NCSL Chronic Disease Prevention and
Health Promotion Policy Program
Frequently Asked Questions
Return to Chronic Disease Prevention Menu Page or Physical Activity, Nutrition & Obesity Menu Page
For information: health-info@ncsl.org
National Conference of State Legislatures
7700 East First Place, Denver CO 80230
Phone: (303) 364-7700 Fax: (303) 364-7800
What are the current state cigarette excise taxes?
NCSL maintains a Web page with a map of state cigarette excise taxes. Please note that the date on this map is July 1, 2003. This map is periodically updated as states increase their excise tax.
What are states doing about vending machines in schools?
According to the Center for Disease Control and Prevention's School Health Policies and Programs Study 2000 (SHPPS), vending machines are available in nearly all high schools, about three quarters of middle schools and nearly half of elementary schools. The most common food items are soft drinks, high-fat salty snacks and high-fat baked goods, although pretzels, 100 percent fruit juice, and bottled water are becoming increasingly available.
For some general information about vending machines in schools, please go to NCSL's Web page on Physical Activity and Nutrition. If you scroll down to the Nutrition Publications and Resources table you will see two documents titled "Vending Machines and Competitive Foods in Schools" and "Nutrition and Obesity: An Issue Brief." The issue brief provides information about policy trends related to foods served in schools and vending machines. (Legislators and legislative staff can access this document for free online. Information about purchasing this document is available on the summary page.) Arkansas is currently the only state to pass legislation to ban all vending machines in elementary schools. California Senate Bill 677 was signed in September and prohibits beverages other than water, milk, 100 percent fruit juice, or fruit-based drinks that are composed of at least 50 percent fruit juice with no added sweeteners, on every elementary school campus beginning July 1, 2004. Also starting July 1, 2004, middle or junior high schools may only sell the following beverages from one-half hour before the start of the school day to one-half hour after the end of the school day:
- Fruit-based drinks that are composed of at least 50 percent fruit juice with no added sweeteners;
- Drinking water;
- Milk, including chocolate milk, soy milk, rice milk;
- Electrolyte replacement beverages that contain no more than 42 grams of added sweetener per 20 ounce serving.
The CDC has provided some strategies employed at the state, district and school levels to improve the nutritional quality of foods available in vending machines.
- Add more machines that feature healthful choices.
- Increase the number of healthful choices in existing machines.
- Market the more healthful choices.
- Ensure the more healthful choices are prominently and attractively displayed.
- Reduce the price of the more healthful choices and increase the price of less healthful choices.
- Decrease the number of less healthful choices in existing machines.
- Remove all less healthful choices.
- Remove all vending machines.
The National Soft Drink Association has information on its Web page about the role of soft drinks in a healthy diet. The Grocery Manufacturers of America has written a white paper on food and health.
What physical activity programs exist for schoolchildren?
According to the Division of Adolescent and School Health at the CDC, many federal agencies and national health and education associations recommend that all schools (K-12) should offer daily physical education for all students and after-school intramural activities and/or physical activity clubs for all interested students. In addition, elementary schools should offer daily recess for all students, and high schools should offer interscholastic sports for all interested students.
To read about policies related to physical education in schools, go to NCSL's Web page on Physical Activity and Nutrition. If you scroll down to the Physical Activity Publications and Resources table, you will see a document titled "Physical Education: An Issue Brief." (Legislators and legislative staff can access this document for free online. Information about purchasing this document is available on the summary page.)
Some other resources include:
What nutrition education programs exist for schoolchildren?
Approximately two-thirds of states require nutrition education to be taught as part of health education (School Health Policies and Programs Study, 2000). To satisfy this demand, a number of nutrition education programs exist, ranging from those in elementary schools to those in high schools. National Health Education Standards can be used to help develop nutrition education curricula or to select from among existing curricula. An additional consideration when developing or selecting curriculum is connecting the classroom and the food-service program in nutrition education. The importance of this connection was reinforced by a New York study in which elementary students ate more of new foods that were offered in the school lunch program when they received prior classroom experience with the new foods.
