Tobacco Use Prevention and Control Position Statement

ASTHO Supports State Efforts in Tobacco Use Prevention and Control

The Association of State and Territorial Health Officials (ASTHO) supports aggressive efforts to reduce all tobacco use, including electronic cigarettes (e-cigarettes) and their associated liquids containing nicotine and other harmful agents. ASTHO supports efforts to address tobacco-attributable health disparities, tobacco-related morbidity and mortality, and the limited regulation of e-cigarettes and their components.

Within This Context, ASTHO Supports the Following Recommendations for State and Territorial Public Health Agencies:

Implement evidence-based strategies while also using innovative approaches:

• Develop programs and policies to reduce tobacco use, related illness, and death, as stated in the Guide to Community Preventive Services and CDC’s Best Practices for Comprehensive Tobacco Control Programs.^1,2  
• Identify priorities in state and territory plans for tobacco prevention and control that align with best practices, recognizing innovative strategies such as retail initiatives to eliminate sale of tobacco products.
• Leverage existing resources available within ASTHO, CDC, CMS (such as administrative matches), FDA, and national organizations to increase use of best practices and to stay connected to the national tobacco control movement.
• Accelerate the reduction of tobacco use using strategies described in the 2014 Surgeon General’s report The Health Consequences of Smoking—50 Years of Progress.³
• Deploy promising practices and innovative approaches, such as translating research to practice and establishing strategic partnerships across sectors.

Prevent youth from using tobacco products:

• Protect minors from illegal sales of all tobacco products, including e-cigarettes, by supporting implementation and enforcement of youth access laws that also address Internet sales.
• Support efforts to raise the minimum age for tobacco purchases to 21.
• Educate youth on the risks of all tobacco products, including e-cigarettes and hookahs.

Restrict marketing of tobacco products and enact counter-marketing:

• Limit advertising and promotion of tobacco products, including e-cigarettes, by reducing the time, place, and manner of such advertisements, including at the point of sale.
• Limit the density of tobacco retailers by supporting zoning and licensing efforts that cap the number of retailers within a geographic area.
• Educate the public through various media channels about the risks of tobacco use, cessation benefits and resources, tobacco policies, and tobacco industry marketing tactics.
• Monitor tobacco industry and its marketing strategies.

Eliminate secondhand smoke exposure:

• Support legislation and policies to eliminate exposure to secondhand smoke and secondhand aerosol from e-cigarettes in workplaces and public places, including restaurants, bars, multi-unit housing, institutions of higher education, beaches, parks, cars, and all other places.
• Support public housing authorities in the implementation of the U.S. Department of Housing and Urban Development final rule requiring smoke-free policies in public housing by providing technical assistance. Offer resources for residents, including referrals to cessation resources.
• Support efforts to advance tobacco- and smoke-free campuses and sporting venues.

Support sustained funding for tobacco control and prevention work:

• Support sustained funding at levels recommended by CDC for comprehensive tobacco prevention and control programs at the state and territory level.
• Support utilizing Master Settlement Agreement revenues and other tobacco funding sources to fund comprehensive tobacco control programs and other public health programs.

Promote tobacco cessation and access to services:

• Support and promote coverage of tobacco cessation programs, including quit line services, evidence-based individual and group counseling, and all FDA-approved pharmacotherapy.
• Work with state and territory partners, including insurance commissioners, to implement tobacco cessation provisions in national and federal guidelines such as public and private coverage with no cost-sharing for tobacco use counseling, medications, and interventions.
• Encourage healthcare providers in primary and specialty care settings, including mental health and substance use treatment providers, to expand tobacco cessation and create systems change to establish a standard of care for cessation treatments.
• Support cessation among priority populations, especially pregnant women and those with mental illness, substance use disorders, and comorbidities.

Monitor and evaluate tobacco use:

• Support expanding national and state surveillance efforts, specifically focused on new products such as e-cigarettes, to identify emerging issues for the tobacco prevention and control field.
• Support further research on emerging tobacco products, such as e-cigarettes.

Monitor the sale and availability of tobacco products:

• Support FDA’s full implementation of the Family Smoking Prevention and Tobacco Control Act including restricting flavors in all products and limiting advertising of e-cigarettes. Support efforts at the state and local level to complement FDA regulatory actions.
• Encourage legislation and programs that address disparate rates of tobacco use, limit use of flavored and menthol tobacco products, and reduce inequities in access to cessation programs.
• Promote safety measures for the production, packaging, and sale of tobacco products, including liquid nicotine, to prevent unintentional poisonings and injuries.
• Support legislative and regulatory autonomy to prevent tobacco consumption, including the preservation of local government autonomy.
• Increase and achieve parity of prices on all tobacco products, including e-cigarettes, to reduce consumption by preventing youth from using tobacco and encouraging tobacco users to quit.
• Address hookah and vape shops through comprehensive smoke-free laws and zoning rules to limit the density and proximity of these establishments to youth-sensitive areas, such as schools and playgrounds.

