oversight

Tobacco Use And Public Health: Federal Efforts to Prevent and Reduce Tobacco Use among Youth

Published by the Government Accountability Office on 2003-11-21.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                United States General Accounting Office

GAO             Report to the Honorable Bill Frist, U.S.
                Senate



November 2003
                TOBACCO USE AND
                PUBLIC HEALTH

                Federal Efforts to
                Prevent and Reduce
                Tobacco Use among
                Youth




GAO-04-41
                                                November 2003


                                                TOBACCO USE AND PUBLIC HEALTH

                                                Federal Efforts to Prevent and Reduce
Highlights of GAO-04-41, a report to the        Tobacco Use among Youth
Honorable Bill Frist, U.S. Senate




Tobacco use is the leading cause of             Some federal programs, research, and activities that aim to address tobacco
preventable death in the United                 use among youth focus only on tobacco while others aim to address tobacco
States. The Centers for Disease                 use as part of broader efforts to address unhealthy behaviors such as
Control and Prevention (CDC)                    substance abuse and violence. Two federal programs within the Department
reported that, on average, over                 of Health and Human Services (HHS) focus only on tobacco use. CDC’s
440,000 deaths and $76 billion in
medical expenditures were
                                                National Tobacco Control Program (NTCP) focuses on preventing and
attributable to cigarette smoking               reducing tobacco use among the general population and explicitly targets
each year from 1995 through 1999.               youth. The Substance Abuse and Mental Health Services Administration’s
Reducing tobacco-related deaths                 program to oversee implementation of a provision of federal law, commonly
and the incidence of disease, along             referred as the Synar Amendment, focuses only on tobacco use among
with the associated costs,                      youth. The Synar Amendment requires states to enact and enforce laws
represents a significant public                 prohibiting the sale of tobacco products to minors. In addition to these
health challenge for the federal                tobacco-focused programs, HHS, and the Departments of Defense (DOD),
government. Most adults who use                 Justice (DOJ), and Education sponsor programs that include tobacco use as
tobacco started using it between                part of broader efforts to address unhealthy behaviors among youth, such as
the ages of 10 and 18. According to             substance abuse and violence. For example, Education’s Safe and Drug-Free
a Surgeon General’s report, if
children and adolescents can be
                                                Schools and Communities program is designed to prevent substance abuse
prevented from using tobacco                    and violence. HHS agencies, such as the National Institutes of Health,
products before they become                     conduct research on tobacco use and nicotine addiction among youth and its
adults, they are likely to remain               health effects on youth. HHS agencies and other federal departments also
tobacco-free for the rest of their              support activities to prevent and reduce tobacco use among youth, such as
lives.                                          education and outreach efforts. HHS and its component agencies coordinate
                                                tobacco-related efforts with other federal, state, and local government
GAO was asked to provide                        agencies and nongovernmental entities.
information on federal efforts to
prevent and reduce youth smoking.               Federal departments and agencies collect a variety of information to monitor
Specifically, this report describes             how programs that aim to address tobacco use among youth are being
(1) federal programs, research, and
activities that aim to prevent and
                                                implemented by grantees and the effectiveness of grantee efforts in meeting
reduce tobacco use among youth,                 program goals. The information is collected through various means,
(2) the efforts of federal                      including grant applications, progress reports, periodic site visits, and
departments and agencies to                     program evaluations. For example, to monitor NTCP, CDC requires states to
monitor their programs, and (3) the             submit biannual reports on the implementation of state NTCP-supported
coordination among federal                      tobacco control programs. The information that federal departments and
departments and agencies in efforts             agencies collect on these programs is also used to provide training and
to prevent and reduce tobacco use               technical assistance to grantees on topics such as conducting program
among youth.                                    evaluation.

                                                In commenting on a draft of this report, HHS stated that the report was very
                                                informative but it did not include programs like Medicaid that are a
                                                substantial element of HHS tobacco prevention efforts. Including programs
                                                that finance health insurance such as Medicaid, however, was beyond the
                                                scope of our review. Also, HHS noted that we did not include information
www.gao.gov/cgi-bin/getrpt?GAO-04-41.
                                                about the challenges other federal agencies face in coordinating tobacco-
To view the full product, including the scope   related issues but DOD, DOJ, and Education did not describe such
and methodology, click on the link above.       challenges. DOD and DOJ had no comments on the report and HHS and
For more information, contact Marjorie E.
Kanof at (202) 512-7101.
                                                Education provided technical comments that we incorporated as
                                                appropriate.
Contents


Letter                                                                                      1
               Results in Brief                                                             3
               Background                                                                   5
               Some Federal Programs, Research, and Activities Focus Only on
                 Tobacco Use, While Others Address Tobacco Use Along with
                 Other Unhealthy Behaviors                                                  7
               Federal Departments and Agencies Collect a Variety of Information
                 on Their Programs That Aim to Prevent Tobacco Use among
                 Youth                                                                    14
               Federal Departments and Agencies Coordinate in Various Ways to
                 Address Tobacco Use among Youth                                          18
               Agency Comments                                                            22

Appendix I     Scope and Methodology                                                      24



Appendix II    Selected Federal Programs That Address or Can
               Address Tobacco Prevention and Reduction among
               Youth                                                                      26



Appendix III   Comments from the Department of Health and
               Human Services                                                             30



Appendix IV    GAO Contact and Acknowledgments                                            32
               GAO Contact                                                                32
               Acknowledgments                                                            32


Tables
               Table 1: Examples of Federal Collaborative Education and
                        Outreach Activities to Address Tobacco Use among Youth            21
               Table 2: Selected Federal Programs That Address or Can Address
                        Tobacco Prevention and Reduction among Youth                      26




               Page i               GAO-04-41 Preventing and Reducing Tobacco Use among Youth
Figure
         Figure 1: Estimated Rate of Current Smoking among 8th, 10th, and
                  12th Grade Students, 1991-2002                                                   5




         Abbreviations

         AHRQ              Agency for Healthcare Research and Quality
         CDC               Centers for Disease Control and Prevention
         CMS               Centers for Medicare & Medicaid Services
         DEFY              Drug Education for Youth Program
         DOD               Department of Defense
         DOJ               Department of Justice
         EPA               Environmental Protection Agency
         HHS               Department of Health and Human Services
         HRSA              Health Resources and Services Administration
         IHS               Indian Health Service
         NCI               National Cancer Institute
         NHLBI             National Heart, Lung, and Blood Institute
         NICHD             National Institute of Child Health and Human Development
         NIDCR             National Institute of Dental and Craniofacial Research
         NIDA              National Institute on Drug Abuse
         NIH               National Institutes of Health
         NTCP              National Tobacco Control Program
         ONDCP             Office of National Drug Control Policy
         SAMHSA            Substance Abuse and Mental Health Services
                            Administration
         TTURCs            Transdisciplinary Tobacco Use Research Centers



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         Page ii                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
United States General Accounting Office
Washington, DC 20548




                                   November 21, 2003

                                   The Honorable Bill Frist
                                   United States Senate

                                   Dear Senator Frist:

                                   Tobacco use is the leading cause of preventable death in the United States.
                                   In its most recent estimates of selected health consequences of cigarette
                                   smoking, the Centers for Disease Control and Prevention (CDC) reported
                                   that, on average, over 440,000 deaths and $76 billion in medical
                                   expenditures were attributable to cigarette smoking each year from 1995
                                   through 1999.1 Reducing the number of tobacco-related deaths, along with
                                   the associated costs, represents a significant public health challenge for
                                   the federal government. The first Surgeon General’s report to the Congress
                                   that specifically focused on tobacco use among youth concluded that
                                   preventing youth from starting to use tobacco is key to reducing the
                                   deaths and incidence of disease attributable to tobacco use.2 Most adults
                                   who use tobacco started using it between the ages of 10 and 18. According
                                   to the report, if children and adolescents can be encouraged to abstain
                                   from using tobacco before they become adults, they are less likely to use
                                   tobacco for the rest of their lives. Although smoking rates (defined as
                                   smoking one or more cigarettes in the previous 30 days) among 12th grade
                                   students have declined from a rate of about 37 percent in 1997, in 2002,
                                   about 27 percent of 12th grade students reported that they smoked. In
                                   1992, the Congress passed legislation, commonly referred to as the Synar
                                   Amendment, designed to prohibit the sale and distribution of tobacco
                                   products to minors.3



                                   1
                                    Centers for Disease Control and Prevention, “Annual Smoking-Attributable Mortality,
                                   Years of Potential Life Lost, and Economic Costs – United States, 1995-1999,” Morbidity
                                   and Mortality Weekly Report, vol. 51, no. 14 (2002) 300-303. The Morbidity and Mortality
                                   Weekly Report disseminates information about the public health issues in which CDC is
                                   involved.
                                   2
                                    U.S. Department of Health and Human Services, Preventing Tobacco Use Among Young
                                   People: A Report of the Surgeon General (Atlanta, Ga.: Centers for Disease Control and
                                   Prevention, 1994).
                                   3
                                    The Synar Amendment is found in §1926 of the Public Health Service Act as added by the
                                   Drug Abuse and Mental Health Administration Reorganization Act, Pub. L. No. 102-321 §
                                   202, 106 Stat. 394 (1992) (classified to 42 U.S.C. § 300x-26 (2000)).