Nutrition education involves the promotion of healthful, sustainable food choices to improve the nutritional status of individuals and groups. The CDC's Adolescent and School Health program describes the characteristics of an ideal nutrition education program as follows.
- Nutrition education occurs from preschool through grade 12 as part of a sequential and comprehensive program.
- Students take nutrition as part of a separate health education course, and health teachings are reinforced in other subject areas.
- The activities are developmentally appropriate, culturally relevant and participatory and help students understand that decisions they make as individuals are influenced by their food environments.
- The program equips them with skills to change both unhealthy individual habits and unhealthy environments.
- It utilizes learning resources within the school, such as cafeteria and vending services, the school library, school personnel who serve as role models, school gardens, health services and food preparation facilities.
- It links learning to students' homes (for example, by using opportunities to reinforce media awareness and culinary skills and to capitalize on parent expertise).
- It links learning to communities (for example, by including field trips or activities from local grocery stores, restaurants and farms).
- Programs are evaluated and updated regularly.
- Staff involved in providing education programs have backgrounds that enable effective teaching or program delivery.
The CDC's "Guidelines for School Health Programs to Promote Lifelong Healthy Eating" elaborates on a number of these recommendations. The ongoing challenges in providing high-quality nutrition education include the need to balance it with other curricular needs; to provide teachers and other staff with the nutrition information and resources they require; and to provide meaningful, behavior-oriented classroom activities for students.
Examples of nutrition education programs include "Eat 5 to 9 a-day" programs that aim to increase fruit and vegetable intake of students (e.g., "5-a-day Power Plus" increased fruit and vegetable among elementary students and "Gimme 5" successfully increased fruit and vegetable intake among high school students using minimal classroom activity).
What are rates of overweight among children and adolescents and what steps are states taking to reduce its prevalence?
CDC data indicates that the prevalence of overweight among children and adolescents is 15 percent, which represents a three-fold increase from 30 years ago, when levels were stable at around 5 percent. Overall, no significant difference in prevalence exists between males and females, but differences do exist within demographic groups. Non-Hispanic blacks between the ages of 12 and 19 had the highest prevalence of overweight at 23.6 percent (females higher than males), closely followed by Mexican Americans at 23.4 percent (males higher than females). Effects of socioeconomic status (SES) indicate a gradient for white females, with higher SES associated with lower prevalence of overweight; the effects are less clear for other ethnic groups.
The basis for the definition of overweight, developed by the Centers for Disease Control and Prevention, is the Body Mass Index (BMI), a ratio of weight to height. Calculating overweight among children, who are still growing and gaining weight, is more complicated than for adults, so cut-off points for overweight, expressed as a percentile, increase with age. Children who are regarded at or above the 95th percentile of BMI for age are regarded as overweight (corresponding to an adult BMI of 30, which is classified as obesity), and children at or above the 85th percentile, but below the 95th percentile, are regarded as at risk of overweight (corresponding to an adult BMI of 25). The word obesity is not generally used with children and youth in an effort to reduce stigmatization. BMI and weight can be calculated at the following Web site: http://www.cdc.gov/nccdphp/dnpa/growthcharts/bmi_tools.htm.
During the past few years, numerous states have addressed the obesity epidemic in children through state legislation. The Health Promotion Program State Legislation and Statutes Database allows you to search bills and statutes on nutrition, obesity and physical activity. Another resource is NCSL's Health Policy Tracking Service's issue brief on Nutrition and Obesity, which describes policy trends related to the obesity epidemic. (Legislators and legislative staff can access this document for free online. Information about purchasing this document is available on the summary page.)
