Quitline, and youth-oriented
supplies and gear. Since the passage of New York’s clean Indoor Air law, the state has
worked to move community members, employers, health care professionals, workers and the
public toward lower tolerance of tobacco use, garner additional support for the Clean Indoor
Air law, and decrease exposure to secondhand smoke in the work place, in public places, and
in private residences (New York State Department of Health, 2006).
• North Dakota: North Dakota’s tobacco settlement payments are governed by a 1999 law
that placed 45 percent of the money into a Water Resource Trust Fund, 45 percent into an
Education Trust Fund and 10 percent into a Community Trust Fund for health purposes. In
The 2001, the state allocated funds to local public health agencies for school and community
health prevention programs and for state aid to local public health agencies. The North
32

Dakota Department of Health currently contracts with all 28 local public health units, four
Indian Tribes and one Indian Service Area for tobacco prevention through the Community
Health Grant Program. More than 92 percent of Tobacco Prevention and Control funding
supports programs and services directly provided by public and private organizations. A
majority of the funding (73 percent) is used to provide grants to local communities for
school- and community-based prevention programs. Fifteen percent of the funding is
dedicated to cessation efforts; 8 percent is used for statewide coordination including program
administration, outreach, technical assistance and training, and program monitoring; and 4
percent is used for public education, program assessment and evaluation (North Dakota
Department of Health, 2004). Although the funds appropriated (3.1 million for the FY2004-
05 biennial budget) are not adequate to fund a comprehensive, statewide approach, the
Community Health Grant Program has contributed to significant declines in the youth
smoking rates and a steady decline in the adult smoking rates (Campaign for Tobacco-Free
Kids, 2006)
• Rhode Island: Rhode Island’s Tobacco Control Program (TCP) consists of a statewide
coalition and a community component, the Comprehensive Tobacco Control (CTC)
Initiative, a multi-component intervention designed to create systems and personal change
within communities. The CTC Initiative supports nine community organizations in five
urban communities (Rhode Island Tobacco Control Program, 2006). Although Rhode Island
has considerable tobacco tax revenue as a result of a 2004 cigarette tax increase that brought
the state’s cigarette tax to the second highest in the nation, funding for Rhode Island’s
tobacco prevention program has been cut every year since FY2003 and the state currently
ranks 35th in funding of tobacco prevention programs .( Campaign for Tobacco-Free Kids,
2006)
• South Dakota: South Dakota ranks 40th in the funding of tobacco prevention programs.
Initially the state’s tobacco settlement payments were placed into the People's Trust Fund,
and only the interest generated by the Fund was available for expenditure and no program
had been designated to receive these funds. In 2000, the state created a tobacco prevention
and cessation program in the Department of Human Services and established a Tobacco
Prevention Trust Fund with an 11-member Tobacco Prevention and Reduction Advisory
Board. The Board was charged with developing a comprehensive plan to prevent and reduce
tobacco use, including establishing program priorities, setting criteria for awarding grants,
and assessing overall program performance. The state currently funds a statewide Quitline,
in partnership with the American Cancer Society, and four community-based pilot programs.
The Tobacco Control Program is located in the Office of Health Promotion, along with the
Cancer Registry, Cardiovascular Health, Chronic Disease – Breast & Cervical Cancer
Control & Screening programs, Coordinated School Health, Diabetes Control, and Oral
Health programs, and additional projects are conducted across program lines, including
training and referral materials that were distributed to health care provider facilities across
the state (South Dakota Department of Health, 2005).
• Utah: Utah was the first state in the country to meet the national Healthy People 2010 goal
of decreasing adult smoking to less than 12 percent of the population, and it continues to be
the only state that meets this standard. In 1995, the state’s Public Indoor Smoking
33

Restrictions (HB50) went into effect, prohibiting smoking in all public places except bars,
private clubs, rooms for loading, and enclosed smoking rooms at the Salt Lake City
International Airport. The state provides an example of the successful use of statewide
media campaigns in partnership with local programs and services. The state’s TRUTH
campaign produces a variety of culturally and linguistically appropriate television ads, radio
ads, posters, billboards, community events and other media efforts to educate residents about
the dangers of tobacco, provide information about quit services, and promote smoke-free
environments. The ads are pervasive and memorable, with more than 90% of residents
stating that they remember seeing or hearing The TRUTH ads in the past month (Utah
BRFSS, 2005 and 2006). The campaign utilizes The Truth from Youth Anti-Tobacco
Advertising Contest to involve 4 th and 5 th graders in the design of billboard, television and
radio ads and works closely with Hispanic community leaders to produce and distribute
culturally and linguistically appropriate television ads, radio ads, posters, and billboards.
The state also partners with local health departments, schools, and numerous communitybased
organizations to offer school and community-based services, media messages, and
policy development and enforcement. The community-based Ethnic Tobacco and Health
Networks to alleviate disparities, and the program has Tobacco Control Program has also
partnered with Medicaid and the Association for Utah Community Health to offer enhanced
cessation services and medications to more than 2,400 uninsured or Medicaid-insured
individuals (Utah Department of Health Tobacco Prevention and Control Program, 2006)
• Vermont: The FY2007 budget appropriated $5.1 million to the state's tobacco prevention
and cessation program, a 5 percent increase over FY2006 funding that continued to
appropriate the majority of tobacco settlement funds to the state Medicaid program. In 2006,
the tobacco control community successfully protected the MSA Strategic Contribution Fund
payments, which Vermont will begin to receive in 2008, from being used on non-tobacco
control initiatives. Vermont will also have an increase in tobacco-generated revenue as a
result of a cigarette tax increase that was effective July 1, 2006, and an additional tax
increase effective in 2008.
Community coalitions are a key component of Vermont’s Tobacco Control Program, with
coalitions in 19 communities receiving grants each year to keep local partners engaged.
School districts also receive grants for prevention curricula. The Health Department creates
mass media and public education materials, including television and radio advertisements,
brochures and giveaways for statewide distribution. The local coalitions use these materials
in a variety of local activities, where the messages are reinforced within the community.
Based on the type of campaign, the coalitions collaborate with partners such as school-based
tobacco coordinators, youth groups and hospital cessation coordinators (State of Vermont,
2006).
• Washington: The state of Washington became the 5th state to implement a comprehensive
statewide law prohibiting smoking in all indoor public places and workplaces including
restaurants, bars, taverns, bowling alleys, skating rinks, and non-tribal casinos in December
of 2005. Tobacco control activities are funded through local health departments and
community organizations in all 39 counties. In addition, the state funds anti-tobacco
34

activities in 27 of 29 tribes and five high risk communities. All nine Educational Service
Districts also receive funding to help schools establish and enforce polices and deliver
curricula to students (Washington State Department of Health, 2005).
More than 92 percent of the Tobacco Prevention and Control Program’s $28.7 million annual
budget supports programs and services directly provided by public and private organizations.
More than $10 million goes to local communities across the state through contracts with
county health departments, community organizations, schools, and tribes. Approximately
one-third of the total budget is allocated to public awareness and one-third to community and
tribal organizations. Schools and Quit programs each account for about ten percent of the
budges, with policy and enforcement, administration and assessment making up the
remainder (Washington State Department of Health, 2005).
There are a variety of approaches to organizing state tobacco control programs and collaborating
with local and community entities. Each of the states does carry out some level of collaboration
with local or county health departments, schools, and community-based organizations, which
indicates the utility of using these organizations to provide services to residents.
35

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