                                   Page 1                     GAO-04-41 Preventing and Reducing Tobacco Use among Youth
Given the harmful effects of tobacco use and the rates of smoking among
youth,4 you asked us to provide information on federal efforts to prevent
and reduce youth smoking. We focused our review on describing
(1) programs, research, and activities that aim to prevent and reduce
tobacco use among youth, (2) the efforts of federal departments and
agencies to monitor their programs, and (3) the coordination among
federal departments and agencies in their efforts to prevent and reduce
tobacco use among youth.

To identify federal programs, research, and activities5 that aim to address
tobacco use among youth, we reviewed the Catalog of Federal Domestic
Assistance, which is a database of federal grant programs, 6 and other
pertinent documents. In addition, we interviewed program officials in
multiple federal agencies.7 As a result, we focused on four federal
departments that support programs and other efforts to prevent and
reduce tobacco use among youth: the Department of Health and Human
Services (HHS) and its component agencies—CDC, Substance Abuse and
Mental Health and Services Administration (SAMHSA), National Institutes
of Health (NIH), and Health Resources and Services Administration
(HRSA); the Department of Defense (DOD); the Department of Justice
(DOJ); and the Department of Education (Education). Where available, we
also obtained fiscal year 2002 funding information on the federal programs
and research that we identified. To identify how federal departments and
agencies monitor their programs, we reviewed agency strategic plans,
annual performance plans and reports, program guidance documents, and
program evaluations. To determine how federal departments and agencies
coordinate their efforts, we reviewed their strategic plans and annual
performance plans and reports and also descriptions of coordination
efforts. In addition, we interviewed agency officials about their program
monitoring and coordination efforts and asked them to describe any
coordination challenges they faced. (For additional information on our
methodology, see app. I.) We conducted our work from January 2003



4
 For the purposes of this report, youth refers to children and adolescents under the age of
18.
5
 In this report, the term “activities” refers to federal efforts to prevent and reduce tobacco
use among youth, such as education and outreach and training and technical assistance.
6
 The General Services Administration maintains this database.
7
The scope of our work did not include programs that finance health insurance such as
Medicaid.




Page 2                       GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                   through October 2003 in accordance with generally accepted government
                   auditing standards.


                   Some federal programs, research, and activities that address tobacco use
Results in Brief   among youth focus only on tobacco use, while others aim to prevent and
                   reduce tobacco use as part of broader efforts to address unhealthy
                   behaviors like substance abuse and violence. We identified two federal
                   programs that focus only on tobacco use. These programs are within HHS,
                   the lead federal department for addressing public health issues related to
                   tobacco. The first program, CDC’s National Tobacco Control Program
                   (NTCP), provides funds through cooperative agreements to state tobacco
                   control programs to prevent and reduce tobacco use among youth and
                   adults. The second tobacco program, SAMHSA’s program to oversee
                   implementation of the Synar Amendment, is the only federal program we
                   identified that focuses only on tobacco use among youth. The Synar
                   Amendment requires states to enact and enforce tobacco control laws to
                   prevent individuals under the age of 18 from purchasing tobacco products.
                   In addition to these tobacco-focused programs, HHS, Education, DOJ, and
                   DOD sponsor programs that aim to address tobacco use among youth as
                   part of broader efforts to prevent unhealthy behaviors, such as substance
                   abuse and violence. For example, Education’s Safe and Drug-Free Schools
                   and Communities program supports state efforts to create learning
                   environments in the nation’s schools that are free of violence and drug
                   use, including tobacco. HHS agencies also conduct research on tobacco
                   use among youth. For example, NIH supports research projects to
                   examine the factors influencing both tobacco use and nicotine addiction
                   among youth and assesses interventions designed to prevent and help
                   youth quit tobacco use. HHS agencies and other federal departments also
                   support activities to prevent and reduce tobacco use among youth, such as
                   education and outreach efforts.

                   To monitor their programs that aim to prevent and reduce tobacco use
                   among youth, federal departments and agencies collect a variety of
                   information on how their programs are being implemented by grantees
                   and the effectiveness of grantees’ efforts in meeting national program
                   goals. This information is obtained from such sources as grant
                   applications, grantee progress reports, periodic site visits, and program
                   evaluations. In fiscal year 2003, CDC took steps to obtain additional
                   information on the design, implementation, and effects of state tobacco
                   control programs. For example, CDC now requires that states submit more
                   detailed information in their biannual reports and dedicate staff to
                   evaluate their individual tobacco control programs. Other federal


                   Page 3                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
departments and agencies obtain information on the efforts and
effectiveness of their programs that aim to prevent and reduce smoking
among youth. For example, SAMHSA annually collects information from
states to determine their compliance with the Synar Amendment and its
implementing regulation regarding the sale and distribution of tobacco
products to minors. Similarly, DOJ is conducting a national evaluation of
the Drug-Free Communities Support program to determine the effects the
program is having on preventing and reducing unhealthy behaviors among
youth, such as the use of tobacco, alcohol, or other drugs.

Federal departments coordinate their efforts to prevent and reduce
tobacco use among youth by participating on various committees and
work groups and collaborating on programs, research, and other
activities—with HHS leading many of these efforts. HHS brings together
representatives from federal, state, and local government agencies and
nongovernmental entities to participate in various interagency committees
and work groups that address tobacco prevention, cessation, and
treatment of nicotine addiction. In addition, HHS and other federal
departments share responsibility for administering programs, conducting
and disseminating information on research, and engaging in education and
outreach activities. Some HHS officials described challenges to
coordination among HHS agencies. Several officials explained that,
although multiple HHS agencies have programs and other efforts that aim
to prevent and reduce tobacco use, coordination can be challenging
because the missions and priorities of these agencies differ.

We provided a draft of this report to HHS, DOD, DOJ, and Education for
comment. In written comments, HHS stated that the report provides a
thorough and informative overview of the federal effort to prevent and
reduce youth smoking. HHS noted that the report does not include the
Centers for Medicare & Medicaid Services programs that are a substantial
element of HHS tobacco prevention, particularly Medicaid. Including joint
federal-state programs that finance health insurance such Medicaid and
the State Children’s Health Insurance Program, was beyond the scope of
our review. HHS also noted that the report does not include information
about the challenges federal agencies other than HHS experienced in
coordinating tobacco-related issues. Officials from DOD, DOJ, and
Education did not provide information on challenges they experienced in
coordinating their tobacco-related efforts. DOD concurred with the report
as written and DOJ officials said they had no comments. HHS and
Education provided technical clarifications which we made, as
appropriate.



Page 4                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
             From 1991 through 2002, smoking rates among youth fluctuated and
Background   reached their highest points around 1997. The estimated rate of current
             smoking among youth (defined as smoking one or more cigarettes during
             the previous 30 days) varied according to grade level8 (see fig.1). For
             example, the rate among 8th grade students peaked at about 21 percent in
             1996 before declining to about 11 percent in 2002. For 10th grade students,
             the smoking rate peaked at 30 percent in 1996 before declining to 18
             percent in 2002. Similarly, smoking among 12th grade students peaked at
             about 37 percent in 1997, before declining to about 27 percent in 2002.

             Figure 1: Estimated Rate of Current Smoking among 8th, 10th, and 12th Grade
             Students, 1991-2002

             100 Percentage




              40




              20




                0
                    1991     1992     1993   1994   1995   1996   1997   1998   1999   2000   2001   2002
                              12th grade
                              10th grade
                             8th grade
             Source: NIDA.


             Note: Based on data from the Monitoring the Future survey, 2002.


             HHS serves as the lead federal department for addressing the nation’s
             public health issues, including tobacco use. HHS is responsible for
             informing the public of the dangers of tobacco use and coordinating


             8
               L.D. Johnston, P.M. O’Malley, and J.G. Bachman, Monitoring the Future: National Results
             on Adolescent Drug Use: Overview of Key Findings, 2002, NIH Publication No. 03-5374
             (Bethesda, Md.: National Institute on Drug Abuse, 2002).