CDC supports coordinated school health programs (CSHPs) to reduce risk factors for chronic diseases (including obesity) such as poor eating habits, physical inactivity, and tobacco use in children. CDC currently funds 22 state education and health agencies to implement CSHP (Arkansas, Ca1ifornia, Colorado, Florida, Hawaii, Indiana, Kansas, Kentucky, Maine, Massachusetts, Michigan, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, West Virginia and Wisconsin).
CSHPs systematically support healthy children and youth through eight components: health education, nutrition services, physical education, health services, health promotion for staff, counseling and psychological services, a healthy school environment, and parent and community involvement. States that receive support for CSHPs are able to provide high-level staff in both education and health agencies to coordinate, implement and evaluate local school health programs. They also are able to establish training plans for health and education professionals at the local level to improve programs and policies.
Several states have implemented successful Coordinated School Health Programs.
West Virginia has adopted one of the strongest standards in the nation for school nutrition. The West Virginia Board of Education prohibits the sale or serving of the following foods at school:
- Chewing gum, flavored ice bars and candy bars.
- Food or drinks containing 40 percent or more sugar or other sweeteners by weight.
- Juice or juice products containing less than 20 percent real fruit or vegetable juice.
- Foods with more than eight grams of fat per one-ounce serving.
- Soft drinks (in elementary and middle schools only).
In addition to implementing these effective policies, the West Virginia Department of Education's Office of Healthy Schools collaborated with the Office of Child Nutrition and the West Virginia Nutrition Coalition to deliver a week-long nutrition symposium for school food service, health education, and school health services professionals.
The Rhode Island Department of Education partnered with Kids First, a community-based agency, to provide nutrition education in schools statewide. From May 1998 through September 2000, Rhode Island provided nutrition services and programs to more than 40,000 children and their parents, 2,100 teachers and 700 food service staff in more than 220 schools.
The Michigan Department of Community Health, the Michigan Department of Education and Kent County, in partnership with the Michigan State University Extension, supported schools in using CDC's School Health Index (SHI): Self-Assessment and Planning Guide to identify strengths and weaknesses of their school health policies and program and to target at least one priority area to improve during the 20022003 school year. Three evaluation activities were implemented to track the progress of 15 schools that received grants of $1,000 each to take part in this program.
Research has shown that carefully designed school health programs can improve health and education outcomes among large populations of young people. For example, a randomized, controlled field trial was conducted in California, Louisiana, Minnesota and Texas to evaluate an elementary school program called CATCH. This program focused on the environment, classroom curricula, and home programs for the primary prevention of cardiovascular disease through physical activity and nutrition programs for third through fifth grade students. The program resulted in decreased fat content in school lunches and significantly increased intensity of physical activity in physical education classes. A follow-up study found that behavioral differences between intervention and control students remained significant three years after the end of the intervention.
What is the smoking prevalence for my state and how does it compare to others?
The Centers for Disease Control and Prevention reports on state smoking prevalence through its State Tobacco Activities Tracking and Evaluation (STATE) system. This information is available by year and state. Data from the National Health Interview Survey indicate that smoking among adults has slowly but steadily declined since 1993; however, more than 20 percent of adults report current cigarette use. Among adolescents, smoking prevalence rates, which had steadily increased from 1991 to 1997, are declining. If tobacco use patterns do not decline more rapidly than current trends indicate, an estimated 6.4 million people who currently are age 18 or younger will die prematurely from a smoking-related disease.
How are states investing in tobacco control activities?
NCSL's Health Policy Tracking Service publishes a report analyzing the states' allocation of tobacco settlement revenue. The October 2003 publication reported that, " over the past four years, states have appropriated more than $17.3 billion in tobacco settlement revenue for health-related services and biomedical research. Additionally, smoking prevention efforts have reached historic levels as 46 states have appropriated $1.8 billion towards this effort -- four times more than the federal government has devoted to similar programs."
States' fiscal crises during the last several years have lead to many competing demands and priorities for state funds. As a result, 24 state tobacco control programs have lost their funding. CDC tracks how much states are spending on diseases attributable to smoking and how much states are investing in tobacco prevention programs. This information is available through CDC's State Tobacco Activities Tracking and Evaluation (STATE) system.
