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

United States General Accounting Office:

GAO:

November 2003:

Tobacco Use and Public Health:

Federal Efforts to Prevent and Reduce Tobacco Use among Youth:

Preventing and Reducing Tobacco Use among Youth:

GAO-04-41:

GAO Highlights:

Highlights of GAO-04-41, a report to the Honorable Bill Frist, U.S. 
Senate 

Why GAO Did This Study:

Tobacco use is the leading cause of preventable death in the United 
States. The Centers for Disease Control and Prevention (CDC) reported 
that, on average, over 440,000 deaths and $76 billion in medical 
expenditures were attributable to cigarette smoking each year from 
1995 through 1999. Reducing tobacco-related deaths and the incidence 
of disease, along with the associated costs, represents a significant 
public health challenge for the federal government. Most adults who 
use tobacco started using it between the ages of 10 and 18. According 
to a Surgeon General’s report, if children and adolescents can be 
prevented from using tobacco products before they become adults, they 
are likely to remain tobacco-free for the rest of their lives. 

GAO was asked to provide information on federal efforts to prevent 
and reduce youth smoking. Specifically, this report describes (1) 
federal programs, research, and activities that aim to prevent and 
reduce tobacco use among youth, (2) the efforts of federal 
departments and agencies to monitor their programs, and (3) the 
coordination among federal departments and agencies in efforts to 
prevent and reduce tobacco use among youth. 

What GAO Found:

Some federal programs, research, and activities that aim to address 
tobacco use among youth focus only on tobacco while others aim to 
address tobacco use as part of broader efforts to address unhealthy 
behaviors such as substance abuse and violence. Two federal programs 
within the Department of Health and Human Services (HHS) focus only on 
tobacco use. CDC’s National Tobacco Control Program (NTCP) focuses on 
preventing and reducing tobacco use among the general population and 
explicitly targets youth. The Substance Abuse and Mental Health 
Services Administration’s program to oversee implementation of a 
provision of federal law, commonly referred as the Synar Amendment, 
focuses only on tobacco use among youth. The Synar Amendment requires 
states to enact and enforce laws prohibiting the sale of tobacco 
products to minors. In addition to these tobacco-focused programs, 
HHS, and the Departments of Defense (DOD), Justice (DOJ), and 
Education sponsor programs that include tobacco use as part of 
broader efforts to address unhealthy behaviors among youth, such as 
substance abuse and violence. For example, Education’s Safe and Drug-
Free Schools and Communities program is designed to prevent substance 
abuse and violence. HHS agencies, such as the National Institutes of 
Health, conduct research on tobacco use and nicotine addiction among 
youth and its health effects on youth. HHS agencies and other federal 
departments also support activities to prevent and reduce tobacco use 
among youth, such as education and outreach efforts. HHS and its 
component agencies coordinate tobacco-related efforts with other 
federal, state, and local government agencies and nongovernmental 
entities. 

Federal departments and agencies collect a variety of information to 
monitor how programs that aim to address tobacco use among youth are 
being implemented by grantees and the effectiveness of grantee 
efforts in meeting program goals. The information is collected through 
various means, including grant applications, progress reports, 
periodic site visits, and program evaluations. For example, to 
monitor NTCP, CDC requires states to submit biannual reports on the 
implementation of state NTCP-supported tobacco control programs. The 
information that federal departments and agencies collect on these 
programs is also used to provide training and technical assistance to 
grantees on topics such as conducting program evaluation. 

