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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
Tobacco Use

Introduction

This toolkit summarizes content from the Tobacco Use Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

From the MCH Block Grant Guidance. Tobacco product use in any form is unsafe, and tobacco product use is typically established during adolescence. Tobacco product use in youths is associated with depression, anxiety, and stress.1 In 2022, 16.5% of high school students reported using any tobacco product, 14.1% reported using e-cigarettes.2 Youth who are more likely to use tobacco products include American Indian/Alaskan Native youth, those identifying as LGB or transgender, those reporting severe psychological distress, those with low family affluence, and those with low academic achievement.2

Goal. To reduce the percent of adolescents who currently use tobacco products.

Note. Access other related measures in this Population Domain through the Toolkits page.

Overview: Read a summary of the issue related to Title V

A primary goal of Healthy People 2030 is reducing current tobacco use and preventing increased tobacco use among adolescents with an emphasis on the negative long-term health impacts of tobacco use, both on the user and those around them.1 Tobacco use includes cigarettes, cigars, smokeless tobacco (e.g., chewing tobacco), electronic vapor products (EVPs) or vapes (e.g., e-cigarettes), hookahs, pipe tobacco, heated tobacco products, and nicotine pouches.2,3 Use of tobacco products in any form by youth is unsafe.3 Since 2014, e-cigarettes have been the most commonly used tobacco product among youth.3 E-cigarettes can contain harmful substances, including nicotine.1 Flavorings in tobacco products can make them more appealing to youth.3

Since tobacco use is primarily started and established during adolescence, preventing tobacco product use among youth is essential to decreasing overall tobacco use in adulthood.3,4 Smoking can cause immediate and long-term health problems in adolescents, including nicotine addiction, tobacco dependence, oral health problems, poor physical fitness, lung damage, early heart disease and cardiovascular issues, and many types of cancer.4,5,6 Tobacco use during adolescence is also associated with high-risk behaviors, such as substance use,7 depression and other mental health conditions,8 and lower educational attainment.9 Combating early tobacco initiation and use is paramount to preventing an estimated 5.6 million premature adolescent deaths that are projected from smoking-related disease.10,11 National, state, and local programs have been shown to reduce and prevent youth tobacco use when implemented together.3,4

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerator:

Number of adolescents in grades 9 through 12 who reported any use of tobacco products (including electronic vapor products, cigarettes, cigars, or smokeless tobacco) in the past 30 days

Denominator:

Number of adolescents in grades 9 through 12

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Tobacco Use (TU) Objective 04: Reduce current tobacco use in adolescents. (Baseline: 18.3% of students in grades 6 through 12 used cigarettes, e-cigarettes, cigars, smokeless tobacco, hookah, pipe tobacco, and/or bidis in the past 30 days in 2018, Target: 11.3%)

DATA SOURCES

Youth Risk Behavior Surveillance System (YRBSS)

MCH POPULATION DOMAIN

Adolescent Health

MEASURE DOMAIN

Health Behavior

Data Sources: Learn more about the issue and access the data directly

This NPM can be measured through data collected from the Youth Risk Behavior Surveillance System (YRBSS) and the National Youth Tobacco Survey (NYTS). According to data from the NYTS, current use of any tobacco product by high school students declined from 16.5% in 2022 to 12.6% in 2023.12,13 From 2022 to 2023, current e-cigarette use among high school students also declined from 14.1% to 10.0%.12,13

1. Accelerate with Evidence—Start with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous
 

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

One practice from state-/community-based programs is found in the Association of Maternal and Child Health Program’s (AMCHP’s) Innovation Hub: Tobacco Free Program (National, 2020). However, several national programs have emerged as promising approaches for advancing the NPM for specific communities or populations.