             Page 5                            GAO-04-41 Preventing and Reducing Tobacco Use among Youth
federal efforts to address tobacco use issues. Within HHS, CDC’s Office on
Smoking and Health has been delegated the lead for all policy and
programmatic issues related to the prevention and reduction of tobacco
use and has primary responsibility within the federal government for
tobacco use prevention efforts.9 Also within HHS, the Surgeon General
serves as the nation’s spokesperson on matters of public health and
reports on issues such as the health effects of tobacco use. Other HHS
agencies, such as SAMHSA, NIH, and HRSA, support efforts to prevent and
reduce tobacco use. Education, DOD, and DOJ also support programs and
activities that aim to address tobacco use among youth.

Several studies have highlighted the importance of addressing tobacco use
among youth. In 1994, the Surgeon General released a report that focused
on the use of tobacco among youth. The report highlighted several factors
that increase the likelihood that youth will begin using tobacco. These
factors include engaging in other unhealthy behaviors, like substance
abuse and violence; peer pressure to smoke; and cigarette advertising and
promotion. In addition, the Surgeon General, CDC, NIH, and the Institute
of Medicine have reported on approaches that can help prevent youth
from starting to use tobacco and help existing users quit. For instance,
they have reported on the demonstrated benefits of interventions such as
implementing counter-marketing campaigns, using school-based
educational programs in combination with providing youth with
alternatives to the illicit use of tobacco, deglamorizing tobacco use, and
restricting minors’ access to tobacco. According to the Surgeon General’s
1994 report, strategies for preventing and reducing tobacco use among
youth should be multifaceted and involve collaborations among those that
can influence the behavior and attitudes of youth, such as family members
and educators.

HHS led federal, state, and local agencies and nongovernmental
organizations in developing a 10-year national plan, the Healthy People
2010 initiative, that includes goals for addressing tobacco use. The Healthy
People 2010 initiative has identified tobacco use as one of 10 leading
health indicators for the nation.10 Healthy People 2010 objectives related to



9
 The Office on Smoking and Health is a division of the National Center for Chronic Disease
Prevention and Health Promotion.
10
 The Healthy People 2010 leading health indicators are physical activity, overweight and
obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury
and violence, environmental quality, immunization, and access to health care.




Page 6                     GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                           tobacco use among youth include, among other objectives, reducing the
                           percentage of adolescents who smoked cigarettes in the past month and
                           increasing the percentage of adolescents who try to quit smoking.


                           Two HHS agencies, CDC and SAMHSA, administer programs that focus
Some Federal               only on tobacco use. CDC’s NTCP targets youth within a broader mission
Programs, Research,        of preventing and reducing tobacco use among the general population.
                           SAMHSA oversees implementation of the Synar Amendment that requires
and Activities Focus       states to enact and enforce tobacco control laws prohibiting the sale of
Only on Tobacco Use,       tobacco products to minors. Other programs and activities administered
                           by HHS, DOD, DOJ, Education, and the Office of National Drug Control
While Others Address       Policy (ONDCP) address tobacco use as part of a broader focus on
Tobacco Use Along          unhealthy behaviors, such as substance abuse and violence. (See app. II
with Other Unhealthy       for examples of federal programs that can address tobacco prevention and
                           reduction among youth.)
Behaviors
Some Federal Programs      We identified two federal programs that focus only on tobacco use. The
Only Address Tobacco Use   first, CDC’s NTCP,11 focuses on preventing and reducing tobacco use
                           among the general population, but it also explicitly targets tobacco use
                           among youth. NTCP provides funds through cooperative agreements to all
                           states.12 In fiscal year 2002, NTCP provided about $58 million to states to
                           address NTCP’s four goals.13 NTCP’s four goals are to (1) prevent youth
                           from starting to smoke, (2) help youth and adults quit smoking, (3)
                           minimize the public’s exposure to secondhand smoke, and (4) identify and
                           mitigate the factors that make some populations more likely to use
                           tobacco than others. NTCP cooperative agreements specify the terms
                           under which federal funds are provided to the states.




                           11
                              In 1999, two HHS demonstration projects—the American Stop Smoking Intervention
                           Study for Cancer Prevention and the Initiatives to Mobilize for the Prevention and Control
                           of Tobacco Use—were combined to form NTCP.
                           12
                             In our discussion of NTCP, the term “states” refers to the 50 states, the District of
                           Columbia, and American Samoa, Guam, the Federated States of Micronesia, the
                           Commonwealth of the Northern Mariana Islands, the Republic of Palau, Puerto Rico, and
                           the U.S. Virgin Islands.
                           13
                            In addition to NTCP funds, states use funds from other sources, such as other federal
                           programs and initiatives, state taxes and state settlements with tobacco companies, and
                           competitive grants from private foundations to finance their tobacco control programs and
                           activities.




                           Page 7                     GAO-04-41 Preventing and Reducing Tobacco Use among Youth
    Under NTCP, CDC encourages states to use multiple types of interventions
    in their efforts to prevent and reduce tobacco use. CDC has developed
    guidance intended to assist states in designing, implementing, and
    evaluating their individual tobacco control programs.14 For instance, CDC
    recommends that states establish comprehensive tobacco control
    programs that include certain components, such as

•   community-based programs to reduce tobacco use that include a wide
    range of prevention activities, such as engaging youth in developing and
    implementing tobacco control interventions, conducting educational
    programs for young people, parents, school personnel, and others, and
    restricting access to tobacco products;
•   school programs to implement school health policies that consist of
    tobacco-free policies, evidence-based curricula, teacher training, parental
    involvement, cessation services, and links between school and other
    community efforts and state media and educational campaigns;
•   marketing campaigns to counter protobacco influences and increase
    prohealth messages and influences, including paid television, radio,
    billboard, and print media campaigns;
•   cessation services to help people quit smoking;
•   enforcement of tobacco control policies by restricting minors’ access to
    tobacco and restricting smoking in public places; and
•   statewide efforts to provide localities with technical assistance on how to
    evaluate tobacco programs, promote media advocacy, implement smoke-
    free policies, and reduce minors’ access to tobacco.

    CDC officials told us that CDC also provides training and technical
    assistance to states in designing, implementing, and evaluating their
    tobacco control programs. For example, in fiscal year 2000, CDC
    conducted three regional workshops for state health departments and
    education agencies aimed at helping such agencies develop coordinated
    plans to prevent youth from starting to use tobacco. According to CDC,
    representatives from 33 states participated in these workshops.

    The second federal program that focuses only on tobacco and aims to
    prevent tobacco use among youth is SAMHSA’s program to oversee state
    implementation of legislation commonly referred to as the Synar
    Amendment. This program is the only one we identified that focuses solely
    on tobacco use among youth. The Synar Amendment and its implementing


    14
     Centers for Disease Control and Prevention, Best Practices for Comprehensive Tobacco
    Control Programs, August 1999 (Atlanta Ga.: 1999).




    Page 8                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                         regulation require states to enact and enforce laws that prohibit the sale of
                         tobacco products to minors, conduct random inspections of tobacco retail
                         or distribution outlets and estimate the percentage of retailers that illegally
                         sell tobacco to minors, and report the results of their efforts to the
                         Secretary of HHS.15 States are also required to report enforcement actions
                         taken against those who violate state laws in order to receive certain
                         federal grants.16 By the end of fiscal year 2003, states may have no more
                         than 20 percent of retail tobacco outlets in violation of state laws that
                         prohibit the sale of tobacco products to minors. To oversee states’ efforts
                         to accomplish this, SAMHSA and the states negotiated interim annual
                         target rates that states should meet. States may use a portion of their
                         Substance Abuse Prevention and Treatment block grant to help fund the
                         design and implementation of their inspection programs. For fiscal year
                         2002, the states reported that they planned to expend more than $5.4
                         million in block grant funds on Synar-related activities.