In commenting on a draft of this report, HHS stated that the report 
was very informative but it did not include programs like Medicaid 
that are a substantial element of HHS tobacco prevention efforts. 
Including programs that finance health insurance such as Medicaid, 
however, was beyond the scope of our review. Also, HHS noted that we 
did not include information about the challenges other federal 
agencies face in coordinating tobacco-related issues but DOD, DOJ, 
and Education did not describe such challenges. DOD and DOJ had no 
comments on the report and HHS and Education provided technical 
comments that we incorporated as appropriate.

www.gao.gov/cgi-bin/getrpt?GAO-04-41.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Marjorie E. Kanof at 
(202) 512-7101.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Some Federal Programs, Research, and Activities Focus Only on Tobacco 
Use, While Others Address Tobacco Use Along with Other Unhealthy 
Behaviors:

Federal Departments and Agencies Collect a Variety of Information on 
Their Programs That Aim to Prevent Tobacco Use among Youth:

Federal Departments and Agencies Coordinate in Various Ways to Address 
Tobacco Use among Youth:

Agency Comments:

Appendix I: Scope and Methodology:

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

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

Appendix IV: GAO Contact and Acknowledgments:

GAO Contact:

Acknowledgments:

Tables:

Table 1: Examples of Federal Collaborative Education and Outreach 
Activities to Address Tobacco Use among Youth:

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

Figure:

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

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: 

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.[Footnote 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.[Footnote 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.[Footnote 3]

Given the harmful effects of tobacco use and the rates of smoking among 
youth,[Footnote 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 activities[Footnote 5] that 
aim to address tobacco use among youth, we reviewed the Catalog of 
Federal Domestic Assistance, which is a database of federal grant 
programs,[Footnote 6] and other pertinent documents. In addition, we 
interviewed program officials in multiple federal agencies.[Footnote 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 through October 
2003 in accordance with generally accepted government auditing 
standards.

Results in Brief:

Some federal programs, research, and activities that address tobacco 
use 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 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.

Background:

From 1991 through 2002, smoking rates among youth fluctuated and 
reached their highest points around 1997. The estimated rate of current 
smoking among youth (defined as smoking one or more cigarettes during 
the previous 30 days) varied according to grade level[Footnote 8] (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:

[See PDF for image]

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

[End of figure]

HHS serves as the lead federal department for addressing the nation's 
public health issues, including tobacco use. HHS is responsible for 
informing the public of the dangers of tobacco use and coordinating 
federal efforts to address tobacco use issues. Within HHS, CDC's Office 
on Smoking and Health has been delegated the lead for all policy and 
programmatic issues related to the prevention and reduction of tobacco 
use and has primary responsibility within the federal government for 
tobacco use prevention efforts.[Footnote 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.[Footnote 10] Healthy People 
2010 objectives related to tobacco use among youth include, among other 
objectives, reducing the percentage of adolescents who smoked 
cigarettes in the past month and increasing the percentage of 
adolescents who try to quit smoking.

Some Federal Programs, Research, and Activities Focus Only on Tobacco 
Use, While Others Address Tobacco Use Along with Other Unhealthy 
Behaviors:

Two HHS agencies, CDC and SAMHSA, administer programs that focus only 
on tobacco use. CDC's NTCP targets youth within a broader mission of 
preventing and reducing tobacco use among the general population. 
SAMHSA oversees implementation of the Synar Amendment that requires 
states to enact and enforce tobacco control laws prohibiting the sale 
of tobacco products to minors. Other programs and activities 
administered by HHS, DOD, DOJ, Education, and the Office of National 
Drug Control Policy (ONDCP) address tobacco use as part of a broader 
focus on unhealthy behaviors, such as substance abuse and violence. 
(See app. II for examples of federal programs that can address tobacco 
prevention and reduction among youth.):

Some Federal Programs Only Address Tobacco Use:

We identified two federal programs that focus only on tobacco use. The 
first, CDC's NTCP,[Footnote 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.[Footnote 12] In fiscal year 2002, 
NTCP provided about $58 million to states to address NTCP's four 
goals.[Footnote 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.

