Tobacco Use And Public Health: Federal Efforts to Prevent and	 
Reduce Tobacco Use among Youth (21-NOV-03, GAO-04-41).		 
                                                                 
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.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-41						        
    ACCNO:   A08906						        
  TITLE:     Tobacco Use And Public Health: Federal Efforts to Prevent
and Reduce Tobacco Use among Youth				 
     DATE:   11/21/2003 
  SUBJECT:   Data collection					 
	     Federal/state relations				 
	     Health hazards					 
	     Minors						 
	     Public health legislation				 
	     Public health research				 
	     Smoking						 
	     Children						 
	     Teenagers						 
	     Program coordination				 
	     HHS Healthy People 2010 Initiative 		 
	     CDC National Tobacco Control Program		 

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GAO-04-41

United States General Accounting Office

GAO

Report to the Honorable Bill Frist, U.S.

                                     Senate

November 2003

TOBACCO USE AND PUBLIC HEALTH

         Federal Efforts to Prevent and Reduce Tobacco Use among Youth

GAO-04-41

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

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.

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.

November 2003

TOBACCO USE AND PUBLIC HEALTH

Federal Efforts to Prevent and Reduce Tobacco Use among Youth

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
tobaccorelated 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.

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

                                       1

                                      3 5

                                       7

                                       14

                                     18 22

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 32

GAO Contact 32 Acknowledgments 32

  Tables

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

  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

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protection in the United States. It may be reproduced and distributed in
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separately.

United States General Accounting Office Washington, DC 20548

November 21, 2003

The Honorable Bill Frist United States Senate

Dear Senator Frist:

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

1Centers 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.

2U.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).

3The Synar Amendment is found in S:1926 of the Public Health Service Act
as added by the Drug Abuse and Mental Health Administration Reorganization
Act, Pub. L. No. 102-321 S: 202, 106 Stat. 394 (1992) (classified to 42
U.S.C. S: 300x-26 (2000)).

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

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

4For the purposes of this report, youth refers to children and adolescents
under the age of

18.

5In 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.

6The General Services Administration maintains this database.

7The scope of our work did not include programs that finance health
insurance such as Medicaid.

  Results in Brief

through October 2003 in accordance with generally accepted government
auditing standards.

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 level8 (see fig.1).
For example, the rate among 8th grade students peaked at about 21 percent
in 1996 before declining to about 11 percent in 2002. For 10th grade
students, the smoking rate peaked at 30 percent in 1996 before declining
to 18 percent in 2002. Similarly, smoking among 12th grade students peaked
at about 37 percent in 1997, before declining to about 27 percent in 2002.

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

100 Percentage

40

20

0

Source: NIDA.

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

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

8L.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).

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

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

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

9The Office on Smoking and Health is a division of the National Center for
Chronic Disease Prevention and Health Promotion.

10The 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.

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

tobacco use among youth include, among other objectives, reducing the
percentage of adolescents who smoked cigarettes in the past month and
increasing the percentage of adolescents who try to quit smoking.

Two HHS agencies, CDC and SAMHSA, administer programs that focus 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,11 focuses on preventing and reducing tobacco use among
the general population, but it also explicitly targets tobacco use among
youth. NTCP provides funds through cooperative agreements to all states.12
In fiscal year 2002, NTCP provided about $58 million to states to address
NTCP's four goals.13 NTCP's four goals are to (1) prevent youth from
starting to smoke, (2) help youth and adults quit smoking, (3) minimize
the public's exposure to secondhand smoke, and (4) identify and mitigate
the factors that make some populations more likely to use tobacco than
others. NTCP cooperative agreements specify the terms under which federal
funds are provided to the states.

11In 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.

12In 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.

13In 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.

Under NTCP, CDC encourages states to use multiple types of interventions
in their efforts to prevent and reduce tobacco use. CDC has developed
guidance intended to assist states in designing, implementing, and
evaluating their individual tobacco control programs.14 For instance, CDC
recommends that states establish comprehensive tobacco control programs
that include certain components, such as

o  	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;

o  	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;

o  	marketing campaigns to counter protobacco influences and increase
prohealth messages and influences, including paid television, radio,
billboard, and print media campaigns;

o  cessation services to help people quit smoking;

o  	enforcement of tobacco control policies by restricting minors' access
to tobacco and restricting smoking in public places; and

o  	statewide efforts to provide localities with technical assistance on
how to evaluate tobacco programs, promote media advocacy, implement
smokefree 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

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

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

    Other Federal Programs 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

1542 U.S.C. S: 300x 26 (2002) Synar Amendment: 45 C.F.R. S: 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).

1642 U.S.C. S: 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, S: 214, 117 Stat. 11, 324.)

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

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

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

17This 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, S:401, 115 Stat.1425, 1734-1765 (classified to 20
U.S.C. S: 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.

18These 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.

19This program was authorized by the Drug-Free Communities Act of 1997,
Pub. L. No. 10520, S: 2, 111 Stat. 224, 226 (classified to 21 U.S.C. S:
1531(2000)).