Key Findings and Emerging Issues: Read more from the literature

The following are key findings emerging from the literature:

  1. Anti-tobacco policies, including smoke-free school policies and under-21 tobacco purchasing bans, have been shown to decrease access to and use of tobacco for adolescents.29,30
  2. Smoke-free policies that target the use of smoke-emanating tobacco products in public spaces can decrease the likelihood of tobacco use by adolescents and shift norms against tobacco products in public spaces.31,32    
  3. A variety of approaches, including school-based prevention programs, clinic-based motivational interviewing programming, and peer-to-peer education programs are integral to effective tobacco prevention strategies.33,34
  4. Increased tobacco taxation and working with tobacco retailers to ensure legal compliance can be effective in decreasing adolescent perceived and actual access to tobacco products.35,36
  5. Increasing the variety of formats of educational and prevention programming to include multi-media modules, and mobile/board games provide new ways to engage with youth.37,38
  6. Multimodal media campaigns such as The Real Cost have been associated with lower intention to smoke, and lower likelihood of smoking participation or initiation.39,40

Research. Multiple strategies emerge as potential approaches to advance this NPM but haven’t been studied with enough rigor to be included in the evidence-based continuum. Additional research is needed to verify outcomes, but initial studies have shown the promise of these strategies in MCH settings:

  • Addressing the SDOH that contribute to tobacco use among adolescents, including socio-economic disparities, exposure to tobacco use, and targeted marketing to specific populations.41
  • Monitoring tobacco use trends among adolescents to inform the development of targeted interventions.42
  • Enacting graphic warning label requirements on tobacco products to deter adolescents from initiating or continuing tobacco use.43,44
  • Encouraging healthcare professionals to regularly screen adolescents for tobacco use to better provide brief counseling interventions, and referrals to appropriate resources.45

Research Gaps: Learn where more study is needed

Topical Area Knowledge Gaps. Lack of studies on:

  • Examining the impact of social and physical environment factors on tobacco initiation among adolescents.
  • Understanding the influence of new and diverse tobacco products on overall tobacco use patterns.
  • Investigating the relationship between tobacco use and other risk behaviors in adolescents.

Specific Intervention Research Gaps. Lack of studies on:

  • Developing tailored interventions for high-risk groups, including LGBTQIA+ youth and those with low academic achievement.
  • Evaluating the effectiveness of comprehensive tobacco control policies on students in grades 9-12.
  • Implementing multi-level interventions combining individual, school, community, and policy approaches.

Methodological Gaps. Lack of studies on:

  • Assessing the long-term impact of tobacco prevention programs on adolescent tobacco use.
  • Developing improved methods for measuring adolescent tobacco use, including e-cigarettes and newer products.

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

2. Think Upstream with Planning Tools—Lead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Title V agencies can use these approaches to help facilitate change in adolescent tobacco use:

Tobacco Education Programs. Title V can support youth tobacco prevention or cessation resources by:

  • Engaging with community partners to develop creative, engaging, and interactive educational programs for youth utilizing digital platforms.
  • Partnering with providers to expand access to tobacco cessation and prevention programs.

Limiting Access and Proximity. Title V can help limit access to and availability of tobacco products by:

  • Advocating for tobacco price increases and more limited tobacco-sale licensing laws.
Supporting universal clear-air policies and zoning laws to limit tobacco sales near schools. 10,16,28

SDOH and Health Equity Considerations: Identify ways to advance health for all

Social Determinants of Health (SDOH)

Initiation of tobacco use during adolescence is due to a wide variety of SDOH. Factors associated with youth tobacco product use include social and physical environment, lower socioeconomic status, accessibility, availability, and price of tobacco products, and seeing tobacco advertising or marketing in stores, on television, on the Internet, in movies, or in publications.3

Elevated availability of tobacco products in the built environment, such as the number of businesses selling tobacco products surrounding schools or parks, or on bus or walking routes, is associated with adolescent tobacco initiation.14 It is important to change the environmental context and ensure equal distribution of resources and services to eliminate tobacco-related disparities for youth.15

Strategies to help mitigate these factors and decrease adolescent tobacco use and initiation include:

  • Limiting or banning tobacco companies from advertising in businesses around schools or areas frequented by youth.
  • Expanding availability of tobacco-use cessation resources in primary care services.