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.[Footnote 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 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.[Footnote 
15] States are also required to report enforcement actions taken 
against those who violate state laws in order to receive certain 
federal grants.[Footnote 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 Address Tobacco Use Along with Other Unhealthy 
Behaviors:

Other federal programs aim to address tobacco use among youth as part 
of a broader focus on unhealthy behaviors. For example, CDC's 
Coordinated School Health program provides grants to states to 
implement school health programs to prevent a range of unhealthy 
behaviors or conditions, such as drug, alcohol, and tobacco use; 
physical inactivity; poor nutrition, and obesity. In fiscal year 2002, 
CDC awarded grants to 22 states, with each state receiving 
approximately $400,000. CDC helps state education and health 
departments identify and implement health education curricula to 
provide youth with information and the decision-making, communication, 
and peer-resistance skills needed to avoid unhealthy behaviors. In 
addition, CDC provides guidance to state and local health education 
agencies on tobacco prevention programs in schools that covers 
policies, programs, and a tobacco-free environment. CDC periodically 
surveys the states, school districts, and schools on the health 
curricula they offer and on school health policies relating to tobacco 
prevention and reduction efforts. According to CDC, the information 
obtained through these survey efforts is used to assess trends in 
school health education programs.

Education's Safe and Drug-Free Schools and Communities program aims to 
prevent violence and drug, alcohol, and tobacco use in the nation's 
schools.[Footnote 17] Under this program in fiscal year 2002, Education 
awarded more than $472 million in grants to state education departments 
and governors' offices.[Footnote 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,[Footnote 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, 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 Research to Address Tobacco Use among Youth:

In addition to supporting programs that aim to address tobacco use 
among youth, HHS agencies conduct research on tobacco use and its 
health effects. NIH's National Cancer Institute (NCI) has identified 
tobacco use among youth as one of its research priorities.[Footnote 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.[Footnote 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 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.[Footnote 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.[Footnote 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 to Address Tobacco Use among Youth:

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

Federal Departments and Agencies Collect a Variety of Information on 
Their Programs That Aim to Prevent Tobacco Use among Youth:

To monitor federal programs that aim to prevent and reduce tobacco use 
among youth, federal departments and agencies collect information on 
how their programs are being implemented by grantees and the 
effectiveness of grantees' efforts in meeting national program goals. 
Federal departments and agencies obtain this information from various 
sources, such as grantee applications for federal funding, progress 
reports, site visits, and program evaluations. According to federal 
officials, the information is used to assist grantees in managing and 
evaluating their programs.

CDC Collects Information on the States' NTCP-Supported Tobacco Control 
Programs:

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

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

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 Information on States' Progress in Prohibiting the Sale 
of Tobacco Products to Minors:

To monitor state compliance with the requirements of the Synar 
Amendment and its implementing regulation, SAMHSA collects data on the 
design and implementation of state compliance efforts. The regulation 
requires that each state report to SAMHSA information on the state's 
efforts to inspect retail tobacco outlets, including the state's 
sampling methodology, inspection protocol, and inspection results. 
SAMSHA reviews the information to determine whether states have 
complied with requirements for enforcing state laws and conducting 
random inspections of retail tobacco outlets. In reviewing these data, 
SAMHSA determines whether a state's estimated retailer violation rate 
meets negotiated annual targets and shows progress toward the 20 
percent goal. Based on the latest data available at the time of our 
review, 49 states met their negotiated retailer violation rate targets 
for 2002.

Federal Departments and Agencies Collect Information on Their Programs 
That Address Unhealthy Behaviors among Youth:

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

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

Federal Departments and Agencies Coordinate in Various Ways to Address 
Tobacco Use among Youth:

HHS and other federal departments coordinate their efforts to prevent, 
treat, and reduce tobacco use among youth by participating on various 
committees and work groups and by collaborating on various programs, 
research projects, and activities. Although HHS has the lead 
responsibility for coordinating these efforts, some HHS officials 
stated that coordination among HHS agencies presents challenges.

