Tobacco Control Interventions

What are effective statewide tobacco interventions for commercial tobacco* use?

Effective population-based commercial tobacco control interventions include tobacco price increases, high-impact anti-tobacco mass media campaigns, comprehensive smoke-free policies, and cessation access. The evidence shows that implementing and enforcing these strategies, both individually and as part of a comprehensive tobacco prevention and control effort, can reduce smoking initiation and use among adults and youths. Comprehensive commercial tobacco prevention and control efforts involve the coordinated implementation of population-based interventions to prevent tobacco initiation among youth and young adults, promote quitting among adults and youth, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities among population groups.^[1] Tobacco products include cigarettes, e-cigarettes, cigars, pipes, hookah, smokeless tobacco, and other products. Programs combine and integrate multiple evidence-based strategies, including educational, regulatory, economic, and social strategies at local, state, or national levels.^[1]

Evidence-based interventions that are key components of a comprehensive commercial tobacco prevention and control effort include:

• Mass-reach health communications campaigns that use multiple-media formats; include hard-hitting or graphic images; are intended to change knowledge, beliefs, attitudes, and behaviors affecting tobacco use; and provide people who use tobacco with information on resources on how to quit.^[2]
• Increases in the unit price for tobacco products, which can decrease the number of people using tobacco, reduce the amount of tobacco consumed, and prevent young people from starting to use tobacco^[3]
• Comprehensive smoke-free policies that prohibit smoking in all indoor areas of workplaces and public places, including restaurants and bars, to prevent involuntary exposure to secondhand smoke.^[4]
• Cessation access strategies, such as^[5] comprehensive insurance coverage for evidence-based cessation treatments^[6,7]; integration of tobacco screening and treatment into routine clinical care^[6,7]; and quitlines, which are highly cost-effective.^[5-7] For more information on cessation access, please see Reduce Tobacco Use | 6|18 Initiative | CDC.

CDC’s EXHALE package features evidence-based strategies to improve asthma control and reduce healthcare costs, including information about comprehensive smoke-free policies.

What is the public health issue?

Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Cigarette smoking harms nearly all organs of the body; it has been linked to heart disease, multiple cancers, lung diseases, and other illnesses. Smoking during pregnancy also causes harm to the fetus.^[6]  In addition to adverse effects on individual- and population-level health, smoking imposes an immense financial burden on society, with over 480,000 premature deaths, over $170 billion in lost productivity costs, and over $225 billion in direct medical care expenditures in the United States each year.^[8] The use of smokeless tobacco, cigars, and pipes can also have deadly consequences, including lung, larynx, esophageal, and oral cancers.^[9-11]  Moreover, the effects of tobacco use are not limited to the user. Secondhand smoke exposure can cause death and many serious diseases, including lung cancer, heart disease, and stroke among adults and respiratory illness, ear infections, asthma attacks, and sudden infant death syndrome among children and infants.^[6] An estimated 1 in 4 nonsmokers (58 million people), including about 2 in 5 children, are exposed to secondhand smoke.^[12]

Electronic cigarettes (e-cigarettes) are not safe for youth, young adults, and pregnant women.^[13]  Most e-cigarettes sold contain nicotine, which is highly addictive and can harm a developing fetus. Nicotine exposure can also harm adolescent and young adult brain development, which continues into the mid-20s. E-cigarette aerosol can contain harmful and potentially harmful chemicals.^[14] And youth e-cigarette use is associated with the use of other tobacco products, including cigarettes.^[13]

The 2020 Surgeon General’s Report on Smoking Cessation highlights the latest scientific evidence on the health benefits of quitting smoking, and proven treatments and strategies to help people successfully quit.

What is the evidence of the health impact and cost effectiveness?^[1-4]

A systematic review of proven population-based commercial tobacco control interventions found that these programs were associated with:

• Reductions in the prevalence of tobacco use among adults and young people.
• Reductions in tobacco product consumption.
• Increased quitting.

States that have made larger investments in com­prehensive tobacco control efforts have seen larger declines in cigarettes sales than the United States as a whole, and the prevalence of cigarette smoking among adults and youth has declined faster as spending for tobacco control programs has increased.^[15]  Comprehensive tobacco control efforts have also contributed to reductions in tobacco-related diseases and deaths, and were effective across diverse racial, ethnic, educational, and socioeconomic groups. The review also found that these programs were cost-effective and that healthcare savings were greater than the cost of the intervention.