Developing and utilizing tobacco education and prevention programs in which schools, parents, teachers, and the community are involved.4,14,16

Health Equity

Health equity is the fair and just opportunity for all people to be as healthy as possible, including the opportunity to be free from tobacco.14 This opportunity is not afforded to all people due to factors such as their race and ethnicity or where they live.14 Tobacco companies target specific historically marginalized groups, including racial and ethnic minority groups, such as Black/African American, Hispanic, American Indian and Alaska Native (AI/AN) populations, along with the LGBTQIA+ populations, and people in low-income communities. These companies utilize tactics such as academic scholarships, giveaways, and product placement in media or social media to appeal to younger potential clientele.14

Tobacco use disproportionately affects youth from communities that have historically experienced high levels of discrimination and stigma.17Data from the 2022 NYTS showed that current use of any tobacco product was higher among certain population groups, including non-Hispanic AI/AN students; those who identified as LGBTQIA+ or as transgender; those who reported severe psychological distress; those with low family affluence; and those with low academic achievement.12 Tobacco prevention and control strategies need to address the historical racism and anti-LGBTQIA+ practices embedded in targeted marketing of tobacco products, and prioritize groups that have received the least benefit from the progress in tobacco control to date.18

Special Considerations: Tease out ways to zoom in on populations of focus

Youth with Special Health Care Needs and Youth with Disabilities. Youth who experience chronic or acute respiratory illnesses are more likely than their peers to be negatively impacted by the environmental impact of tobacco use.10,19 Although the specific impact of exhaled vapor from smokeless tobacco products and e-cigarettes is not yet clear, increased respiratory inflammation and increased risk of cardiovascular disease are well documented.20,21 Evidence also shows increases in coughing and wheezing, and overall asthma exacerbation in adolescents with asthma.20,21 Further, e-cigarette use more than 5 times per month is associated with bronchitis and shortness of breath, which can compound with other chronic health conditions.22

Research has found that adolescents with disabilities have demonstrated higher instances of e-cigarette and tobacco use in relation to their peers without disabilities.23,24,25 In addition to screening for tobacco use and offering treatment options that appeal to adolescents, such as web-based smoking cessation programs, there is a need for education, prevention, and health promotion activities for adolescents who are considered more at risk for tobacco use.23,24,25,26  

 

3. Work Together with Implementation Tools—Move from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Key Resources

Decades of research show that the most effective youth tobacco use prevention strategies are comprehensive and include interventions at multiple levels.3,4,10,27 Effective public health approaches need to be extended to include e-cigarettes and other emerging tobacco products to combat the youth tobacco epidemic.17,27 The literature also discusses the importance of addressing the SDOH leading to adolescent tobacco initiation, such as decreasing the physical ability to purchase tobacco products or advocating for price-increasing policies to discourage adolescent tobacco purchasing.14,15

Search the Established Evidence database for peer-reviewed research articles related to strategies for reducing adolescent tobacco use.

Find field-based resources focused on reducing tobacco use relevant to Title V programs in the MCH Digital Library.

Additional Resources:

Implementation Resources: Use these field-generated resources to affect change

Practice. The following tools can be used to translate evidence to action to advance this NPM:

  • quitSTART App (SmokeFreeTeen). App for adolescent tobacco users seeking to quit by creating a structured plan, and providing tailored information.
  • Tobacco Prevention Toolkit (Stanford Medicine REACH Lab). These courses support educators and parents in teaching about tobacco prevention.

Partnership. The following organizations focus efforts on decreasing adolescent tobacco use:

  • Become an Ex. Mayo Clinic-supported set of anti-tobacco and smoking cessation advice, guides, and tools for all ages.
  • Truth Initiative. Provides educational resources, disseminates anti-tobacco research, and runs anti-tobacco media campaigns.

References

Introductory References: From the MCH Block Grant Guidance

1 Centers for Disease Control and Prevention. Youth and Tobacco Use. 2022 November 10. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
2Park-Lee E, Ren C, Cooper M, Cornelius M, Jamal A, Cullen KA. Tobacco Product Use Among Middle and High School Students - United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(45):1429-1435. Published 2022 Nov 11. doi:10.15585/mmwr.mm7145a1
https://www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7145a1-h.pdf