Other Federal Programs   Other federal programs aim to address tobacco use among youth as part of
Address Tobacco Use      a broader focus on unhealthy behaviors. For example, CDC’s Coordinated
Along with Other         School Health program provides grants to states to implement school
                         health programs to prevent a range of unhealthy behaviors or conditions,
Unhealthy Behaviors      such as drug, alcohol, and tobacco use; physical inactivity; poor nutrition,
                         and obesity. In fiscal year 2002, CDC awarded grants to 22 states, with
                         each state receiving approximately $400,000. CDC helps state education
                         and health departments identify and implement health education curricula
                         to provide youth with information and the decision-making,
                         communication, and peer-resistance skills needed to avoid unhealthy


                         15
                          42 U.S.C. § 300x 26 (2002) Synar Amendment: 45 C.F.R. § 96.130 (2002) implementing
                         regulation. SAMHSA requires states to develop and implement a consistent sample design
                         and a standardized inspection procedure. SAMHSA provides guidance to states on effective
                         ways to conduct unannounced inspections and to estimate statewide violation rates. See
                         U.S. General Accounting Office, Synar Amendment Implementation: Quality of State
                         Data on Reducing Youth Access to Tobacco Could Be Improved, GAO-02-74 (Washington,
                         D.C.: Nov. 7, 2001).
                         16
                           42 U.S.C. § 300x-26(b)(2)(B)(i) (2000). States must comply with the Synar Amendment
                         and its implementing regulation to obtain federal Substance Abuse Prevention and
                         Treatment block grants. The Synar Amendment provides for a 40 percent reduction in a
                         state’s Substance Abuse Prevention and Treatment block grant for noncompliance with
                         Synar requirements. However, provisions contained in the HHS annual appropriations acts
                         since fiscal year 2000 have prohibited the Secretary of HHS from withholding grant funds
                         from noncompliant states that pledge to commit state funds to ensure compliance with
                         state laws prohibiting tobacco sales to minors. (See, e.g., Consolidated Appropriations
                         Resolution, 2003, Pub. L. No. 108-7, Div. G, § 214, 117 Stat. 11, 324.)




                         Page 9                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
behaviors. In addition, CDC provides guidance to state and local health
education agencies on tobacco prevention programs in schools that covers
policies, programs, and a tobacco-free environment. CDC periodically
surveys the states, school districts, and schools on the health curricula
they offer and on school health policies relating to tobacco prevention and
reduction efforts. According to CDC, the information obtained through
these survey efforts is used to assess trends in school health education
programs.

Education’s Safe and Drug-Free Schools and Communities program aims
to prevent violence and drug, alcohol, and tobacco use in the nation’s
schools.17 Under this program in fiscal year 2002, Education awarded more
than $472 million in grants to state education departments and governors’
offices.18 Similarly, the Safe Schools/Healthy Students program, which is
funded by Education, HHS, and DOJ, provides local education agencies
with grants that support a variety of services designed to promote healthy
childhood development and prevent substance abuse (which can include
the use of tobacco) and violence. These services target preschoolers,
school-aged children, and adolescents. The Safe Schools/Healthy Students
program’s activities totaled about $172 million for fiscal year 2002.

DOJ and DOD support drug prevention programs that also aim to prevent
tobacco use among youth. For example, the Drug-Free Communities
Support program,19 which is administered by ONDCP and DOJ, is designed
to support the efforts of community coalitions that aim to prevent and
reduce young people’s use of drugs, alcohol, and tobacco. These coalitions
consist of youth, parents, health care professionals, educators, law
enforcement officials, and other community partners. In fiscal year 2002,


17
  This program was authorized under the Safe and Drug-Free Schools and Communities
Act, Title IV, Part A of the Elementary and Secondary Education Act of 1965 as amended by
the No Child Left Behind Act of 2001, Pub. L. No. 107-110, §401, 115 Stat.1425, 1734-1765
(classified to 20 U.S.C. § 7101-7165 (Supp. I 2002)). The program has two main components,
a state grant program and a national program. The national program provides discretionary
funding for demonstration projects, special initiatives, technical assistance to states and
districts, evaluation, and other efforts to improve drug and violence prevention.
18
  These grants afford grantees significant discretion in implementing the federal program.
In general, the Safe and Drug-Free Schools and Communities Act State Grants program
funds a variety of violence, drug, alcohol, and tobacco prevention activities, including
prevention instruction for students; and teacher and staff training and support services for
students.
19
 This program was authorized by the Drug-Free Communities Act of 1997, Pub. L. No. 105-
20, § 2, 111 Stat. 224, 226 (classified to 21 U.S.C. § 1531(2000)).




Page 10                     GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                          DOJ awarded about $46 million to community coalitions located in 50
                          states. Approximately $7 million was given in new awards to 70
                          community coalitions, and $39 million was given in renewed funding to
                          462 existing community coalitions. Another program, the Drug Education
                          for Youth program (DEFY), which is sponsored by DOD and DOJ, targets
                          youth aged 9 to 12 to improve awareness of the harmful effects of alcohol
                          and other drugs, including tobacco. According to agency officials, the
                          program aims to promote positive self-images and lifestyles. In fiscal year
                          2002, DOD funding totaled over $1 million for 55 local DEFY programs.
                          DOJ provided approximately $850,000 in funding to implement 111 local
                          DEFY programs.


HHS Agencies Support      In addition to supporting programs that aim to address tobacco use among
Research to Address       youth, HHS agencies conduct research on tobacco use and its health
Tobacco Use among Youth   effects. NIH’s National Cancer Institute (NCI) has identified tobacco use
                          among youth as one of its research priorities.20 In fiscal year 2002, NCI
                          funded more than 40 grants, totaling almost $30 million, for research on
                          ways to understand, prevent, reduce, and treat tobacco use among youth.
                          Similarly, NIH’s National Institute on Drug Abuse (NIDA) supports
                          research on effective tobacco use prevention and reduction interventions
                          for youth. For example, NIDA established and funds a teen tobacco
                          addiction treatment research center to examine methods of eliminating
                          dependence on nicotine and assess the effectiveness of these strategies.
                          The center is assessing the safe use and effectiveness of nicotine patches
                          and gum for adolescents. According to NIDA, in fiscal year 2002, funding
                          for its research projects that focused on substance abuse, including
                          tobacco use among youth, totaled about $124 million.

                          In fiscal year 1999, NCI and NIDA jointly established seven
                          Transdisciplinary Tobacco Use Research Centers (TTURCs) at academic
                          institutions in an effort to identify effective ways to prevent and reduce
                          tobacco use.21 According to HHS officials, additional information on ways
                          to reduce tobacco use among youth is needed because of the limited
                          knowledge available about cessation interventions that work best for
                          young people. The 5-year TTURCs research effort is designed to study new


                          20
                           Other NIH institutes, such as the National Institute of Child Health and Human
                          Development (NICHD) and the National Institute of Dental and Craniofacial Research
                          (NIDCR) also conduct research on tobacco use among youth.
                          21
                               The Robert Wood Johnson Foundation also provides funding for TTURCs.




                          Page 11                      GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                              ways of preventing tobacco use and nicotine addiction. According to HHS
                              officials, in fiscal year 2002, NCI and NIDA provided over $15 million to
                              TTURCs, which included funding for research on youth and adolescent
                              tobacco use and nicotine addiction at four of the seven centers. These four
                              centers are conducting studies on adolescent smoking.22 According to NCI,
                              one study found that students with high academic performance, perceived
                              academic competence, and involvement in school-related clubs and sports
                              teams were less likely to smoke.23

                              CDC also supports research on health promotion and disease prevention
                              including research on tobacco use among youth, through its network of 28
                              research centers that are affiliated with schools of public health, medicine,
                              or osteopathy located throughout the country. According to CDC officials,
                              these research centers focus on identifying effective prevention strategies
                              that can be applied at the community level. One center is examining
                              factors that can influence youth and young adults to start using tobacco
                              and two other centers are conducting research that examines youth
                              cessation programs, according to CDC. HRSA is working with certain
                              federally supported community health centers on a multiyear initiative to
                              address health disparities among youth. HRSA officials said that the effort
                              would involve developing interventions to address the needs of high-risk
                              medical subpopulations, such as young people with asthma or
                              cardiovascular conditions for whom tobacco use can pose especially high
                              risks.


Federal Activities Also Aim   In addition to research, HHS and other federal departments conduct a
to Address Tobacco Use        variety of tobacco-focused activities that aim to prevent and reduce
among Youth                   tobacco use among youth. For example, officials from HHS, Education,
                              and other federal departments, along with experts from national
                              organizations and professional associations, developed guidance to help
                              schools identify and implement strategies for preventing tobacco use




                              22
                               These four centers are located at Brown University, the University of
                              Pennsylvania/Georgetown University, the University of Southern California, and the
                              University of California at Irvine. The other funded research centers are located at the
                              University of Minnesota, University of Wisconsin Medical School, and Yale University.
                              23
                                The Nation’s Investment in Cancer Research for Fiscal Year 2003, National Cancer
                              Institute, National Institutes of Health (http:/plan2003.cancer.gov/scipri/tobacco.htm).