Additional systematic reviews examining the impact of single interventions that may be implemented individually or included as part of a comprehensive commercial tobacco control program, such as mass-media campaigns, price increases, and smoke-free policies, also found strong evidence of their efficacy and cost-effectiveness.

Mass-reach Communications Campaigns
Mass-media campaigns were associated with lower prevalence of tobacco use, increased cessation and use of available cessation services, and decreased initiation of tobacco use among young people:

• Median decrease of 5.0 percentage points in the prevalence of tobacco use among adults,^[2]
• Median decrease of 3.4 percentage points in the prevalence of tobacco use among young people (11 to 24 years of age),^[2]
• Median increase of 3.5 percentage points in cessation of tobacco use^[2]
• Median relative increase of 132 percent in the number of calls to quitlines,^[2]  and
• Decrease of 6.7 percentage points in tobacco use initiation among young people (11 to 24 years of age).^[2]
• From 2012–2018, CDC estimates that more than 16.4 million people who smoke have attempted to quit and approximately one million have successfully quit because of exposure to the Tips From Former Smokers campaign.^[16]
• The Tips campaign was correlated with a 3.9% increase in quit attempts per quarter during 2012–2018.^[16]

An economic review of the evidence found that:

• The cost for mass-reach health communications campaigns was between $0.25 to $3.35 per person per year. The campaigns resulted in cost savings; averted health costs were greater than the cost of the campaign.^[17]
• Quitline promotion campaigns resulted in an estimated cost of $260 for each additional call to the Quitline.^[2]

Individual studies found that:

• The return on investment (ROI) for the FDA’s The Real Cost Campaign was $128 for every $1 spent.^[18]
• The ROI for the FinishIt campaign was $174 for every $1 spent. The cost effectiveness measure for FinishIt was $1076 for every QALY gained.^[19]
• During 2012–2018, CDC’s Tips From Former Smokers campaign helped prevent an estimated 129,000 early deaths and helped save an estimated $7.3 billion in smoking-related healthcare costs.^[20-22]
• For every $3,800 spent on the Tips campaign between 2012-2018, it is estimated that one early death was prevented.^[20]

Increasing the price of tobacco products

Increases in the price of tobacco products reduce the quantity demanded for tobacco, thereby prompting quit attempts, reducing consumption among those who do not quit, and preventing youth from starting.^[6,21] Increasing the unit price of tobacco by 20 percent would reduce overall consumption of tobacco products by 10.4%, prevalence of adult tobacco use by 3.6%, and initiation of tobacco use by young people by 8.6%.^[3]

An economic review of the evidence estimated that healthcare cost savings from a 20 percent price increase for tobacco products ranged from -$0.14 to $90.02 per person per year (2011 dollars) in addition to averted productivity losses.^[2,3]

Comprehensive smoke-free policies

Comprehensive smoke-free policies have been shown to substantially improve indoor air quality, reduce secondhand smoke exposure, change social norms regarding the acceptability of smoking, prevent smoking initiation by youth and young adults, help people who smoke quit, and reduce heart attack and asthma hospitalizations among people who don’t smoke.^[6,10,21]  Comprehensive smoke-free policies were associated with:

• Decreased exposure to secondhand smoke.^[4]
• Decreased prevalence of tobacco smoking.^[4]
• Decreased tobacco consumption.^[4]
• Fewer deaths and hospitalizations from cardiovascular disease^[4]
• Decreased asthma attacks and hospitalizations.^[4,23-25]
• Decreased morbidity,^[4] hospitalizations, and deaths from respiratory diseases.^[26]
• Decreased risk of preterm birth.^[23-25]
• A decrease in deaths from Sudden Infant Death Syndrome (SIDS).^[25]

An economic review of the evidence estimated that indoor smoke-free policies are cost-effective,^[4] and do not reduce profits for hospitality businesses.^[4,25,27] The policies, which have implementation costs of $25 or less per person,^[4] lead to reduced mortality and health care costs,^[4] and save quality adjusted life years (QALYs),^[4,28] The policies have the potential to avert health care costs of $150,000 to $4.8 million per 100,000 persons.^[4]

* “Commercial tobacco” means harmful products that are made and sold by tobacco companies. It does not include “traditional tobacco” used by Indigenous groups for religious or ceremonial purposes.