Toolkit References: From the Evidence Accelerator

1 Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives/tobacco-use
2 Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2023/2023_YRBS_National_HS_Questionnaire.pdf
3 Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
4 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012
5 Harvey, J., Chadi, N., Canadian Paediatric Society, & Adolescent Health Committee. (2016). Preventing smoking in children and adolescents: Recommendations for practice and policy. Paediatrics & child health, 21(4), 209-214.
6 Gill, K. & Barry, S. (2024 January). Why teen smoke and how to help them quit. Teen Smoking: Facts, Risks, and How to Help Teens Quit (healthline.com).
7 Cavazos‐Rehg, P. A., Krauss, M. J., Spitznagel, E. L., Grucza, R. A., & Bierut, L. J. (2014). Youth tobacco use type and associations with substance use disorders. Addiction, 109(8), 1371-1380.
8 Lechner, W. V., Janssen, T., Kahler, C. W., Audrain-McGovern, J., & Leventhal, A. M. (2017). Bi-directional associations of electronic and combustible cigarette use onset patterns with depressive symptoms in adolescents. Preventive medicine, 96, 73-78.
9 Bugbee, B. A., Beck, K. H., Fryer, C. S., & Arria, A. M. (2019). Substance use, academic performance, and academic engagement among high school seniors. Journal of school health, 89(2), 145-156.
10 National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2014.
11 Retrieved from https://www.lung.org/quit-smoking/smoking-facts/tobacco-use-among-children#:~:text=If%20current%20tobacco%20use%20patterns,from%20a%20smoking%2Drelated%20disease
12 Park-Lee, E., Ren, C., Cooper, M., Cornelius, M., Jamal, A., & Cullen, K. A. (2022). Tobacco Product Use Among Middle and High School Students - United States, 2022. MMWR. Morbidity and mortality weekly report, 71(45), 1429–1435. https://doi.org/10.15585/mmwr.mm7145a1
13 Birdsey, J., Cornelius, M., Jamal, A., Park-Lee, E., Cooper, M., Wang, J., Sawdey, M. D., Cullen, K. A., Neff, L. (2023). Tobacco Product Use Among US Middle and High School Students—National Youth Tobacco Survey, 2023. MMWR. Morbidity and Mortality Weekly Report, 72.
14 Retrieved from https://www.cdc.gov/tobacco/tobacco-features/health-equity.html
15 Brady, K. T. (2020). Social determinants of health and smoking cessation: a challenge. American Journal of Psychiatry, 177(11), 1029-1030.
16 Liu, J., Gaiha, S. M., & Halpern-Felsher, B. (2020). A Breath of Knowledge: Overview of Current Adolescent E-cigarette Prevention and Cessation Programs. Current addiction reports, 7(4), 520–532.
17 Jenssen, B. P., Walley, S. C., Boykan, R., Little Caldwell, A., Camenga, D., & SECTION ON NICOTINE AND TOBACCO PREVENTION AND TREATMENT, COMMITTEE ON SUBSTANCE USE AND PREVENTION Groner Judith A. MD, FAAP Marbin Jyothi N. MD, FAAP Mih Bryan MD, MPH, FAAP Rabinow Lily MD Blake Gregory H. MD Smith Karen S. Baumberger James D. MPP. (2023). Protecting children and adolescents from tobacco and nicotine. Pediatrics, 151(5), e2023061806.
18 Tobacco Education and Research Oversight Committee. Achieving Health Equity: Toward a Commercial Tobacco-Free California, 2021-2022. Sacramento, CA: Tobacco Education and Research Oversight Committee. 2021. Retrieved from https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/TEROC/MasterPlan/Overview.pdf
19 Thacher, J. D., Schultz, E. S., Hallberg, J., Hellberg, U., Kull, I., Thunqvist, P., Pershagen, G., Gustafsson, P. M., Melén, E., & Bergström, A. (2018). Tobacco smoke exposure in early life and adolescence in relation to lung function. The European respiratory journal, 51(6), 1702111.
20 Walley, S. C., Wilson, K. M., Winickoff, J. P., & Groner, J. (2019). A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL. Pediatrics, 143(6), e20182741.
21 Livingston, J. A., Chen, C. H., Kwon, M., & Park, E. (2022). Physical and mental health outcomes associated with adolescent E-cigarette use. Journal of pediatric nursing, 64, 1–17.
22 Chaffee, B. W., Barrington-Trimis, J., Liu, F., Wu, R., McConnell, R., Krishnan-Sarin, S., Leventhal, A. M., & Kong, G. (2021). E-cigarette use and adverse respiratory symptoms among adolescents and Young adults in the United States. Preventive medicine, 153, 106766.
