The National Association of County and City Health Officials (NACCHO) is the national organization representing local health departments. It supports efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity, and supporting effective local public health practice and systems.
This column discusses the revised NACCHO guidelines for reducing and preventing tobacco use.
Julie Nelson Ingoglia, MPH, is Program Manager, Community Health, National Association of County and City Health Officials, Washington, District of Columbia.
Melissa Werner, MPH, MAT, is Consultant, National Association of County and City Health Officials, Washington, District of Columbia.
Corresponding Author: Julie Nelson Ingoglia, MPH, National Association of County and City Health Officials, 1100 17th St, NW 2nd Floor, Washington, DC 20036 (email@example.com).
Much of the text in this article was drawn from NACCHO's 2010 Guidelines. Special thanks to Michael Seserman, MPH, RD, the primary author of the updated Guidelines.
History and Purpose of the Guidelines
In spring 2010, the National Association of County and City Health Officials (NACCHO) released its revised Program and Funding Guidelines for Comprehensive Local Tobacco Program (Guidelines), an update of the 2001 NACCHO publication of the same name. Adapted from the Centers for Disease Control and Prevention's (CDC's) Best Practices for Comprehensive Tobacco Control Programs, the NACCHO Guidelines address the specific needs and realities of tobacco control programs at the local level.
The updated Guidelines are designed to help local decision makers and health planners select and fund evidence-based interventions for reducing and preventing tobacco use, identifying and eliminating health disparities related to tobacco use, and protecting people from secondhand smoke. The Guidelines will also enable localities to assess the adequacy of current programs and estimate funding deficits for each program component compared to recommended funding levels.
Tobacco use is the single most preventable cause of death and disease in the United States. Tobacco-related illness is the largest modifiable risk factor for chronic disease and eats up 75 percent of healthcare dollars spent in the United States.1 In 2004, tobacco addiction cost the nation almost $200 billion in medical expenses and lost productivity. In 2005, the Society of Actuaries estimated that the effects of exposure to secondhand smoke cost the United States $10 billion per year.2 State and some local governments bear a substantial portion of these excess costs, funding for public health insurance programs and treatment of the uninsured.
With tobacco-related chronic diseases disproportionately affecting city and county populations compared with other public health concerns such as infectious disease, governments at all levels have a large stake in reducing the prevalence of tobacco use. Accordingly, local health departments (LHDs) also need to develop a strong infrastructure to support a broad range of tobacco-control activities at the community level. Such activities can significantly improve community health and save money for all levels of government by reducing the incidence of tobacco-related chronic disease.
Components of a Comprehensive Local Tobacco Program
The revised NACCHO Guidelines discuss the following five evidence-based program components essential to an effective tobacco program.
1. Community interventions. For meaningful change to occur in the way tobacco products are marketed, sold, and used, community involvement is critical. For example, promoting smoke-free environments and enforcing policies that restrict tobacco advertising help to change social norms about tobacco use. Raising taxes on tobacco is among the most effective ways to reduce use, especially among young people and the poor.3 Restricting access to tobacco products discourages youth from initiating tobacco use, and with the new Food and Drug Administration legislation, localities will have more opportunity to influence where, when, and how tobacco products are displayed and sold (Box 1).
2. Health communications. There is considerable evidence that communication campaigns are effective at reducing tobacco consumption. A well-coordinated mass media campaign that reaches a wide market and warns individuals about the dangers of tobacco use can promote cessation and prevent initiation in the general population and hard-to-reach groups.3 Media messages can have a powerful influence on public support for tobacco control policies and help reinforce school and community efforts.4
3. Cessation interventions. More than two-thirds of adult smokers report a desire to quit.4 Cessation interventions offer the quickest and largest short-term public health benefit compared with any other component of the comprehensive tobacco control program.5 Many effective treatments for tobacco dependence now exist but are currently underused. We know how to end the epidemic of smoking in our communities. Evidence-based tobacco control programs that are comprehensive, sustained, and accountable have been shown to reduce smoking rates, tobacco-related deaths, and diseases caused by smoking.
4. Program administration and management. Each LHD requires dedicated personnel who can perform strategic planning, staffing, and fiscal management functions and a well-trained workforce that has the skills required to carry out program activities.
5. Surveillance and evaluation. Surveillance and evaluation are essential elements of a comprehensive tobacco control program. A successful program should assess the use of tobacco, local factors contributing to tobacco use, and progress toward planned outcomes, and should report data useful to policy makers and the public.
Smoking prevalence among adults and youth has declined more in states, making a larger investment as compared with states where spending for tobacco control programs has remained level or decreased. According to the CDC, states that have made larger investments in comprehensive tobacco control programs have seen cigarette sales drop more than twice as much as in the United States as a whole. Evidence-based tobacco control represents some of the most cost-effective health interventions available to LHDs. Treatment of tobacco use ranked the third highest among adult preventive services in terms of health impact and cost-effectiveness. Yet, treatment is provided to less than 35 percent of tobacco users.6 If state and local governments pay for proven and coordinated tobacco control now, they will reap large financial and health-related benefits for their communities in the future. In California, the state with the longest-running comprehensive program, smoking rates among adults have declined substantially and lung cancer incidence is declining four times faster than in the rest of the nation.2 California's reduction in smoking prevalence is responsible in no small part for substantial, rapid, and growing reductions in per capita personal healthcare expenditures. These savings have appeared quickly, grown over time, and totaled approximately 50 times the expenditures for tobacco control in 2004.7
With the critical importance of budgeting in mind, NACCHO has included the following budgeting tools in the updated Guidelines:
* Recommended funding ranges for each program component, with explanations of how the recommendations were derived.
* Simple and detailed sample tobacco control program budgets.
* Funding spreadsheets that can be used to adapt CDC's funding/budgeting recommendations to the specific needs and realities of local tobacco control programs.
Training on the Guidelines
Work is currently under way on a curriculum to train LHD staff and partners on the revised Guidelines. The curriculum will provide step-by-step directions for interactive training in a flexible modular format. Pilot testing of the training will take place in May 2010; release of the curriculum is planned for summer 2010. NACCHO will be offering a condensed version of the training in July 2010 at NACCHO Annual in Memphis, Tennessee. In addition, NACCHO will be creating an on-line self-study version of the training.
1. Anderson G, et al. Chronic Conditions: Making the Case for Ongoing Care
. Baltimore, MD: Partnership for Solutions; 2004.
2. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs
. Atlanta, GA: Centers for Disease Control and Prevention; 2007.
4. Centers for Disease Control and Prevention. Reducing Tobacco Use: A Report of the Surgeon General
. Washington, DC: Department of Health and Human Services for sale by the Supt of Docs, US GPO; 2000,
5. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs, August 1999.
Atlanta, GA: Centers for Disease Control and Prevention; 1999.
6. Maciosek MV, Coffield AB, Edwards NM, Goodman MJ, Flottemesch TJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med.
7. Lightwood JM, Dinno A, Glantz SA. Effect of the California tobacco control program on personal health care expenditures. PLoS Med,