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.20 In fiscal year 2002, NCI
funded more than 40 grants, totaling almost $30 million, for research on
ways to understand, prevent, reduce, and treat tobacco use among youth.
Similarly, NIH's National Institute on Drug Abuse (NIDA) supports research
on effective tobacco use prevention and reduction interventions for youth.
For example, NIDA established and funds a teen tobacco addiction treatment
research center to examine methods of eliminating dependence on nicotine
and assess the effectiveness of these strategies. The center is assessing
the safe use and effectiveness of nicotine patches and gum for
adolescents. According to NIDA, in fiscal year 2002, funding for its
research projects that focused on substance abuse, including tobacco use
among youth, totaled about $124 million.

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

20Other 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.

21The Robert Wood Johnson Foundation also provides funding for TTURCs.

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

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

Federal Activities Also Aim In addition to research, HHS and other federal
departments conduct a to Address Tobacco Use variety of tobacco-focused
activities that aim to prevent and reduce among Youth tobacco use among
youth. For example, officials from HHS, Education,

and other federal departments, along with experts from national
organizations and professional associations, developed guidance to help
schools identify and implement strategies for preventing tobacco use

22These 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.

23The Nation's Investment in Cancer Research for Fiscal Year 2003,
National Cancer Institute, National Institutes of Health
(http:/plan2003.cancer.gov/scipri/tobacco.htm).

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

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

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

24Centers 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.

25U.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).

26This program was developed by the Boys and Girls Club of America.

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

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

To monitor federal programs that aim to prevent and reduce tobacco use
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.27

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

27According to CDC officials, evaluations of state tobacco control
programs have been completed by Arizona, California, Florida, Maine,
Massachusetts, Mississippi, Oregon, and Texas.

28Goldie 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).

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 tobaccorelated risks.
According to DOJ officials, the information obtained from reports and site
visits is used to provide grantees with training and technical assistance.
DOJ is also overseeing a 5-year evaluation of the effectiveness of this
federal grant program. The evaluation, which is scheduled for completion
in 2004, is designed to take into consideration both the similarities and
differences among the coalitions and their communities and aims to assess
the effectiveness of the coalitions' efforts to reduce the use of tobacco,
alcohol, and illicit drugs among youth.

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

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

  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.30

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

30Other 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.

31Nonfederal 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.

32Center 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).

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.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 issues34 and serves as a forum for
committee members and the public to share information and discuss a
variety of tobacco-related issues and efforts. Committee meetings that
have specifically focused on tobacco use among youth have covered such

33Comprehensive Smoking Education Act of 1984, Pub. L. No. 98-474 S: 3, 98
Stat. 2200-2201 (classified to 15 U.S.C. S:1341(b) (2000)).

34As 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.

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
NCIand NIDA-supported TTURCs initiative, NCI led the creation of an
NIHwide 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

                                    Federal

Activity or departments project or agencies

Tobacco-Free CDC, NCI, Sports SAMHSA, and ONDCP

Entertainment CDC, NIDA Industry SAMHSA, and Outreach ONDCP

Description

An initiative that involves sports stars, sport leagues, and youth
organizations helping to deliver tobaccofree 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.

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.

Pathways to CDC and NCI A self-help guide intended to motivate and assist

Freedom 	African American adults and youth to stop smoking. The guide is
intended to prevent young children from developing the smoking behaviors
of their parents who use tobacco and to prevent exposure to secondhand
smoke.

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

                  Source: HHS agencies, Education, and ONDCP.

    HHS Officials Identified Several Challenges to Coordination within the
    Department

  Agency Comments

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.

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

                       Appendix I: Scope and Methodology

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

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

1The General Services Administration maintains this database.

2The scope of our work did not include programs that finance health
insurance such as Medicaid.

Appendix I: Scope and Methodology

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

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

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

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

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

Funding fiscal Targeted Grant program Program year 2002a Eligible
applicantsb beneficiaries description

                    Department of Health and Human Services

Centers for Disease Control and Prevention

National Tobacco Control $58,000,000 States General population 	To support
state tobacco control programs to prevent and reduce tobacco use,
including preventing youth from starting to smoke.

Tribal Support     $1,600,000 Tribes and    American     To support seven  
      Centers                        tribal                
                              organizations Indian/Alaskan tribal centers in  
                                               Natives     developing tobacco 
                                                            control programs  
                                                                   to         
                                                           prevent and reduce 
                                                                 tobacco use, 
                                                                    including 
                                                             preventing youth 
                                                                         from 
                                                           starting to smoke. 

Coordinated School       $11,000,000 State and local   To support school   
         Health          education Students in grades 9 
                             agencies through 12        health programs in    
                                                            discouraging      
                                                        unhealthy behaviors,  
                                                        such as poor eating   
                                                          habits, physical    
                                                              inactivity, and 
                                                                      tobacco 
                                                                use.          

