2020-00819. Achieving Health Equity in the Advancement of Tobacco Control Practices To Prevent Initiation of Tobacco Use Among Youth and Young Adults, Eliminate Exposure to Secondhand Tobacco Product Emissions, and Identify and Eliminate Disparities ...

AGENCY:

Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS).

ACTION:

Request for information.

SUMMARY:

The Centers for Disease Control and Prevention (CDC) within the Department of Health and Human Services (HHS) leads comprehensive efforts to prevent the initiation of tobacco use among youth and young adults; eliminate exposure to secondhand tobacco product emissions (e.g., secondhand smoke and aerosol); help current smokers quit; and identify and eliminate tobacco-related disparities. From 2017 to late 2018, CDC solicited input from the public through a Federal Register Notice (FRN Docket Number: CDC-2017-0103); regarding these comprehensive prevention efforts. CDC has reviewed these comments, posted to www.regulations.gov,, and received helpful feedback. Now, CDC is seeking additional information to inform future activities that assist in achieving health equity in tobacco prevention and control by eliminating differences in tobacco use and dependency and exposure to secondhand tobacco product emissions (e.g., secondhand smoke and aerosol) among certain population groups.

DATES:

Electronic or written comments must be received by March 23, 2020.

ADDRESSES:

You may submit comments, identified by CDC-2020-0005 by any one of the following methods:

• Federal eRulemaking Portal: http://www.regulations.gov,, Please follow the directions on the site to submit comments; or
• Mail: Karena Sapsis, Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Hwy., Mail Stop S107-7, Atlanta, GA 30341.

Instructions: All information received in response to this notice must include the agency name and docket number (CDC-2020-0005). All relevant comments received will be posted without change to http://www.regulations.gov,, including any personal information provided.

FOR FURTHER INFORMATION CONTACT:

Karena Sapsis, Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Hwy., Mail Stop S107-7, Atlanta, GA 30341; Telephone [phone]; Email: [e-mail].

SUPPLEMENTARY INFORMATION:

Scope of Problem

Tobacco use is the leading cause of preventable disease, disability, and death in the United States (Ref. 1). Cigarette smoking alone causes more than 480,000 deaths each year, including more than 41,000 secondhand smoke related deaths, and costs the country over $300 billion annually in health care spending and lost productivity (Refs. 1 and 2). Cigarette smoking is causally linked to numerous types of cancer, respiratory and cardiovascular diseases, diabetes, eye disease, complications to pregnancy and reproduction, and compromises the immune system.

Tobacco product use among youth, irrespective of whether it is smoked, smokeless, or electronic, is also a public health concern (Ref. 3). In 2018, nearly 4.9 million United States middle and high school students currently used (≥1 day in past 30 days) at least one type of tobacco product, with e-cigarettes being the most commonly used tobacco product (Ref. 3). The use of e-cigarettes may also lead to future cigarette smoking among some youth (Ref. 4). In addition to e-cigarettes, youth also use several other types of tobacco products (e.g., cigarettes, flavored hookahs, smokeless tobacco, cigars, tobacco in pipes), and disparities in use of these products (e.g., menthol cigarette use among non-Hispanic blacks) exist across population groups (Ref. 5).

In addition to concerns regarding the safety of tobacco product use, exposure to secondhand tobacco product emissions (e.g., secondhand smoke and aerosol) can also be harmful. The U.S. Surgeon General has concluded that there is no risk-free level of secondhand smoke exposure; even brief exposure can be harmful to health (Refs. 6 and 7). During 2011-2012, about 58 million nonsmokers in the United States were exposed to secondhand smoke, and exposure remains higher among children, non-Hispanic blacks, those living in poverty, and those who rent their housing (Ref. 8).

Achieve Health Equity and Identify and Eliminate Tobacco-Related Disparities

Health Equity in tobacco prevention and control is an opportunity for all people to live a “healthy, tobacco-free life, regardless of their race or ethnicity, level of education, gender identity, sexual orientation, the job they have, the neighborhood they live in, or whether or not they have a disability” (Ref. 9). Advancing health equity is rooted in addressing social determinants of health, which are the conditions in which people are born, grow, live, work and age, and include the wider set of forces and systems shaping the conditions of daily life (Ref. 10). Although progress has been made in reducing tobacco use and dependency in the general population, tobacco use and dependency and exposure to tobacco product emissions (e.g., secondhand smoke and aerosol) is still higher among certain population groups (Ref. 9). Persistent disparities can affect populations on the basis of certain factors, including but not limited to: (Refs. 9, 11, and 12).

• Age
• Disability
• Educational attainment
• Geographic location (e.g., rural/urban)
• Income
• Mental health and substance abuse conditions
• Employment status
• Race/ethnicity
• Sex
• Sexual orientation and gender identity
• Veteran and military status
• Housing instability
• Incarceration status

Addressing the social and environmental factors that influence tobacco use and exposure to secondhand tobacco product emissions can advance equity in tobacco prevention and control, and reduce tobacco-related disparities among populations disproportionately impacted by tobacco use (Refs. 10 and 13). These efforts can help reduce the overall prevalence of tobacco use in addition to the prevalence of tobacco use within one or across several population groups.