                              Page 12                     GAO-04-41 Preventing and Reducing Tobacco Use among Youth
among youth.24 For example, the guidelines recommend that schools
develop and enforce a school policy on tobacco use, provide tobacco-use
prevention education from kindergarten through 12th grade, provide
instructions about the short- and long-term consequences of tobacco use,
and provide training for teachers. Similarly, in 1997, SAMHSA issued
guidance that describes strategies that communities can use to prevent
and reduce tobacco use among youth.25

In other activities, HHS agencies develop and promote educational
materials to prevent and reduce a range of unhealthy behaviors among
adolescents, including tobacco use. For example, Girl Power!, a national
public education campaign, is designed to prevent 9- to 13-year-old girls
from using tobacco, alcohol, and illegal drugs and includes a Web site that
offers articles, games, and quizzes that teach girls about the dangers of
tobacco use. Similarly, CDC’s Tobacco Information and Prevention Source
Web site offers a variety of educational materials for youth, such as tips on
how to quit using tobacco and information on the health consequences of
using tobacco. CDC also disseminates information for parents, such as a
kit that offers advice on ways to increase parental involvement in their
children’s lives and incorporate tobacco prevention messages into daily
activities. In addition, DOD sponsors Web sites that include information on
preventing and reducing tobacco use among youth and supports various
youth activities that address unhealthy behaviors, including tobacco use.
For example, one project identified was Smart Moves,26 which aims to
prevent tobacco, alcohol, and drug use by bolstering youths’ self-esteem
and their resistance to unhealthy behaviors.

HHS agencies also support activities that use various media, such as print,
radio, television, and videotapes, to counteract the impact of tobacco
product marketing. For example, CDC supports a variety of entertainment-
related outreach activities that enlist celebrities as spokespersons to
deliver antismoking messages and to increase prohealth messages in



24
 Centers for Disease Control and Prevention, Guidelines for School Health Programs to
Prevent Tobacco Use and Addiction, Morbidity and Mortality Weekly Report, vol. 43, no.
RR-2, 1-18 1994 (Atlanta, Ga.: 1994), 43.
25
 U.S. Department of Health and Human Services, Reducing Tobacco Use Among Youth:
Community-Based Approaches, Prevention Enhancement Protocol, 1997, DHHS
Publication No. 97-3146 (Rockville, Md., Substance Abuse and Mental Health
Administration: 1997).
26
     This program was developed by the Boys and Girls Club of America.




Page 13                       GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                           entertainment programming. CDC also supports the Media Campaign
                           Resource Center, a clearinghouse offering antitobacco media products
                           developed for television, radio, print, and outdoor advertising. In addition,
                           CDC and SAMHSA developed Media Sharp, a media literacy guide for
                           educators and community leaders who work with middle school and high
                           school age youth to dissuade youth from using tobacco.


                           To monitor federal programs that aim to prevent and reduce tobacco use
Federal Departments        among youth, federal departments and agencies collect information on
and Agencies Collect       how their programs are being implemented by grantees and the
                           effectiveness of grantees’ efforts in meeting national program goals.
a Variety of               Federal departments and agencies obtain this information from various
Information on Their       sources, such as grantee applications for federal funding, progress reports,
                           site visits, and program evaluations. According to federal officials, the
Programs That Aim to       information is used to assist grantees in managing and evaluating their
Prevent Tobacco Use        programs.
among Youth

CDC Collects Information   To monitor the NTCP, CDC collects information on the design,
on the States’ NTCP-       implementation, and effectiveness of state tobacco control programs. CDC
Supported Tobacco          obtains this information through various sources, such as states’
                           applications for NTCP funding, state progress reports, periodic site visits,
Control Programs           surveys, and program evaluations conducted by various states. For
                           instance, the applications that states submit when applying for NTCP
                           funding must include strategic plans that provide information on the
                           design and implementation of their tobacco control programs. The plans
                           must also include information on how states will achieve NTCP’s goals.
                           According to CDC officials, other important sources of information are the
                           biannual reports that the agency requires states to submit on the progress
                           of their tobacco control programs. These reports provide CDC with
                           additional information, such as enforcement strategies used to prevent the
                           sale of tobacco products to minors, information campaigns to increase the
                           public’s awareness of the health consequences of using tobacco, and
                           efforts to promote tobacco-free schools and positive role models for
                           youth.




                           Page 14                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
CDC also obtains information on state tobacco control programs through
other sources. For example, CDC officials said that NTCP project officers,
who are responsible for monitoring state tobacco control programs, visit
each of their assigned states approximately every 12 to 18 months. CDC
officials said that through these visits they obtain more in-depth
information about the design and implementation of the states’ programs,
and they gain a better understanding of the challenges that states may face
in achieving NTCP’s goals. In addition, these officials said that they
monitor the effects of state tobacco control programs through periodic
national and state youth tobacco surveys. Through these surveys, CDC
obtains information on changes in tobacco use among youth and their
knowledge, attitudes, and behaviors towards tobacco use. CDC officials
said that they work with the states to design the state surveys and to help
states interpret and use the survey data. CDC officials also said that they
have obtained useful information from evaluations that several states
completed on the effectiveness of their tobacco control programs.27

According to CDC officials, the information they obtain has been used in
various ways. For example, in developing its best practice guidance for
comprehensive tobacco control programs, CDC used information from
analyses of tobacco control programs in California and Massachusetts and
CDC officials’ experience in providing technical assistance in other states.
CDC officials also said that the agency has provided a variety of training
and technical assistance to help states, among other things, adopt
evidence-based interventions for preventing tobacco use. In addition, CDC
developed guidance in 2001 on how states could evaluate their individual
tobacco control programs.28 The guidance includes information on
approaches for designing evaluations; measuring outcomes of specific
program components; and analyzing, interpreting, and using evaluation
results to improve operations and enhance the impact of tobacco control
programs.




27
 According to CDC officials, evaluations of state tobacco control programs have been
completed by Arizona, California, Florida, Maine, Massachusetts, Mississippi, Oregon, and
Texas.
28
 Goldie MacDonald and others, Introduction to Program Evaluation for Comprehensive
Tobacco Control Programs (Atlanta, Ga.: Centers for Disease Control and Prevention,
November 2001) and Centers for Disease Control and Prevention, Surveillance and
Evaluation Data Sources for Comprehensive Tobacco Control Programs (Atlanta, Ga.:
November 2001).




Page 15                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                              In fiscal year 2003, CDC took action to collect additional information on
                              the design, implementation, and effectiveness of state tobacco control
                              programs. For instance, CDC now requires that states submit additional
                              information in their biannual reports. These officials said that the
                              expanded NTCP data collection effort should enable CDC to obtain a more
                              comprehensive picture of state tobacco control programs and the extent
                              to which program activities are consistent with NTCP’s goals. CDC
                              officials said that they anticipate that these changes, along with the
                              redesign of the NTCP information system, will facilitate more
                              comprehensive comparisons within and across states and regions on
                              progress towards reducing tobacco use. The changes should also enable
                              CDC to better identify state-specific or systemic issues, according to these
                              officials.

                              In fiscal year 2003, CDC began requiring that each state dedicate staff to
                              evaluate the state’s tobacco control program. Each state was required to
                              submit detailed information with its NTCP funding application that
                              described how it intended to evaluate the program’s effectiveness. The
                              application had to include information on the specific performance
                              indicators the state intends to use and its methodologies for collecting and
                              analyzing data, projected time lines for completing evaluation efforts, and
                              plans for using evaluation results to improve its program. CDC officials
                              told us that they recognize that conducting program evaluations can
                              present financial and methodological challenges for state tobacco control
                              programs, but that CDC had instituted this requirement because evidence
                              on the impact of individual state programs has been generally limited.
                              These officials noted that while evaluations have been completed by eight
                              states, the results of these evaluations and other studies provide only a
                              limited picture of the impact of all states’ programs in achieving NTCP’s
                              goals.


SAMHSA Collects               To monitor state compliance with the requirements of the Synar
Information on States’        Amendment and its implementing regulation, SAMHSA collects data on
Progress in Prohibiting the   the design and implementation of state compliance efforts. The regulation
                              requires that each state report to SAMHSA information on the state’s
Sale of Tobacco Products      efforts to inspect retail tobacco outlets, including the state’s sampling
to Minors                     methodology, inspection protocol, and inspection results. SAMSHA
                              reviews the information to determine whether states have complied with
                              requirements for enforcing state laws and conducting random inspections
                              of retail tobacco outlets. In reviewing these data, SAMHSA determines
                              whether a state’s estimated retailer violation rate meets negotiated annual
                              targets and shows progress toward the 20 percent goal. Based on the latest


                              Page 16                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                          data available at the time of our review, 49 states met their negotiated
                          retailer violation rate targets for 2002.