In CDC's Best Practices for Comprehensive Tobacco Control Programs, CDC recommends that states establish tobacco prevention and control programs that are comprehensive, sustainable, and accountable. Best Practices identified that the approximate annual costs to implement all the recommended program components would range from $7 to $20 per capita in smaller states (population under 3 million), $6 to $17 per capita in medium-sized states (population 3 million to 7 million) and $5 to $16 per capita in larger states (population over 7 million). In 2002, six states (Hawaii, Maine, Maryland, Minnesota, Mississippi and Ohio) met CDC's budgetary recommendations for a comprehensive tobacco control program.
How does an increase in cigarette excise taxes affect consumption and revenue?
According to the Centers for Disease Control and Prevention, increases in tobacco excise taxes reduce average cigarette consumption and overall prevalence of tobacco use by deterring smoking among youth and prompting cessation among adults and pregnant women. The generally accepted conclusion is that a 10 percent increase in price will reduce overall cigarette consumption by 3 percent to 5 percent. Youth, minorities and low-income smokers are two to three times more likely to quit or smoke less than other smokers in response to price increases.
Higher cigarette prices are effective in preventing youth (under age 17) from smoking and influencing young adults (between the ages of 17 and 24) to attempt to quit smoking. A 10 percent increase in the real price of cigarettes decreases the probability of youth smoking by approximately 6.5 percent and reduces overall consumption by 13 percent. A 10 percent increase in the real price of cigarettes increases the probability of cessation in young adults by approximately 3.4 percent. Studies suggest that increasing the price of smokeless tobacco products also would reduce the prevalence of smokeless tobacco use.
Lower income groups are more price sensitive, since cigarette purchases take up a larger portion of their income; therefore, CDC recommends that funding be dedicated to tobacco control programs that work with lower income communities to assist with cessation and prevention efforts. Every state that has significantly increased its cigarette taxes has significantly increased its tax revenue. This occurs despite lost sales caused by lower smoking prevalence and lower rates of cigarette consumption, and despite the related smoking declines and any associated increases in cigarette smuggling or other tax-avoidance sales.
NCSL's Health Policy Tracking Service's issue brief on State Tobacco Excise Taxes (non-members can read the summary and order a copy of this publication at (http://www.ncsl.org/programs/health/ttaxes1.htm) addresses the issue of tax-avoidance sales. "A Forrester Research report estimated that in 2005 states collectively will lose $1.4 billion in tax revenue as the sale of Internet tobacco reaches $5 billion. Officials in California estimate that the state lost $13 million from May 1999 through September 2001 due to noncompliance with the Jenkins Act. The Jenkins Act requires any person who sells and ships cigarettes across state lines to report the sale to the buyer's state tobacco tax administrator. The General Accounting Office (GAO) conducted and released the results of an August 2002 study on Internet cigarette sales and the enforcement of the Jenkins Act. The GAO report stated that none of the surveyed web sites posted information that indicated compliance with the Jenkins Act. In fact, 78 percent of the 147 surveyed web sites indicated that they did not comply with the Jenkins Act. A number of Internet vendors listed specific reasons for noncompliance, including protecting customers' privacy, freedom from taxation under the Internet Tax Freedom Act, and the sovereign nation status of Native American Vendors. However, the GAO concluded that the Internet Tax Freedom Act does not supersede the Jenkins Act and that the Jenkins Act does not exempt Native American vendors. State legislatures therefore have the authority to mandate payment of excise taxes on Internet sales."
What is the fiscal effect of smoking bans and restrictions in restaurants and gaming facilities?