HHS Leads Coordination Efforts to Address Tobacco Use:

HHS leads efforts among its agencies and others to develop strategies 
for addressing tobacco use among youth in support of the Healthy People 
initiative, which includes objectives to reduce tobacco use among 
youth. As part of this initiative, representatives from various federal 
departments and nongovernmental organizations participate in work 
groups that focus on tobacco use objectives. For example, the Healthy 
People 2010 Tobacco Use Work Group, chaired by CDC, includes 
representatives from other HHS agencies as well as the Environmental 
Protection Agency (EPA), the Federal Trade Commission, and nonfederal 
organizations. The work group meets periodically to discuss strategies 
and challenges in addressing issues related to tobacco use.[Footnote 
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.[Footnote 31] In 2000, 
the collaborative published an action plan to facilitate planning and 
priority-setting on the need for tobacco cessation for youth.[Footnote 
32] In addition, three members of the collaborative--CDC, NCI, and 
the Robert Wood Johnson Foundation--are working together on the 
Helping Young Smokers Quit initiative, a 4-year project that aims to 
identify, characterize, and evaluate the effectiveness of various 
youth cessation programs.

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

HHS Established the Interagency Committee on Smoking and Health to 
Coordinate Federal Efforts:

In 1984, the Congress passed legislation requiring, among other things, 
that HHS establish an interagency committee to coordinate the 
department's research, educational programs, and other smoking and 
health efforts with similar efforts of other federal departments and 
nonfederal organizations.[Footnote 33] As a result, in 1985, HHS 
established the Interagency Committee on Smoking and Health. According 
to CDC officials, the committee brings together representatives of 
federal agencies and nonfederal organizations involved in tobacco use 
issues[Footnote 34] and serves as a forum for committee members and the 
public to share information and discuss a variety of tobacco-related 
issues and efforts. Committee meetings that have specifically focused 
on tobacco use among youth have covered such topics as the health 
effects of smoking on young people, the sale of cigarettes to minors, 
and strategies for preventing tobacco use.

HHS and Other Federal Departments Coordinate Their Efforts by Jointly 
Administering Programs and Supporting Research and Activities:

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

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

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

Table 1: Examples of Federal Collaborative Education and Outreach 
Activities to Address Tobacco Use among Youth:

Activity or project: Tobacco-Free Sports; Federal departments or 
agencies: CDC, NCI, SAMHSA, and ONDCP; Description: An initiative that 
involves sports stars, sport leagues, and youth organizations helping 
to deliver tobacco-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.

Activity or project: Entertainment Industry Outreach; Federal 
departments or agencies: CDC, NIDA SAMHSA, and ONDCP; Description: A 
multifaceted outreach effort to, among other things, enlist celebrities 
to serve as national spokespersons 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.

Activity or project: Pathways to Freedom; Federal departments or 
agencies: CDC and NCI; Description: A self-help guide intended to 
motivate and assist 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.

Activity or project: Got a Minute? Give It to Your Kids; Federal 
departments or agencies: CDC, SAMHSA, Education, and ONDCP; 
Description: A guide to educate parents on how to comprehensively 
address their children's health needs, including information on how to 
prevent their children from using tobacco. Education is assisting CDC 
in disseminating the guide to schools nationwide.

Source: HHS agencies, Education, and ONDCP.

[End of table]

HHS Officials Identified Several Challenges to Coordination within the 
Department:

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

Agency Comments:

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

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

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

Sincerely yours,

Marjorie E. Kanof: 
Director, Health Care--Clinical Health Care Issues:

Signed by Marjorie E. Kanof: 

[End of section]