Approach

Health equity is achieved when every person has the opportunity to attain his or her “highest level of health” and everyone is “valued equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities” (Ref. 14). CDC is seeking input to inform future activities to achieve health equity in the advancement of tobacco control practices to prevent initiation of tobacco use among youth and young adults; eliminate exposure to secondhand tobacco product emissions; and identify and eliminate tobacco-related disparities. The information gathered will be used to inform activities that support or are otherwise related to state tobacco control programming (e.g., mass media campaigns; cessation; recommending policies related to smoke-free and tobacco pricing) and collaborative work with national governmental and nongovernmental partners, who share CDC's goals to prevent initiation of tobacco use among youth and young adults; eliminate exposure to secondhand tobacco product emissions; and identify and eliminate tobacco-related disparities.

CDC is specifically interested in receiving information on the following issues:

(1) What evidence-based or well-evaluated approaches/strategies, specifically addressing the social determinants of health, are being used to advance health equity goals related to tobacco use, dependency, and exposure to secondhand tobacco product emissions (e.g., secondhand smoke and aerosol) in states, intra-state regions, counties, cities and/or communities/neighborhoods? Please provide the following information: (1) A description of indicated approaches/strategies; (2) where or from whom can CDC find additional information on identified approaches/strategies; and (3) the places (e.g., state, region, city name) and populations covered by any identified approaches/strategies.

(2) What logic models, indicators, and measurement tools have been used to evaluate the effectiveness and efficacy of health equity strategies implemented in states or intra-state regions, counties, cities, and/or communities/neighborhoods (process and outcomes), including but not limited to those regarding tobacco prevention and control? Please provide a description for each logic model, indicator and measurement tool identified, including where it has been utilized and how it can be accessed (e.g., publication reference, website address).

(3) What promising practices are working in states or intra-state regions, counties, cities, and/or communities/neighborhoods to advance health equity goals: (1) Related to tobacco use, dependency, and exposure to secondhand tobacco product emissions (e.g., secondhand smoke and aerosol); (2) specifically among population groups with the greatest burden of tobacco use, dependency and exposure to secondhand tobacco product emissions, or (3) both?

(4) What science, tools, or resources on health equity would be useful to enhance and sustain tobacco prevention and control efforts among different population groups?

(5) In addition to building workforce capacity, are there other ways through which CDC may support state and local health departments and their partners to advance health equity related to tobacco use, dependency, and secondhand tobacco product emissions?

(6) What partners and stakeholders might CDC seek to engage to advance tobacco related health equity? Please list partners in the following sectors whose work is related to or can affect tobacco use, dependency, and secondhand tobacco product emissions:

• Public health
• Business (e.g., Agriculture, Industry, Production, Manufacturing, Transport, Advertising)
• Healthcare
• Research/academic institutions
• Government
• Other

References

1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: 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, 2014.

2. Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine 2014; 48(3):326-33.

3. U.S. Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2016 [Accessed 2019 Sept 17].

4. National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi: https://doi.org/​10.17226/​24952.

5. Centers for Disease Control and Prevention. Flavored Tobacco Product Use Among Middle and High School Students—United States, 2014. Morbidity and Mortality Weekly Report. 2015; 64(38);1066-1070. [Accessed 2019 Sept 17].

6. Department of Health and Human Services. A Report of the Surgeon General: How Tobacco Smoke Causes Disease: What It Means to You. 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, 2010 [Accessed 2019 Sept 17].

7. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: 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, 2006 [Accessed 2019 Sept 17].

8. Centers for Disease Control and Prevention. Vital signs: disparities in nonsmokers' exposure to secondhand smoke-United States, 1999-2012. Morbidity and Mortality Weekly Report. 2015;64:103-108. [Accessed 2019 Sept 17].

9. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. 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, 2015.

10. World Health Organization. Social Determinants of Health. http://www.who.int/​social_​determinants/​en/​. [Accessed on September 26, 2019].

11. Centers for Disease Control and Prevention. Cigarette smoking—United States, 1965-2008. Morbidity and Mortality Weekly Report. 2011;60(01):109-3. [Accessed 2019 Sept 17].

12. King BA, Dube SR, Tynan MA. Current tobacco use among adults in the United States: findings from the National Adult Tobacco Survey. American Journal of Public Health 2012; 102(11):e93-e100. [Accessed 2019 Sept 17].

13. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014. 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, 2014 [Accessed 2019 Sept 17].

14. U.S. Department of Health and Human Services. National stakeholder strategy for achieving health equity. April 8, 2011. Available at: http://www.minorityhealth.hhs.gov/​npa/​templates/​content.aspx?​lvl=​1&​lvlid=​33&​ID=​286 [Accessed 2019 Sept17].

Dated: January 15, 2020.

Sandra Cashman,

Executive Secretary, Centers for Disease Control and Prevention.