An article from the November 4, 2002, issue of State Health Notes (to order a copy, call [303] 364-7812) discussed the economic issues associated with smoking bans. A tobacco industry-sponsored survey of 600 California restaurant owners to gauge the effects of the 1995 smoking ban found that 52 percent lost business, 6 percent gained business and the rest did not know. Of the 37 percent with favorable effects, 32 percent had outdoor seating and 57 percent had bar seating areas that at the time were exempted. Most affected were establishments that catered to smokers and had relatively small nonsmoking sections. The survey takers argued against comparing cities with smoking laws and those without unless such comparisons control for other factors that affect sales such as differences in tourism, weather, tax rates and employment growth, all of which could have an influence on business' profits.
Americans for Nonsmokers Rights says that surveys conducted by the tobacco industry often target restaurant owners, reflecting their perceptions of the effect of smoking restrictions, and are not supported up by hard data. For its part, the public health community suggests looking at restaurant sales tax receipts, typically from the state Board of Equalization or an equivalent state agency, to measure the effect of a smoking ban on sales. Researchers recommend that economic impact studies include tax data for several years before a law is enacted and for all quarters after enactment in order to account for a drop in sales that may simply be an annual downward trend at a specific time of the year. Other recommendations include comparing restaurant sales with total retail sales to provide an overview of a city's general economy and comparing sales to those in comparable cities in the area to suggest trends in the restaurant economy as a whole.
In November 2001, the California Department of Health Services published a case study evaluating the California smoke-free workplace act which included bars, taverns and gaming clubs. Because statewide data was not yet available, the case study addresses the economic effects of smoking bans by studying cities that had previously adopted smoke-free ordinances.
The Community Preventive Services Task Force strongly recommends smoking bans and restrictions (through policies, regulations and laws) as effective ways to reduce exposure to environmental tobacco smoke. Studies have found that moderate or extensive laws for clean indoor air are associated with a lower smoking prevalence and higher quit rates among smokers. Smoke-free environmental policies may also be associated with a reduction in the daily consumption of cigarettes. Prohibiting smoking in public places and workplaces increases public awareness of the negative health effects of smoking and reduces social acceptability of smoking. Although convened by the U.S. Department of Health and Human Services, the task force is an independent, decision-making body.
How are states using tobacco settlement funds?
NCSL's Health Policy Tracking Service recently released State Management and Allocations of Tobacco Settlement Revenues 2003. The report showed that during the past four years, states have appropriated more than $17.3 billion in tobacco settlement revenue for health-related services and biomedical research. In addition, smoking prevention efforts have reached historic levels as 46 states have appropriated $1.8 billion toward this effort--four times more than the federal government has devoted to similar programs. (Members can download a copy of the report at http://www.ncsl.org/programs/press/2003MSA.pdf, non-members can purchase the report by calling (202)624-3567.)
Do states penalize youth or vendors when youth are able to purchase tobacco products?
(Taken from HPTS' Issue Brief on Youth Access) During the past three years, an increasing number of state legislatures have proposed legislation to criminalize attempts by minors to purchase and possess tobacco products. These bills supplement existing prohibitions on sales to minors. States are addressing both parties to the transaction and are holding both parties accountable. Proponents of criminalizing the purchase and possession by minors assert that this policy adds an additional deterrent to adolescent smoking. The current rate of teenage smoking warrants further legislation. Critics of these bills contend it is the retailers' responsibility to screen customers and implement other measures to eliminate sales to minors. Therefore, legal responsibility and liability should remain with tobacco retailers.
During the 2003 legislative sessions, 22 state legislatures proposed legislation to prohibit the purchase or possession of tobacco by minors or to amend existing state statutes. The majority of the introduced legislation imposes monetary penalties for purchasing or possessing tobacco products. For instance, a Connecticut bill imposes a $50 fine for a first offense and no more than a $100 fine for subsequent offenses. Proposed legislation in the Indiana, Louisiana and Massachusetts legislatures run counter to this trend by proposing temporary revocation of the driver's licenses of minors who are convicted of possessing or purchasing tobacco products.