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.[Footnote 35] 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.[Footnote 36] As a result, we focused on four 
federal departments: HHS and its component agencies--CDC, SAMHSA, NIH, 
and HRSA; Education; DOJ; and DOD. We then obtained more detailed 
information on the programs they fund. We interviewed officials in HHS, 
DOD, DOJ, and Education and obtained information on program 
characteristics, including the purpose, target audience, and program 
and financial requirements. We also obtained information on research 
and activities that involve federal departments and agencies, such as 
education and outreach efforts intended to prevent the initiation of 
tobacco use among youth and help youth quit tobacco use. In conducting 
this work, we also reviewed strategic and annual performance plans, 
along with budgetary and other pertinent documents, including national 
action plans and tobacco use prevention and cessation guidance. Where 
available, we obtained fiscal year 2002 funding information on the 
federal programs and research that we identified. However, we were 
unable to determine the extent of spending by federal agencies on 
efforts to prevent and reduce tobacco use among youth because, in many 
instances, funding information covers more than the prevention and 
reduction of tobacco use among youth. The programs, research, and 
activities that we discuss in this report do not represent an 
exhaustive list of all federal efforts to prevent and reduce tobacco 
use among youth, but highlight a range of such efforts.

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

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

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

[End of section]

Appendix II: Selected Federal Programs That 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:

Department of Health and Human Services: 

Program: Centers for Disease Control and Prevention: 

Program: National Tobacco Control; Funding fiscal year 2002[A]: 
Department of Health and Human Services: Centers for Disease Control 
and Prevention: $58,000,000; Eligible applicants[B]: Department of 
Health and Human Services: States; Targeted beneficiaries: Department 
of Health and Human Services: General population; Grant program 
description: Department of Health and Human Services: To support state 
tobacco control programs to prevent and reduce tobacco use, including 
preventing youth from starting to smoke.

Program: Tribal Support Centers; Funding fiscal year 2002[A]: 
Department of Health and Human Services: Centers for Disease Control 
and Prevention: $1,600,000; Eligible applicants[B]: Department of 
Health and Human Services: Tribes and tribal organizations; Targeted 
beneficiaries: Department of Health and Human Services: American 
Indian/Alaskan Natives; Grant program description: Department of Health 
and Human Services: To support seven tribal centers in developing 
tobacco control programs to prevent and reduce tobacco use, including 
preventing youth from starting to smoke.

Program: Coordinated School Health; Funding fiscal year 2002[A]: 
Department of Health and Human Services: Centers for Disease Control 
and Prevention: $11,000,000; Eligible applicants[B]: Department of 
Health and Human Services: State and local education agencies; Targeted 
beneficiaries: Department of Health and Human Services: Students in 
grades 9 through 12; Grant program description: Department of Health 
and Human Services: To support school health programs in discouraging 
unhealthy behaviors, such as poor eating habits, physical inactivity, 
and tobacco use.

Program: Preventive Services Block Grant to States; Funding fiscal year 
2002[A]: Department of Health and Human Services: Centers for Disease 
Control and Prevention: $408,450[C]; Eligible applicants[B]: 
Department of Health and Human Services: States; Targeted 
beneficiaries: Department of Health and Human Services: General 
population; Grant program description: Department of Health and Human 
Services: To carry out public health activities, including preventing 
tobacco sales to minors.

Program: Health Resources and Services Administration: 

Program: Healthy Schools, Healthy Communities; Funding fiscal year 
2002[A]: Department of Health and Human Services: Centers for Disease 
Control and Prevention: $19,500,000; Eligible applicants[B]: 
Department of Health and Human Services: Public and nonprofit private 
entities, including faith-based and community-based organizations; 
Targeted beneficiaries: Department of Health and Human Services: 
Students attending schools (kindergarten through grade 12) that serve 
low-income or high-risk children; Grant program description: Department 
of Health and Human Services: To increase access to comprehensive 
primary and preventive health care for underserved children, 
adolescents, and their families, including tobacco prevention and 
reduction programs.

Program: Community Health Centers; Funding fiscal year 2002[A]: 
Department of Health and Human Services: Centers for Disease Control 
and Prevention: $1,077,578,000; Eligible applicants[B]: Department of 
Health and Human Services: Public and nonprofit private entities, 
including faith-based and community-based organizations; Targeted 
beneficiaries: Department of Health and Human Services: People in 
medically underserved areas; Grant program description: Department of 
Health and Human Services: To develop and operate community health 
centers that provide preventive and primary health care services, and 
link clients with Medicaid and mental health and substance abuse 
treatment, including that for tobacco use.