23 Wells M. B. (2023). Tobacco Use in Adolescents With Disabilities: A Literature Review. Substance abuse: research and treatment, 17, 11782218231179599.
24 Nagarajan, V. D., & Okoli, C. T. (2016). A systematic review of tobacco use among adolescents with physical disabilities. Public health, 133, 107–115.
25 Senders, A., & Horner-Johnson, W. (2020). Disparities in E-Cigarette and Tobacco Use Among Adolescents With Disabilities. Preventing chronic disease, 17, E135.
26 Green, D. M., Lewis, H., & Vogt, S. (2020). Prevention of tobacco use in youth with disabilities: A video experimental model. J Public Health Issues Pract, 4, 168.
27 Retrieved from https://catch.org/wp-content/uploads/2021/05/SAMHSA-CATCH-My-Breath-Reducing-Vaping-Among-Youth-and-Young-Adults.pdf
28 Food and Drug Administration’s (FDA’s) Youth Tobacco Prevention Plan. Retrieved from: https://www.fda.gov/tobacco-products/youth-and-tobacco/fdas-youth-tobacco-prevention-plan
29 Chu, K. H., Matheny, S., Furek, A., Sidani, J., Radio, S., Miller, E., Valente, T., & Robertson, L. (2021). Identifying student opinion leaders to lead e-cigarette interventions: protocol for a randomized controlled pragmatic trial. Trials, 22(1), 31.
30 Mélard, N., Grard, A., Robert, P. O., Kuipers, M. A. G., Schreuders, M., Rimpelä, A. H., Leão, T., Hoffmann, L., Richter, M., Kunst, A. E., & Lorant, V. (2020). School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study. Preventive medicine, 138, 106142.
31 Cole, A. G., Aleyan, S., Qian, W., & Leatherdale, S. T. (2019). Assessing the strength of secondary school tobacco policies of schools in the COMPASS study and the association to student smoking behaviours. Canadian journal of public health = Revue canadienne de sante publique, 110(2), 236–243.
32 Rayens, M. K., McGeeney, T., Wiggins, A. T., Bucher, A., Ickes, M., Huntington-Moskos, L., Clark, P., & Hahn, E. J. (2022). Smoke-free Ordinances and Youth Tobacco Use in Kentucky. American journal of health promotion: AJHP, 36(4), 673–677.
33 Wilhelm, A. K., Kingsbury, J. H., Eisenberg, M. E., Shyne, M., Helgertz, S., & Borowsky, I. W. (2022). Local Tobacco 21 Policies are Associated With Lower Odds of Tobacco Use Among Adolescents. Nicotine & tobacco research, 24(4), 478–483.
34 Hollis, J. F., Polen, M. R., Whitlock, E. P., Lichtenstein, E., Mullooly, J. P., Velicer, W. F., & Redding, C. A. (2005). Teen reach: outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics, 115(4), 981–989.
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36 Azagba, S., Shan, L., & Latham, K. (2020). E-cigarette Retail Licensing Policy and E-cigarette Use Among Adolescents. The Journal of adolescent health, 66(1), 123–125.
37 Van Hurck, M. M., Nuyts, P. A. W., Monshouwer, K., Kunst, A. E., & Kuipers, M. A. G. (2019). Impact of removing point-of-sale tobacco displays on smoking behaviour among adolescents in Europe: a quasi-experimental study. Tobacco control, 28(4), 401–408.
38 Khalil, G. E., Wang, H., Calabro, K. S., Mitra, N., Shegog, R., & Prokhorov, A. V. (2017). From the Experience of Interactivity and Entertainment to Lower Intention to Smoke: A Randomized Controlled Trial and Path Analysis of a Web-Based Smoking Prevention Program for Adolescents. Journal of medical Internet research, 19(2), e44.
39 Scholten, H., Luijten, M., & Granic, I. (2019). A randomized controlled trial to test the effectiveness of a peer-based social mobile game intervention to reduce smoking in youth. Development and psychopathology, 31(5), 1923–1943.
40 Müssener, U., Linderoth, C., Thomas, K., & Bendtsen, M. (2020). mHealth smoking cessation intervention among high school students: 3-month primary outcome findings from a randomized controlled trial. PloS one, 15(3), e0229411.
41 Garrett, B. E., Dube, S. R., Babb, S., & McAfee, T. (2015). Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities. Nicotine & tobacco, 17(8), 892–897.
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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.