Federal Departments and   Federal agencies with programs that address tobacco use, along with
Agencies Collect          other unhealthy behaviors among youth, obtain information on grantees’
Information on Their      efforts to design and implement their programs. They obtain this
                          information by various means, such as periodic reports and visits to
Programs That Address     grantee sites. For example, DOJ requires community antidrug coalitions
Unhealthy Behaviors       that participate in the Drug-Free Communities Support program to submit
among Youth               annual progress reports on their programs. As part of this reporting
                          requirement, coalitions must report on certain measures of youth
                          behavior, such as the age youth first started to use tobacco, the frequency
                          of tobacco use in the past 30 days, and youths’ perceptions of tobacco-
                          related risks. According to DOJ officials, the information obtained from
                          reports and site visits is used to provide grantees with training and
                          technical assistance. DOJ is also overseeing a 5-year evaluation of the
                          effectiveness of this federal grant program. The evaluation, which is
                          scheduled for completion in 2004, is designed to take into consideration
                          both the similarities and differences among the coalitions and their
                          communities and aims to assess the effectiveness of the coalitions’ efforts
                          to reduce the use of tobacco, alcohol, and illicit drugs among youth.

                          Similarly, to monitor their programs, DOJ and DOD contracted for
                          evaluations of the effectiveness of some DEFY components. For instance,
                          one study examined the effectiveness of the summer camp component in
                          1997 at 18 DOJ DEFY camps and 28 military DEFY camps. The study
                          included the use of pre- and postcamp questionnaires to assess youths’
                          attitudes towards smoking cigarettes and to determine how often they
                          smoked.29




                          29
                               We did not review the methodology used in the evaluation of DEFY.




                          Page 17                       GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                         HHS and other federal departments coordinate their efforts to prevent,
Federal Departments      treat, and reduce tobacco use among youth by participating on various
and Agencies             committees and work groups and by collaborating on various programs,
                         research projects, and activities. Although HHS has the lead responsibility
Coordinate in Various    for coordinating these efforts, some HHS officials stated that coordination
Ways to Address          among HHS agencies presents challenges.
Tobacco Use among
Youth
HHS Leads Coordination   HHS leads efforts among its agencies and others to develop strategies for
Efforts to Address       addressing tobacco use among youth in support of the Healthy People
Tobacco Use              initiative, which includes objectives to reduce tobacco use among youth.
                         As part of this initiative, representatives from various federal departments
                         and nongovernmental organizations participate in work groups that focus
                         on tobacco use objectives. For example, the Healthy People 2010 Tobacco
                         Use Work Group, chaired by CDC, includes representatives from other
                         HHS agencies as well as the Environmental Protection Agency (EPA), the
                         Federal Trade Commission, and nonfederal organizations. The work group
                         meets periodically to discuss strategies and challenges in addressing
                         issues related to tobacco use.30

                         HHS also plays a leadership role in the Youth Tobacco Cessation
                         Collaborative. Established in 1998, the collaborative brings together CDC,
                         NCI, NICHD, NIDA, the National Heart, Lung, and Blood Institute (NHLBI),
                         and several nonfederal organizations to help ensure young tobacco users’
                         access to cessation interventions.31 In 2000, the collaborative published an
                         action plan to facilitate planning and priority-setting on the need for
                         tobacco cessation for youth.32 In addition, three members of the




                         30
                           Other HHS agencies represented on the Tobacco Use Work Group are the Administration
                         for Children and Families, the Agency for Healthcare Research and Quality (AHRQ), the
                         Centers for Medicare & Medicaid Services (CMS), HRSA, the Indian Health Service (IHS),
                         NIH, and SAMHSA.
                         31
                            Nonfederal members involved in the collaborative include the American Cancer Society,
                         the American Legacy Foundation, the American Lung Association, the Canadian Tobacco
                         Research Initiative, the National Cancer Institute of Canada, and the Robert Wood Johnson
                         Foundation.
                         32
                          Center for the Advancement of Health for the Youth Tobacco Cessation Collaborative,
                         National Blueprint for Action: Youth and Young Adult Tobacco-Use Cessation
                         (Washington, D.C.: 2000).




                         Page 18                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                             collaborative—CDC, NCI, and the Robert Wood Johnson Foundation—are
                             working together on the Helping Young Smokers Quit initiative, a 4-year
                             project that aims to identify, characterize, and evaluate the effectiveness
                             of various youth cessation programs.

                             Other work groups focus on broader adolescent health issues that include
                             tobacco use among youth. For example, both the Healthy People 2010
                             Adolescent Health Work Group, cochaired by CDC and HRSA, and the
                             related National Initiative to Improve Adolescent Health by 2010 aim to
                             foster greater involvement by various professions to improve the overall
                             health of adolescents, in part by reducing their use of tobacco. According
                             to HRSA officials, members of the national initiative are trying to educate
                             health care and other professionals on the importance of screening for
                             tobacco use and other unhealthy behaviors during routine health care
                             visits, providing counseling on the benefits of quitting tobacco use, and
                             providing referrals for youth, their parents, and other family members to
                             tobacco cessation services. As part of the national initiative, CDC, HRSA,
                             and the American Academy of Pediatrics are collaborating on the
                             development of a prevention guide to help pediatricians address unhealthy
                             behaviors among youth, including tobacco use.


HHS Established the          In 1984, the Congress passed legislation requiring, among other things, that
Interagency Committee on     HHS establish an interagency committee to coordinate the department’s
Smoking and Health to        research, educational programs, and other smoking and health efforts with
                             similar efforts of other federal departments and nonfederal organizations.33
Coordinate Federal Efforts   As a result, in 1985, HHS established the Interagency Committee on
                             Smoking and Health. According to CDC officials, the committee brings
                             together representatives of federal agencies and nonfederal organizations
                             involved in tobacco use issues34 and serves as a forum for committee
                             members and the public to share information and discuss a variety of
                             tobacco-related issues and efforts. Committee meetings that have
                             specifically focused on tobacco use among youth have covered such




                             33
                              Comprehensive Smoking Education Act of 1984, Pub. L. No. 98-474 § 3, 98 Stat. 2200-2201
                             (classified to 15 U.S.C. §1341(b) (2000)).
                             34
                              As of October 2003, other federal entities represented on the Interagency Committee on
                             Smoking and Health are HHS’s AHRQ, CDC, CMS, HRSA, IHS, NCI, NICHD, NIDA, NHLBI,
                             and SAMHSA; the Departments of Labor and Transportation; EPA; and the Federal Trade
                             Commission.




                             Page 19                   GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                           topics as the health effects of smoking on young people, the sale of
                           cigarettes to minors, and strategies for preventing tobacco use.


HHS and Other Federal      Federal departments also collaborate on efforts to prevent and reduce
Departments Coordinate     tobacco use among youth by jointly administering programs, conducting
Their Efforts by Jointly   research, and supporting education and outreach activities. For example,
                           Education, DOJ, and HHS jointly administer the Safe Schools/Healthy
Administering Programs     Students program. Through interagency agreements, Education handles
and Supporting Research    grants management activities, HHS provides technical advice and financial
and Activities             assistance, and DOJ oversees program evaluation efforts. Similarly, for the
                           Drug-Free Communities Support program, ONDCP directs the program
                           and through an interagency agreement transfers funds to DOJ to cover
                           grant awards, grants management, and evaluation activities. Both ONDCP
                           and DOJ provide technical assistance to program grantees.

                           HHS agencies also coordinate on efforts to jointly support research on
                           tobacco use prevention and cessation. For example, in addition to the NCI-
                           and NIDA-supported TTURCs initiative, NCI led the creation of an NIH-
                           wide Tobacco and Nicotine Research Interest Group in January 2003.
                           According to NCI officials, the group was established to leverage expertise
                           and resources across NIH for tobacco research. In addition to NCI,
                           representatives from other NIH institutes, such as NICHD, NIDA, NHLBI,
                           and the National Institute of Dental and Craniofacial Research (NIDCR)
                           have participated in the group. Representatives from CDC are also
                           participating in the group’s meetings.

                           Furthermore, HHS agencies, Education, ONDCP, and nonfederal
                           organizations collaborate on education and outreach activities aimed at
                           discouraging youth from starting to use tobacco and encouraging existing
                           users to quit. For example, CDC and Education collaborated on the
                           development and dissemination of a guide for parents on how to address
                           their children’s health needs, including preventing and reducing tobacco
                           use. Table 1 highlights various education and outreach activities aimed at
                           preventing and reducing tobacco use among youth that HHS and other
                           federal departments and agencies work on together.




