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. Some Federal Programs Only Address Tobacco Use

We identified two federal programs that focus only on tobacco use. The  first, CDC’s NTCP, focuses on preventing and reducing tobacco use  among the general population, but it also explicitly targets tobacco use  among youth. For instance, CDC  recommends that states establish comprehensive tobacco control  programs that include certain components, such as    community-based programs to reduce tobacco use that include a wide  range of prevention activities, such as engaging youth in developing and  implementing tobacco control interventions, conducting educational  programs for young people, parents, school personnel, and others, and  restricting access to tobacco products;    school programs to implement school health policies that consist of  tobacco-free policies, evidence-based curricula, teacher training, parental  involvement, cessation services, and links between school and other  community efforts and state media and educational campaigns;    marketing campaigns to counter protobacco influences and increase  prohealth messages and influences, including paid television, radio,  billboard, and print media campaigns;    cessation services to help people quit smoking;    enforcement of tobacco control policies by restricting minors’ access to  tobacco and restricting smoking in public places; and    statewide efforts to provide localities with technical assistance on how to  evaluate tobacco programs, promote media advocacy, implement smoke- free policies, and reduce minors’ access to tobacco. 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. 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. 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. Federal Departments and Agencies Collect a Variety of Information on Their Programs That Aim to Prevent Tobacco Use among Youth

To monitor federal programs that aim to prevent and reduce tobacco use  among youth, federal departments and agencies collect information on  how their programs are being implemented by grantees and the  effectiveness of grantees’ efforts in meeting national program goals. 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. They obtain this  information by various means, such as periodic reports and visits to  grantee sites. HHS agencies also coordinate on efforts to jointly support research on  tobacco use prevention and cessation. Agency Comments

We provided a draft of this report to HHS, DOD, DOJ, and Education for  comment. 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. 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. However, these officials did not cite any challenges  they had experienced with coordinating their tobacco-related efforts. 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). 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.
Why GAO Did This Study

Tobacco use is the leading cause of preventable death in the United States. The Centers for Disease Control and Prevention (CDC) reported that, on average, over 440,000 deaths and $76 billion in medical expenditures were attributable to cigarette smoking each year from 1995 through 1999. Reducing tobacco-related deaths and the incidence of disease, along with the associated costs, represents a significant public health challenge for the federal government. Most adults who use tobacco started using it between the ages of 10 and 18. According to a Surgeon General's report, if children and adolescents can be prevented from using tobacco products before they become adults, they are likely to remain tobacco-free for the rest of their lives. GAO was asked to provide information on federal efforts to prevent and reduce youth smoking. Specifically, this report describes (1) federal programs, research, and activities that aim to prevent and reduce tobacco use among youth, (2) the efforts of federal departments and agencies to monitor their programs, and (3) the coordination among federal departments and agencies in efforts to prevent and reduce tobacco use among youth.

What GAO Found

Some federal programs, research, and activities that aim to address tobacco use among youth focus only on tobacco while others aim to address tobacco use as part of broader efforts to address unhealthy behaviors such as substance abuse and violence. Two federal programs within the Department of Health and Human Services (HHS) focus only on tobacco use. CDC's National Tobacco Control Program (NTCP) focuses on preventing and reducing tobacco use among the general population and explicitly targets youth. The Substance Abuse and Mental Health Services Administration's program to oversee implementation of a provision of federal law, commonly referred as the Synar Amendment, focuses only on tobacco use among youth. The Synar Amendment requires states to enact and enforce laws prohibiting the sale of tobacco products to minors. In addition to these tobacco-focused programs, HHS, and the Departments of Defense (DOD), Justice (DOJ), and Education sponsor programs that include tobacco use as part of broader efforts to address unhealthy behaviors among youth, such as substance abuse and violence. For example, Education's Safe and Drug-Free Schools and Communities program is designed to prevent substance abuse and violence. HHS agencies, such as the National Institutes of Health, conduct research on tobacco use and nicotine addiction among youth and its health effects on youth. HHS agencies and other federal departments also support activities to prevent and reduce tobacco use among youth, such as education and outreach efforts. HHS and its component agencies coordinate tobacco-related efforts with other federal, state, and local government agencies and nongovernmental entities. Federal departments and agencies collect a variety of information to monitor how programs that aim to address tobacco use among youth are being implemented by grantees and the effectiveness of grantee efforts in meeting program goals. The information is collected through various means, including grant applications, progress reports, periodic site visits, and program evaluations. For example, to monitor NTCP, CDC requires states to submit biannual reports on the implementation of state NTCP-supported tobacco control programs. The information that federal departments and agencies collect on these programs is also used to provide training and technical assistance to grantees on topics such as conducting program evaluation. In commenting on a draft of this report, HHS stated that the report was very informative but it did not include programs like Medicaid that are a substantial element of HHS tobacco prevention efforts. Including programs that finance health insurance such as Medicaid, however, was beyond the scope of our review. Also, HHS noted that we did not include information about the challenges other federal agencies face in coordinating 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.