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Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Research has shown that second-hand smoke also affects non-users, causing thousands of cancer and heart disease deaths every year. Great strides have been made in lowering cigarette use and initiation, but new, novel tobacco products continue to flood the market. While fewer kids are smoking cigarettes, experimentation with other tobacco products are on the rise. Vaping is the new frontier in the war on tobacco, with recent polls showing that an estimated 10% of adults now using these products. According to the Centers for Disease Control and Prevention (CDC),  tobacco use costs the United States approximately $170 billion in direct medical costs and $156 billion in lost productivity every year.

Policy levers, such as minimum age restrictions and pricing requirements, are effectively curbing tobacco initiation. Clean air laws have become fairly common place, but holes exist. Newer innovations in the tobacco control fight include local regulations of e-cigarettes, as well as attempts to pass Tobacco 21 laws, where the legal minimum sales age is adjusted to 21. In major cities across the country, advocates have worked with local leaders to address tobacco use in Major League Baseball (MLB) stadiums. At the start of the 2017 season, nearly half of the MLB stadiums are tobacco-free, including some located in several BCHC member cities.

Learn what The Big Cities Health Coalition and its members are doing to address the issue



Preventing young people from ever starting the habit is critical to maintaining declines in tobacco use. According to the National Survey on Drug Use and Health, 95 percent of adult smokers started before the age of 21, and 80 percent first tried smoking before 18. A report by the National Academy of Medicine, found that raising the tobacco sale age to 21 nationwide would reduce adult smoking by about 12 percent by the time today’s teenagers are adults. 


In June of 2009, the Tobacco Control Act was signed into law, giving FDA the authority to regulate the “manufacture, distribution, and marketing” of tobacco products. It included specific and stringent restrictions on sales to minors, particularly related to “traditional” tobacco products, such as cigarettes. Localities across the country, however, are working to further raise the minimum legal age of sale to 21. So-called Tobacco-21 laws are now in more than 200 localities and two states as of May 2017.

For further information on Tobacco 21, please see the CityHealth Project's Tobacco 21 Policies and visit the Tobacco Control Legal Consortium website. 

PRICING STRATEGIES                      

State and local taxes affect the overall price of cigarettes and contribute to prevention. Pricing strategies go hand-in-hand with minimum age laws in preventing youth initiation. According to research from the Campaign for Tobacco Free Kids, Chicago is leading the effort of heavily taxing tobacco products with $6.18 per pack tax, with New York City not far behind at $5.85 a pack tax. Raising tobacco product prices effectively lowers demand and can also reduce  disparities in tobacco use related to race, ethnicity and income. According to the Guide to Community Preventive Services, a 20 percent increase in the unit price of tobacco products would lower consumption by more than 10 percent. More details on effective pricing strategies can be found through CDC's HI-5 Tobacco initiative. 


In the ever-evolving tobacco market, new products, such as e-cigarettes, are being marketed to particularly appeal to youth, with devastating results. These products threaten to undermine progress made in reducing tobacco use.  E-cigarette use among high school students increased dramatically "from 1.5 percent in 2011 to 16 percent in 2015 (a more than 900 percent increase)", and poisonings involving e-cigarettes and liquid nicotine have also increased. The creation of new federal regulations represent an important step in addressing this public health threat. The Food and Drug Administration (FDA) finalized a rule in August 2016 to extend its regulatory authority to all tobacco products, including e-cigarettes. Health warnings will now be required on all newly regulated tobacco products and free samples will be banned. In addition, the rule prohibits the sale of e-cigarettes and other new, regulated tobacco products to minors and will require photo ID verification at purchase. The FDA will also have the authority to evaluate the ingredients, product design, and health risks of these tobacco products. This is an important step: while many local health departments have taken action to curb sales and use of e-cigarettes, not all localities have sufficient regulatory authority. It is important to remember that FDA regulation of these tobacco products does not mean they have been deemed safe to use. 

In addition to the FDA regulation, a number of cities are regulating the use and sale of e-cigarettes. Regulating flavored tobacco products, including those used in vaping, and ensuring other tobacco products are taxed equally with cigarettes are additional policy levers. More information, along with a model ordinance, can be found in the Tobacco Control Legal Consortium’s March 2017 publication, Regulating Electronic Cigarettes & Similar Devices.



Mass media campaigns come in a variety of mediums and are designed to educate a large portion of the public about health risks. The Community Preventive Services Task Force finds mass media campaigns to have “strong evidence of effectiveness” to decrease initiation and use. Campaigns can be national in nature, such as CDC’s Tips From Former Smokers, The U.S. Department of Health and Human Services' The Real Cost or the National Institute of Health’s Smoke-Free Teen campaign. These initiatives can also be spearheaded by local health leaders, as is the case in New York City. The most effective campaigns are not only “hard hitting,” but also offer information to help people seek treatment and quit smoking. More details can be found on the CDC's HI-5 Tobacco page.


Smoke-free policies are generally said to be “comprehensive” if they ban smoking in all indoor areas of public places (see Guide to Community Preventive Services), though there are differing definitions of such laws. Some localities, for example, allow smoking in bars, while not in restaurants, and often, these decisions are made based on the authority a local body, such a Board of Health, might possess.

The CityHealth project examined a number of policies affecting health, and rated clean indoor air policies in public places, including restaurants and bars across the largest 40 cities in the country. A number of BCHC member cities achieved a “gold medal,” in this area. It is important to note that many jurisdictions are preempted or limited by state statute from locally implementing clean air (or other) laws, while some localities benefit from having strong state statutes.

According to research compiled by the CDC’s HI-5 INITIATIVE, comprehensive clean air policies have been shown to not only affect the health of those in the community, but also change social norms regarding tobacco use. Some research shows that clean air policies have real economic implications, while a number of studies have found that smoke free policies do not affect commerce in restaurants, bars, or other such establishments.

In recent years, many localities and states have been contemplating clean outdoor air laws that regulate use of tobacco products at beaches, parks, restaurant/bar patios, transit platforms, and elsewhere.

CESSATION -  Helping Those Users Quit

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Quitting smoking has immediate and long term benefits for the user's health and financial standing,  as well as the health of those around them. According to the CDC, covering evidence-based, comprehensive cessation treatment with little to no out-of-pocket costs for the consumer would decrease tobacco use and medical bills. The agency's 6|18 Initiative outlines relatively simple steps payers and providers (including Medicaid) can take to impact the public's health with regard to tobacco.  Largely due to the Affordable Care Act, as of June 2015, Medicaid programs in 30 states covered all seven FDA-approved cessation medications with little or no copayment. A CDC review found that in eight out of 10 studies, the return on investment of such comprehensive coverage outweighed the cost within 10 years.



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Note: These are highlights of selected activities going on in cities across the country, and are not meant to be comprehensive.