                           Page 20                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
Table 1: Examples of Federal Collaborative Education and Outreach Activities to
Address Tobacco Use among Youth

                         Federal
 Activity or             departments
 project                 or agencies          Description
 Tobacco-Free            CDC, NCI,   An initiative that involves sports stars, sport leagues,
 Sports                  SAMHSA, and and youth organizations helping to deliver tobacco-
                         ONDCP       free messages. The initiative is intended to depict
                                     positive role models and provide information about
                                     how to make positive health choices related to
                                     tobacco use, physical activity, and nutrition.
 Entertainment           CDC, NIDA   A multifaceted outreach effort to, among other things,
 Industry                SAMHSA, and enlist celebrities to serve as national spokespersons
 Outreach                ONDCP       to deliver antismoking messages and to educate
                                     young people on how to interpret depictions of
                                     tobacco use in entertainment media. As part of this
                                     effort, federal agencies have collaborated on
                                     promoting a video-based media literacy program,
                                     Scene Smoking: Cigarettes, Cinema, and the Myth of
                                     Cool, aimed at high school and college students.
 Pathways to             CDC and NCI          A self-help guide intended to motivate and assist
 Freedom                                      African American adults and youth to stop smoking.
                                              The guide is intended to prevent young children from
                                              developing the smoking behaviors of their parents
                                              who use tobacco and to prevent exposure to
                                              secondhand smoke.
 Got a Minute?           CDC,                 A guide to educate parents on how to
 Give It to Your         SAMHSA,              comprehensively address their children’s health
 Kids                    Education,           needs, including information on how to prevent their
                         and ONDCP            children from using tobacco. Education is assisting
                                              CDC in disseminating the guide to schools
                                              nationwide.

Source: HHS agencies, Education, and ONDCP.




Page 21                             GAO-04-41 Preventing and Reducing Tobacco Use among Youth
HHS Officials Identified   HHS officials said that coordinating on tobacco-related issues within HHS
Several Challenges to      presents challenges. They pointed out that, although multiple HHS
Coordination within the    agencies have programs and other efforts to address the prevention and
                           reduction of tobacco use, the missions and funding priorities of the
Department                 agencies differ. For example, CDC officials told us that they had initiated
                           discussions in fiscal year 2003 with HRSA to collaborate on offering
                           tobacco prevention and cessation services to underserved populations
                           that obtain health care through HRSA’s network of community health
                           centers. However, this effort has been delayed largely due to HRSA’s
                           competing funding priorities and limited resources. In another instance,
                           NCI officials noted that NIDA and NIDCR decided to fund a proposal to
                           translate research findings on alcohol, tobacco, and other drug prevention
                           and treatment research to clinical dental practice settings. However,
                           according to an NCI official, NCI did not learn about the proposal in time
                           to consider it for fiscal year 2003 funding.


                           We provided a draft of this report to HHS, DOD, DOJ, and Education for
Agency Comments            comment. DOD concurred with the report as written and DOJ did not have
                           comments. HHS and Education provided technical comments that we
                           incorporated as appropriate.

                           In written comments, HHS stated that the report was very informative and
                           provided a thorough overview of nicotine and tobacco activities related to
                           youth, but did not include programs within CMS that are a substantial
                           element of HHS tobacco prevention. Specifically, HHS stated that under
                           Medicaid, states are required to cover certain smoking cessation services
                           for children and adolescents. Including joint federal-state programs that
                           finance health insurance such Medicaid and the State Children’s Health
                           Insurance Program, was beyond the scope of our review. HHS also noted
                           that the report did not include information about the challenges other
                           federal agencies experienced in coordinating tobacco-related issues. We
                           discussed coordination of tobacco-related issues with officials from DOD,
                           DOJ, and Education. However, these officials did not cite any challenges
                           they had experienced with coordinating their tobacco-related efforts.




                           Page 22               GAO-04-41 Preventing and Reducing Tobacco Use among Youth
As agreed with your office, unless you release its contents earlier, we plan
no further distribution of this report until 30 days after the issue date. At
that time, we will send copies of this report to the Secretary of Health and
Human Services, the Secretary of Defense, the Attorney General, the
Secretary of Education, appropriate congressional committees, and other
interested parties. We will also make copies available to others upon
request. In addition, the report is available at no charge on the GAO Web
site at http://www.gao.gov. If you or your staff have questions about this
report, please contact me at (202) 512-7101. An additional contact and staff
acknowledgments are provided in appendix III.

Sincerely yours,




Marjorie E. Kanof
Director, Health Care—Clinical Health Care Issues




Page 23                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
             Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


             To do our work, we obtained and reviewed program documents, strategic
             and performance plans, pertinent program reports and special studies,
             surveillance and other data, and federal Web sites from the Department of
             Health and Human Services (HHS) including the Office of the Secretary,
             the Office of the Assistant Secretary for Planning and Evaluation, Office of
             Public Health and Science, Agency for Healthcare Research and Quality,
             Centers for Disease Control and Prevention (CDC), Centers for Medicare
             & Medicaid Services, Health Resources and Services Administration
             (HRSA), Indian Health Service, National Institutes of Health (NIH), and
             Substance Abuse and Mental Health Services Administration (SAMHSA);
             the Departments of Defense (DOD), Justice (DOJ), and Education; the
             Environmental Protection Agency; the Federal Trade Commission; and the
             Office of National Drug Control Policy (ONDCP). We also reviewed the
             relevant literature and documents prepared by federal interagency
             committees and work groups that focused on the prevention and
             reduction of tobacco use among youth and adults.

             To identify federal programs that aim to prevent and reduce tobacco use
             among youth (defined as children and adolescents under age 18), we
             reviewed the Catalog of Federal Domestic Assistance, a database of
             federal grant programs.1 We also reviewed pertinent documents and
             federal Web sites. After identifying federal programs, we interviewed and
             collected information from federal program officials to confirm that these
             programs supported efforts to prevent and reduce tobacco use among
             youth.2 As a result, we focused on four federal departments: HHS and its
             component agencies—CDC, SAMHSA, NIH, and HRSA; Education; DOJ;
             and DOD. We then obtained more detailed information on the programs
             they fund. We interviewed officials in HHS, DOD, DOJ, and Education and
             obtained information on program characteristics, including the purpose,
             target audience, and program and financial requirements. We also
             obtained information on research and activities that involve federal
             departments and agencies, such as education and outreach efforts
             intended to prevent the initiation of tobacco use among youth and help
             youth quit tobacco use. In conducting this work, we also reviewed
             strategic and annual performance plans, along with budgetary and other
             pertinent documents, including national action plans and tobacco use
             prevention and cessation guidance. Where available, we obtained fiscal


             1
              The General Services Administration maintains this database.
             2
             The scope of our work did not include programs that finance health insurance such as
             Medicaid.




             Page 24                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
Appendix I: Scope and Methodology




year 2002 funding information on the federal programs and research that
we identified. However, we were unable to determine the extent of
spending by federal agencies on efforts to prevent and reduce tobacco use
among youth because, in many instances, funding information covers
more than the prevention and reduction of tobacco use among youth. The
programs, research, and activities that we discuss in this report do not
represent an exhaustive list of all federal efforts to prevent and reduce
tobacco use among youth, but highlight a range of such efforts.

To determine how federal departments and agencies monitor programs
that aim to prevent and reduce tobacco use among youth and the types of
monitoring information that departments and agencies collect, we
obtained and reviewed descriptive information on federal departments
and agencies’ monitoring efforts. Specifically, we reviewed strategic plans,
annual performance plans and reports, performance monitoring reports,
program evaluation guidance, and copies of federal and state program
evaluation reports. We also interviewed program officials to obtain a more
detailed understanding of their monitoring efforts.

To determine how federal departments and agencies coordinate their
efforts to address youth tobacco use, we focused our attention on
identifying the key coordination mechanisms and the results of such
coordination. Specifically, we reviewed strategic and annual performance
plans and reports, interagency agreements, memorandums of
understanding, minutes of interagency meetings, and other pertinent
documents. We also interviewed federal program officials and obtained
information from these officials describing the characteristics of various
federal efforts, including information on purpose, federal agencies
involved, and the target audience. We also obtained their perspectives on
any factors presenting coordination challenges related to addressing youth
tobacco use.

We conducted our work from January 2003 through October 2003 in
accordance with generally accepted government auditing standards. Our
findings are limited to the select examples identified and thus do not
necessarily reflect the full scope of federal programs and other activities
related to preventing and reducing tobacco use among youth. We did not
assess the effectiveness of federal programs, monitoring efforts, or
coordination activities.




Page 25                  GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                                             Appendix II: Selected Federal Programs That
Appendix II: Selected Federal Programs That  Address or Can Address Tobacco Prevention
                                             and Reduction among Youth


Address or Can Address Tobacco Prevention
and Reduction among Youth
                                             Table 2 lists selected federal grant programs that may be used to address
                                             tobacco use among youth. The list includes programs from four
                                             departments.