In addition, state legislatures in 15 states introduced legislation to make the purchase of tobacco by minors more difficult and to increase the applicable legal penalties. These state legislatures proposed legislation to prohibit the use of false identification by adolescents. This legislation is representative of a broader trend in state public policy that criminalizes attempts by minors to purchase tobacco products. State legislators have introduced similar legislation in prior sessions. However, a greater number of bills were enacted in previous sessions, which may indicate that the trend is decreasing.
(Members can access this document online at http://www.ncsl.org/legis/health/ya-03.pdf; non-members can call (202)624-3567 to purchase a copy of this report.)
Which states ban smoking in public places?
NCSL's Health Policy Tracking Service has an issue brief detailing laws and bills from the 2003 legislative session on public place smoking. (Members can access this document online at http://www.ncsl.org/legis/health/pps.pdf; non-members can call (202)624-3567 to purchase a copy of this report.)
The Americans for Nonsmokers' Rights' web page has a listing of municipalities and states that ban smoking in workplaces including restaurants; in workplaces excluding restaurants; and only in restaurants. (This Web page can be accessed at http://www.no-smoke.org/100ordlist.pdf.)
Do any states cover the treatment of morbid obesity, and how effective are these treatments?
In 1999, Georgia enacted a mandated offering law. The law requires every health benefit policy that provides major medical benefits to offer coverage for the treatment of morbid obesity.
In 2000, two states passed morbid obesity coverage laws requiring insurers to offer coverage for treatment.
Indiana requires the state to provide coverage under group insurance plans for public employees for nonexperimental, surgical treatment of morbid obesity. Insurers that issue an accident and sickness insurance policy and HMOs that provide coverage for basic health care services are reqyured to offer coverage for the treatment of morbid obesity.
Virginia requires insurers and state health plans to offer and make available coverage under any such policy, contract or plan for the treatment of morbid obesity through gastric bypass surgery or other methods recognized by the National Institutes of Health.
In 2001, Maryland enacted a law requiring insurers, nonprofit health service plans, HMOs and managed care organizations that provide individual and group policies to provide coverage for gastric bypass surgery or any other surgical method that is recognized or approved by NIH for the treatment of morbid obesity.
A morbid obesity mandate was not enacted in 2002 or 2003. Although Arkansas and Illinois do not have mandates for obesity treatment, they do not exempt treatment of obesity when certified by a physician as morbid obesity, i.e., at least two times normal body weight.
The Web site for the American Obesity Association reported the following statistics about the success of obesity surgery.
Effectiveness
Researchers have found greater weight loss in gastric bypass (93.3 pounds) compared to gastroplasty (67 pounds) after one year. Over two years, gastric bypass surgery patients have been shown to lose two-thirds of excess weight. The success rate for weight loss for Roux-en-Y Gastric Bypass (RGB) is 68 percent to 72 percent of excess body weight over a three-year period, and 75 percent for Biliopancreatic Diversion (BPD). After five years, the average excess weight loss from gastric bypass surgery ranges from 48 percent to 74 percent.
Which states levy taxes on soft drinks and snack foods?
NCSL's Health Promotion State Legislation and Statutes Database can help you find the states that levy taxes on soft drinks and snack foods. The database is located at http://www.ncsl.org/programs/health/pp/healthpromo.cfm.
In the box labeled "Issue Areas," click on Food Tax and then click on "Get Records" at the bottom of the page. This will create a list of laws related to taxes on foods and beverages.
Where can I find presentations from past NCSL Health Promotion Program meetings or sessions?
The Health Promotion Program has a number of presentations on its Web pages. The best place to start is on its Chronic Disease Prevention Menu page. On this page you will find links to most of the presentations at our Health Promotion Policy Institutes. From this Web page you can link to the Physical Activity and Nutrition and Obesity Menu page, where you will find presentations from the Obesity Roundtable at the 2003 NCSL Annual Meeting. Finally, the Heart Disease and Stroke Web page includes a presentation discussing policies on stroke prevention and treatment.
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