Background: Improving States’ and Territories’ Tobacco Prevention and Control Efforts

Tobacco use is the single most preventable cause of disease, disability, and death in the United States. Nearly 500,000 people die prematurely each year from smoking or exposure to secondhand smoke, and another 16 million have a serious illness caused by tobacco use.⁴ Coupled with this enormous health toll is the huge economic burden associated with tobacco use. More than $170 billion per year is spent on medical expenses and another $156 billion per year is spent on lost productivity.^5,6

Though the public health community has made strides in preventing tobacco use and helping people to quit, many continue smoking, including youth. Among middle and high school students, 4.7 million report using at least one tobacco product, including e-cigarettes.⁷ Despite a reduction in cigarette smoking among youth, the rate of e-cigarette use is rising, with 16 percent of high school students using e-cigarettes in the past 30 days.⁸ Between 2013 and 2014, use of e-cigarettes among middle and high school students tripled.⁹ The 2016 Surgeon General’s report E-Cigarette Use Among Youth and Young Adults provides guidance that e-cigarettes have become a public health issue given the increasing use among youth and young adults and the harm that nicotine exposure can have on the developing adolescent brain.¹⁰ This trend is especially concerning as initial research identified variability in the chemicals within e-cigarettes, including substances that are toxic and carcinogenic.¹¹

Disparities in tobacco use persist based on a variety of demographic factors. To address these disparities, the Consortium of National Networks to Impact Populations Experiencing Tobacco-Related and Cancer Health Disparities is working to prevent initiation and reduce tobacco use among priority populations. The networks are a resource for state and territorial health agencies in order to develop partnerships and enact strategies to engage groups that are the most burdened by tobacco use.Tobacco policy interventions have helped to protect the public from secondhand smoke exposure and change norms around tobacco use. Though smoke-free policy and price interventions were widely used between 2000-2009 – with 46 states and the District of Columbia increasing tobacco excise taxes – progress has stalled since 2010, with a marked decline in the amount of activity in smoke-free and price policies across states.¹² In 2015, 49.6 percent of the U.S. population was protected by comprehensive smoke-free laws in 27 states, including Washington, D.C.¹³ This percentage represents an increase from 47.8 percent of the population protected by smoke-free laws in 2010 and 2.7 percent in 2000. California’s updated law enacted in 2016 brings the total to 28 states, including Washington, D.C., with nearly 60 percent of the U.S. population covered by comprehensive laws.¹⁴ State and local comprehensive smoke-free policies are still needed in many places in order to provide protection to the entire U.S. population.¹⁵

Comprehensive and sustained statewide tobacco control programs have been shown to reduce smoking rates, tobacco-related deaths, and diseases caused by smoking.¹⁶ A comprehensive program is a coordinated effort to prevent initiation of tobacco use, protect the public from secondhand smoke, and promote cessation. This approach combines social, economic, regulatory, clinical, and educational strategies, and also focuses on identifying and eliminating tobacco-related disparities. CDC’s Best Practices for Comprehensive Tobacco Control Programs—2014 outlines this approach and guides state and territory programs in implementing effective tobacco control and prevention efforts.

CDC continues to recognize proven evidence-based interventions for tobacco control as reliable and necessary to improve the public’s health. Yet, tobacco control programs continue to be underfunded compared to CDC-recommended levels.¹⁷ Strained economies have continued to force cuts to funding for comprehensive tobacco control programs. Efforts to make up for the gap in funding through tobacco price increases have stalled as described above, with the average state tobacco excise rate at $1.69 per pack, which is below the 70 percent excise tax share in final consumer price recommended by the World Health Organization.^18,19 However, opportunities exist within the Family Smoking Prevention and Tobacco Control Act and provisions of other federal guidelines to strengthen state tobacco control programs. State and territorial health agencies can use these resources to support disease prevention initiatives, insurance coverage of tobacco cessation, quit line services, and evidence-based policies to reduce tobacco use. In addition, tobacco control programs can further their efforts by collaborating with chronic disease and other public health programs.

States and localities are also leveraging new strategies to reduce tobacco use and prevent initiation by raising the minimum legal age of sale for tobacco products. The 2015 National Academies of Sciences, Engineering, and Medicine report Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products offers evidence to support raising the minimum age to 21, which would have the effect of lowering initiation rates among youth, thus reducing prevalence and disease in the long-term.²⁰ Policies that raise the minimum age of sale to 21, coupled with the implications of FDA’s deeming rule to regulate all tobacco products (finalized in 2016), help to reduce tobacco use and prevent initiation among youth, especially for emerging products like e-cigarettes.