Table 2: Selected Federal Programs That Address or Can Address Tobacco Prevention and Reduction among Youth

                                        Funding fiscal                                  Targeted                 Grant program
                                                     a
Program                                    year 2002 Eligible applicantsb               beneficiaries            description
Department of Health and Human Services
Centers for Disease Control and Prevention
National Tobacco Control                      $58,000,000 States                        General population       To support state
                                                                                                                 tobacco control
                                                                                                                 programs to prevent
                                                                                                                 and reduce tobacco
                                                                                                                 use, including
                                                                                                                 preventing youth from
                                                                                                                 starting to smoke.
Tribal Support Centers                         $1,600,000 Tribes and tribal             American                 To support seven
                                                          organizations                 Indian/Alaskan           tribal centers in
                                                                                        Natives                  developing tobacco
                                                                                                                 control programs to
                                                                                                                 prevent and reduce
                                                                                                                 tobacco use, including
                                                                                                                 preventing youth from
                                                                                                                 starting to smoke.
Coordinated School Health                     $11,000,000 State and local education Students in grades 9         To support school
                                                          agencies                  through 12                   health programs in
                                                                                                                 discouraging
                                                                                                                 unhealthy behaviors,
                                                                                                                 such as poor eating
                                                                                                                 habits, physical
                                                                                                                 inactivity, and tobacco
                                                                                                                 use.
Preventive Services Block Grant                 $408,450c States                        General population       To carry out public
to States                                                                                                        health activities,
                                                                                                                 including preventing
                                                                                                                 tobacco sales to
                                                                                                                 minors.
Health Resources and Services Administration
Healthy Schools,                              $19,500,000 Public and nonprofit          Students attending       To increase access to
Healthy Communities                                       private entities, including   schools (kindergarten    comprehensive
                                                          faith-based and               through grade 12) that   primary and
                                                          community-based               serve low-income or      preventive health care
                                                          organizations                 high-risk children       for underserved
                                                                                                                 children, adolescents,
                                                                                                                 and their families,
                                                                                                                 including tobacco
                                                                                                                 prevention and
                                                                                                                 reduction programs.




                                             Page 26                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                                         Appendix II: Selected Federal Programs That
                                         Address or Can Address Tobacco Prevention
                                         and Reduction among Youth




                                       Funding fiscal                               Targeted                 Grant program
                                                    a
Program                                   year 2002 Eligible applicantsb            beneficiaries            description
Community Health Centers               $1,077,578,000 Public and nonprofit          People in medically      To develop and
                                                      private entities, including   underserved areas        operate community
                                                      faith-based and                                        health centers that
                                                      community-based                                        provide preventive and
                                                      organizations                                          primary health care
                                                                                                             services, and link
                                                                                                             clients with Medicaid
                                                                                                             and mental health and
                                                                                                             substance abuse
                                                                                                             treatment, including
                                                                                                             that for tobacco use.
Maternal and Child Health                $595,727,279 States                        Pregnant women,          To maintain and
Services Block Grant to States                                                      mothers, infants and     strengthen state
                                                                                    children, and children   leadership in planning,
                                                                                    with special health      promoting,
                                                                                    care needs,              coordinating, and
                                                                                    particularly those of    evaluating health care
                                                                                    low-income families      services. Funds can
                                                                                                             be used for tobacco
                                                                                                             prevention programs
                                                                                                             and activities.
Substance Abuse and Mental Health Services Administration
Synar Amendment                           $5,448,273d States                        Children under age 18 To enable states to
                                                                                                          implement the Synar
                                                                                                          survey requirements
                                                                                                          to assess state
                                                                                                          compliance and
                                                                                                          enforcement of
                                                                                                          tobacco access
                                                                                                          control laws that
                                                                                                          prohibit the sale and
                                                                                                          distribution of tobacco
                                                                                                          products to individuals
                                                                                                          under age 18.
Substance Abuse Prevention and         $1,725,000,000 States                        General population       To provide financial
Treatment Block Grant                                                                                        assistance to states
                                                                                                             for the purpose of
                                                                                                             planning, carrying out,
                                                                                                             and evaluating
                                                                                                             activities to prevent
                                                                                                             and treat substance
                                                                                                             abuse, including youth
                                                                                                             tobacco use.
State Incentive Grants                    $58,480,885 States                        Adolescents              To prevent and reduce
                                                                                                             alcohol, tobacco, and
                                                                                                             illicit drug use by
                                                                                                             adolescents ages
                                                                                                             12-17.




                                         Page 27                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                                         Appendix II: Selected Federal Programs That
                                         Address or Can Address Tobacco Prevention
                                         and Reduction among Youth




                                       Funding fiscal                             Targeted                   Grant program
                                                    a
Program                                   year 2002 Eligible applicantsb          beneficiaries              description
Department of Education
Office of Elementary and Secondary Education
Safe and Drug-Free Schools and           $472,017,000 State departments           Children and youth         To support programs
Communities: State Grants                             of education                who are enrolled and       that seek to prevent
                                                                                  attending school           violence in and around
                                                                                  (primarily kindergarten    schools; prevent illegal
                                                                                  through grade 12)          use of alcohol,
                                                                                                             tobacco, and drugs;
                                                                                                             and coordinate with
                                                                                                             federal, state, school,
                                                                                                             and community efforts
                                                                                                             to foster a safe and
                                                                                                             drug-free learning
                                                                                                             environment.
                                                        Governors                 Children and youth not     To support programs
                                                                                  normally served by         of drug use (including
                                                                                  state or local             tobacco) and violence
                                                                                  educational agencies,      prevention.
                                                                                  or populations that
                                                                                  need special services
                                                                                  or additional resources
                                                                                  (for example, youth in
                                                                                  detention facilities and
                                                                                  runaway and
                                                                                  homeless youth)
Multiagency programs
Drug-Free Communities Support             $46,000,000 Community coalitions        Youth                      To support coalitions
(DOJ and ONDCP)                                                                                              engaged in efforts to
                                                                                                             prevent youth alcohol,
                                                                                                             tobacco, illicit drug,
                                                                                                             and inhalant abuse.
Drug Education for Youth (DOJ              $1,869,136 Community coalitions        Youth ages 9 to 12         To support a
and DOD)                                                                                                     multiphased program
                                                                                                             for 9- to 12-year-olds
                                                                                                             to reduce risk factors
                                                                                                             that scientific research
                                                                                                             has linked to
                                                                                                             adolescent substance
                                                                                                             abuse, including
                                                                                                             tobacco use, school
                                                                                                             failure, delinquency,
                                                                                                             and violence.




                                         Page 28                    GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                                                                Appendix II: Selected Federal Programs That
                                                                Address or Can Address Tobacco Prevention
                                                                and Reduction among Youth




                                                              Funding fiscal                                        Targeted                  Grant program
                                                                           a
 Program                                                         year 2002 Eligible applicantsb                     beneficiaries             description
 Safe Schools/Healthy Students                                  $171,588,449 Local education agencies               Preschool and school-     To assist school
 (Education, HHS and DOJ)                                                    in partnership with local              age children,             districts in developing
                                                                             public mental health                   adolescents, and their    comprehensive
                                                                             authorities, and law                   families who are at       services to promote
                                                                             enforcement agencies                   risk of being involved    healthy childhood
                                                                                                                    in drug abuse, or         development and
                                                                                                                    violence as               prevent violence and
                                                                                                                    perpetrators, victims,    alcohol and other drug
                                                                                                                    or witnesses              abuse, including
                                                                                                                                              tobacco use.

Sources: Agency program officials, agency documents, and the Catalog of Federal Domestic Assistance.
                                                                a
                                                                    All funding is amount appropriated or allocated.
                                                                b
                                                                 In this column, the term “state” includes the District of Columbia and some or all of the following: the
                                                                Commonwealth of Puerto Rico, the U.S. Virgin Islands, the Republic of Palau, the Federated States
                                                                of Micronesia, and other territories or possessions of the United States unless otherwise noted.
                                                                c
                                                                    Total block grant funding for chronic disease programs was $49,601,321.
                                                                d
                                                                    State-reported planned expenditures for fiscal year 2002.




                                                                Page 29                                GAO-04-41 Preventing and Reducing Tobacco Use among Youth
             Appendix III: Comments from the Department
Appendix III: Comments from the
             of Health and Human Services



Department of Health and Human Services




             Page 30                  GAO-04-41 Preventing and Reducing Tobacco Use among Youth
Appendix III: Comments from the Department
of Health and Human Services




Page 31                  GAO-04-41 Preventing and Reducing Tobacco Use among Youth
                  Appendix IV: GAO Contact and
Appendix IV: GAO Contact and
                  Acknowledgments



Acknowledgments

                  James O. McClyde, (202) 512-7152
GAO Contact
                  In addition to the person named above, contributors to this report were
Acknowledgments   Alice London, Donna Bulvin, Krister Friday, and Lawrence Solomon.




(290239)
                  Page 32                  GAO-04-41 Preventing and Reducing Tobacco Use among Youth
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