Program: Maternal and Child Health Services Block Grant to States; 
Funding fiscal year 2002[A]: Department of Health and Human Services: 
Centers for Disease Control and Prevention: $595,727,279; Eligible 
applicants[B]: Department of Health and Human Services: States; 
Targeted beneficiaries: Department of Health and Human Services: 
Pregnant women, mothers, infants and children, and children with 
special health care needs, particularly those of low-income families; 
Grant program description: Department of Health and Human Services: To 
maintain and strengthen state leadership in planning, promoting, 
coordinating, and evaluating health care services. Funds can be used 
for tobacco prevention programs and activities.

Substance Abuse and Mental Health Services Administration: 

Program: Synar Amendment; Funding fiscal year 2002[A]: Department of 
Health and Human Services: Centers for Disease Control and Prevention: 
$5,448,273[D]; Eligible applicants[B]: Department of Health and Human 
Services: States; Targeted beneficiaries: Department of Health and 
Human Services: Children under age 18; Grant program description: 
Department of Health and Human Services: 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.

Program: Substance Abuse Prevention and Treatment Block Grant; Funding 
fiscal year 2002[A]: Department of Health and Human Services: Centers 
for Disease Control and Prevention: $1,725,000,000; Eligible 
applicants[B]: Department of Health and Human Services: States; 
Targeted beneficiaries: Department of Health and Human Services: 
General population; Grant program description: Department of Health and 
Human Services: To provide financial assistance to states for the 
purpose of planning, carrying out, and evaluating activities to prevent 
and treat substance abuse, including youth tobacco use.

Program: State Incentive Grants; Funding fiscal year 2002[A]: 
Department of Health and Human Services: Centers for Disease Control 
and Prevention: $58,480,885; Eligible applicants[B]: Department of 
Health and Human Services: States; Targeted beneficiaries: Department 
of Health and Human Services: Adolescents; Grant program description: 
Department of Health and Human Services: To prevent and reduce alcohol, 
tobacco, and illicit drug use by adolescents ages 12-17.

Department of Education: 

Program: Office of Elementary and Secondary Education: 

Program: Safe and Drug-Free Schools and Communities: State Grants; 
Funding fiscal year 2002[A]: Centers for Disease Control and 
Prevention: $472,017,000; Eligible applicants[B]: State departments 
of education; Targeted beneficiaries: Children and youth who are 
enrolled and attending school (primarily kindergarten through grade 
12); Grant program description: To support programs that seek to 
prevent violence in and around schools; prevent illegal use of 
alcohol, tobacco, and drugs; and coordinate with federal, state, 
school, and community efforts to foster a safe and drug-free learning 
environment.

Eligible applicants[B]: Governors; Targeted beneficiaries: Children 
and youth not normally served by state or local educational agencies, 
or populations that need special services or additional resources 
(for example, youth in detention facilities and runaway and homeless 
youth); Grant program description: To support programs of drug use 
(including tobacco) and violence prevention.

Multiagency programs: 

Program: Drug-Free Communities Support (DOJ and ONDCP); Funding fiscal 
year 2002[A]: Centers for Disease Control and Prevention: 
$46,000,000; Eligible applicants[B]: Community coalitions; Targeted 
beneficiaries: Youth; Grant program description: To support 
coalitions engaged in efforts to prevent youth alcohol, tobacco, 
illicit drug, and inhalant abuse.

Program: Drug Education for Youth (DOJ and DOD); Funding fiscal year 
2002[A]: Centers for Disease Control and Prevention: $1,869,136; 
Eligible applicants[B]: Community coalitions; Targeted beneficiaries: 
Youth ages 9 to 12; Grant program description: To support a 
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.