Preventive Services Block  $408,450c States     General To carry out       
             Grant                              population public             
           to States                                       health activities, 
                                                                    including 
                                                                   preventing 
                                                            tobacco sales to  
                                                                minors.       

Health Resources and Services Administration

Healthy Schools, $19,500,000 Public and nonprofit

Healthy Communities 	private entities, including faith-based and
community-based organizations Students attending schools (kindergarten
through grade 12) that serve low-income or high-risk children To increase
access to comprehensive primary and preventive health care for underserved
children, adolescents, and their families, including tobacco prevention
and reduction programs.

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

Funding fiscal Targeted Grant program Program year 2002a Eligible
applicantsb beneficiaries description

Community Health  $1,077,578,000 Public and    People in   To develop and  
       Centers               nonprofit            medically  
                     private entities, including underserved operate          
                                                    areas    community        
                                 faith-based and              health centers  
                                                                   that       
                                                                      provide 
                                 community-based               preventive and 
                           organizations                     primary health   
                                                             care             
                                                              services, and   
                                                                   link       
                                                             clients with     
                                                             Medicaid         
                                                                   and mental 
                                                                   health and 
                                                             substance abuse  
                                                             treatment,       
                                                             including        
                                                             that for tobacco 
                                                             use.             

     Maternal and Child   $595,727,279  Pregnant women,     To maintain and   
           Health            States                       
    Services Block Grant                 mothers, infants  strengthen state   
         to States                                    and 
                                            children, and       leadership in 
                                                 children           planning, 
                                             with special     promoting,      
                                                   health 
                                          care needs,      coordinating, and  
                                       particularly those   evaluating health 
                                                       of                care 
                                               low-income services. Funds can 
                                                 families 
                                                          be used for tobacco 
                                                          prevention programs 
                                                            and activities.   

Substance Abuse and Mental Health Services Administration Synar Amendment
                    $5,448,273d States Children under age 18

To enable states to implement the Synar survey requirements to assess
state compliance and enforcement of tobacco access control laws that
prohibit the sale and distribution of tobacco products to individuals
under age 18.

       Substance Abuse     $1,725,000,000 States     General To provide       
       Prevention and                             population financial        
    Treatment Block Grant                                    assistance to    
                                                             states           
                                                             for the purpose  
                                                                    of        
                                                                    planning, 
                                                                carrying out, 
                                                              and evaluating  
                                                             activities to    
                                                             prevent          
                                                             and treat        
                                                             substance        
                                                             abuse, including 
                                                                        youth 
                                                               tobacco use.   

State Incentive Grants $58,480,885 States Adolescents 	To prevent and
reduce alcohol, tobacco, and illicit drug use by adolescents ages 12-17.

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

Funding fiscal Targeted Grant program Program year 2002a Eligible
applicantsb beneficiaries description

                            Department of Education

Office of Elementary and Secondary Education

Safe and Drug-Free Schools and $472,017,000 State departments Children and
youth

Communities: State Grants of education 	who are enrolled and attending
school (primarily kindergarten through grade 12) 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.

Governors 	Children and youth not To support programs normally served by
of drug use (including state or local tobacco) and violence educational
agencies, prevention. or populations that need special services or
additional resources (for example, youth in detention facilities and
runaway and homeless youth)

                              Multiagency programs

Drug-Free Communities      $46,000,000 Community Youth          To support 
          Support                        coalitions                coalitions 
      (DOJ and ONDCP)                                      engaged in efforts 
                                                                           to 
                                                                prevent youth 
                                                                     alcohol, 
                                                             tobacco, illicit 
                                                                        drug, 
                                                          and inhalant abuse. 

Drug Education for    $1,869,136 Community Youth ages     To support a     
       Youth (DOJ                  coalitions 9 to 12    
        and DOD)                                          multiphased program 
                                                         for 9- to            
                                                         12-year-olds         
                                                         to reduce risk       
                                                         factors              
                                                              that scientific 
                                                                     research 
                                                            has linked to     
                                                         adolescent substance 
                                                           abuse, including   
                                                         tobacco use, school  
                                                         failure,             
                                                         delinquency,         
                                                            and violence.     

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

Funding fiscal Targeted Grant program Program year 2002a Eligible
applicantsb beneficiaries description

Safe Schools/Healthy Students $171,588,449 Local education agencies
Preschool and school-To assist school

(Education, HHS and DOJ) in partnership with local age children, districts
in developing public mental health adolescents, and their comprehensive
authorities, and law families who are at services to promote enforcement
agencies risk of being involved healthy childhood in drug abuse, or
development and violence as prevent violence and perpetrators, victims,
alcohol and other drug or witnesses abuse, including tobacco use.

Sources: Agency program officials, agency documents, and the Catalog of
Federal Domestic Assistance.

aAll funding is amount appropriated or allocated.

bIn 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.

cTotal block grant funding for chronic disease programs was $49,601,321.

dState-reported planned expenditures for fiscal year 2002.

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

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

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.

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