With the creation of incentives by federal agencies and the technical support provided by organizations such as ASTHO, state and territorial health agencies can make significant progress in reducing tobacco use and preventing tobacco-attributable health inequities, ultimately leading to improved health outcomes.

Approval History

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a future development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Board of Directors. Position Statements are not voted on by the full ASTHO membership.

Prevention Policy Committee Approval: February 6, 2017
Board Review and Approval: March 7, 2017
Policy Expires: September 8, 2020
Expiration Date Extension due to COVID-19: September 2022

This Position Statement supersedes the Position Statement approved on September 8, 2014, which expires on September 8, 2017.

Related ASTHO Documents

Prevention Policy Statement

Comprehensive Tobacco Control: Guide for State and Territorial Health Officials

Smoking Cessation Strategies for Women Before, During, and After Pregnancy: Recommendations for State and Territorial Health Agencies

ASTHO Comprehensive Tobacco Cessation Expert Roundtable: Summary of Meeting and Expert Recommendations

References

1. Community Preventive Services Task Force. “Tobacco.” Available at https://www.thecommunityguide.org/topic/tobacco. Accessed 10-14-2016.
2. CDC. “Best Practices for Comprehensive Tobacco Control Programs—2014.” Available at http://www.cdc.gov/tobacco/stateandcommunity/best_practices/. Accessed 10-14-2016.
3. HHS. “The Health Consequences of Smoking—50 Years of Progress, A Report of the Surgeon General, Executive Summary.” Available at https://www.surgeongeneral.gov/library/reports/50-years-of-progress/exec-summary.pdf. Accessed 11-03-2016.
4. CDC. “At A Glance 2016: Tobacco Use – Extinguishing the Epidemic.” Available at http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/tobacco-aag.pdf. Accessed 10-14-2017.
5. Ibid.
6. CDC. “Fast Facts: Smoking & Tobacco Use.” Available at http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/. Accessed 10-14-2016.
7. CDC. “At A Glance 2016: Tobacco Use – Extinguishing the Epidemic.” Available at http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/tobacco-aag.pdf. Accessed 10-14-2017.
8. Ibid.
9. Arrazola R, Sing T, Core C, et al. “Tobacco Use Among Middle and High School Students — United States, 2011–2014.” Morbidity and Mortality Weekly Report. April 2015. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a3.htm. Accessed 10-20-2016.
10. HHS. “E-Cigarette Use Among Youth and Young Adults, A Report of the Surgeon General.” Available at https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_508.pdf. Accessed 3-07-2017.
11. Cheng T. “Chemical evaluation of electronic cigarettes.” Tobacco Control. February 2014. Available at http://tobaccocontrol.bmj.com/content/tobaccocontrol/23/suppl_2/ii11.full.pdf. Accessed 3-08-2017.
12. Homes C, King B, Babb S. “Stuck in Neutral: Stalled Progress in Statewide Comprehensive Smoke-Free Laws and Cigarette Excise Taxes, United States, 2000–2014.” Preventing Chronic Disease. June 2016. Available at https://www.cdc.gov/pcd/issues/2016/15_0409.htm. Accessed 10-20-2016.
13. Tynan M, Holmes C, Promoff G, et al. “State and Local Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars — United States, 2015.” Morbidity and Mortality Weekly Report. June 2016. Available at http://www.cdc.gov/mmwr/volumes/65/wr/mm6524a4.htm. Accessed 10-20-2016.
14. Ibid.
15. Ibid.
16. CDC. “Best Practices for Comprehensive Tobacco Control Programs—2014.” Available at http://www.cdc.gov/tobacco/stateandcommunity/best_practices/. Accessed 10-14-2016.
17. Campaign for Tobacco-Free Kids. “FY2017 State Rankings: States Ranked by Percent of CDC-Recommended Funding Levels.” Available at http://www.tobaccofreekids.org/microsites/statereport2017/pdf/3_FY2017_Rankings_Funding_Prevention_Programs.pdf. Accessed 1-16-2017.
18. Campaign for Tobacco-Free Kids. “State Cigarette Excise Tax Rates & Rankings.” Available at https://www.tobaccofreekids.org/research/factsheets/pdf/0097.pdf. Accessed 1-16-2017.
19. World Health Organization. “Taxation.” Available at http://www.who.int/tobacco/economics/taxation/en/index1.html. Accessed 1-16-2017.
20. Institute of Medicine. “Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products.” The National Academies Press. March 2015. Available at http://tobacco21.org/wp-content/uploads/2015/03/Public-Health-Implications-of-Raising-the-Minimum-Age-of-Legal-Access-to-Tobacco-Products-Institute-of-Medicine.pdf. Accessed 10-20-2016.