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

[End of table]

[End of section]

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

DEPARTMENT OF HEALTH & HUMAN SERVICES	
Office of inspector General:

OCT 31 2003:

Ms. Marjorie E. Kanof:

Director, Health Care - Clinical Health Care Issues United States 
General Accounting Office 
Washington, D.C. 20548:

Dear Ms. Kanof:

Enclosed are the Department's comments on your draft report entitled, 
"Tobacco Use and Public Health: Federal Efforts to Prevent and Reduce 
Tobacco Use Among Youth." The comments represent the tentative position 
of the Department and are subject to reevaluation when the final 
version of this report is received.

The Department also provided several technical comments directly to 
your staff.

The Department appreciates the opportunity to comment on this draft 
report before its publication.

Sincerely,

Signed by: 

Dara Corrigan:

Acting Principal Deputy Inspector General:

Enclosure:

The Office of Inspector General (01G) is transmitting the Department's 
response to this draft report in our capacity as the Department's 
designated focal point and coordinator for General Accounting Office 
reports. OIG has not conducted an independent assessment of these 
comments and therefore expresses no opinion on them.

Comments of the Department of Health and Human Services on the U.S. 
General Accounting Office's Draft Report, "Tobacco Use and Public 
Health: Federal Efforts to Prevent and Reduce Tobacco Use Among Youth" 
(GAO-04-41):

The Department of Health and Human Services (HHS) appreciates the 
opportunity to comment on the above-referenced draft report. HHS 
recognizes the importance of addressing tobacco use among youth, and is 
pleased that efforts such as the National Tobacco Control Program were 
reviewed and included as examples of the Department's activity and 
leadership in this area. The report is very informative of Federal 
efforts to prevent and reduce youth smoking, and HHS appreciates the 
extensive efforts that the General Accounting Office (GAO) expended in 
assembling this thorough overview of nicotine and tobacco activities 
related to youth.

However, the draft report appears to have missed a substantial element 
of HHS tobacco prevention by not including programs within the Centers 
for Medicare & Medicaid Services (CMS). Within Medicaid, the Federal 
guidelines specifically permit coverage of tobacco cessation therapy 
with a particular focus on children (and on pregnant women). A State 
Medicaid Director letter on the CMS web site [Hyperlink, 
http://www.cms.hhs.gov/states/letters/smdOI051.asp], notes that: 
"States are required to cover smoking cessation drug therapy when it 
is determined medically necessary for eligible individuals under age 
21 ." The letter continues by noting that: "States also are required 
as part of EPSDT screening component to discuss tobacco use and 
provide counseling for smoking cessation to children and adolescents 
at appropriate ages." Therefore, the draft report would have benefited 
from including a discussion of CMS programs as well.

In several places (e.g., pages 4, 18, and 23), the draft report refers 
to HHS officials commenting that coordination between multiple HHS 
agencies across programs can be difficult because of differing missions 
and priorities. Challenges experienced by other Departments, if any, 
are not noted. If GAO has information related to coordination 
challenges in other Departments, the inclusion in the report of this 
kind of information may create more of a balance. In addition, HHS 
believes that these kinds of comments are useful only if presented in 
the context of a background in which specific examples are cited to 
indicate how real roadblocks, if any exist, may be removed.

[End of section]

Appendix IV: GAO Contact and Acknowledgments:

GAO Contact:

James O. McClyde, (202) 512-7152:

Acknowledgments:

In addition to the person named above, contributors to this report were 
Alice London, Donna Bulvin, Krister Friday, and Lawrence Solomon.

FOOTNOTES

[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)).

[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.

[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).

[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.

[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.

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

[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.)

[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)). 

[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. 

[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).

[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.

[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).

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

[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).

[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.

[35] The General Services Administration maintains this database.

[36] The scope of our work did not include programs that finance health 
insurance such as Medicaid.

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