Youth Tobacco Prevention What Works?
Sharon Barbour, MPH
Regional Evaluation Specialist
UW-Extension
Overview of session
“What works” in general
Review of specific interventions and the
amount of evidence supporting their
effectiveness
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
“Youth Prevention” defined
In this presentation, it includes:
Preventing youth smoking initiation.
Inhibiting progression from experimenter to addicted
smoker.
…and does not include:
Cessation efforts.
Reducing exposure to ETS.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Learning from what we
currently know…
Though evaluation research is still limited, enough
exists to provide guidance regarding “what works” in
youth tobacco control.
As information grows, recommendations may shift.
There is still some murkiness and contradiction.
Your evaluations help to inform “what works” for your
community & other communities. Keep it up!
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
What seems to work?
In general…
Youth prevention requires a comprehensive approach.
There is no “magic bullet.”
It requires a long-term commitment to inter-related
initiatives that consider:
Youth have many social arenas and influences inside and
outside of school.
Policy changes affect youth as well as adults.
Changing social norms regarding tobacco use can make a longterm difference.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
The good news…
Community coalitions are well-suited for
doing this type of work! You…
Are not tied to one issue, one approach,
or one organization.
Have many arms to reach into the
community.
Know your community.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Ok, but what do we do?
Consider…
Initiatives that have at least some proof
of effectiveness.
What you’re doing already.
Interests, experiences, connections,
strengths of coalition members.
What your community is ready for.
What will have greatest impact
considering your resources.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Effectiveness research
How did we determine the level of
effectiveness for the various
approaches?
Reviewed individual studies.
Reviewed analyses of multiple studies.
Reviewed recommendations of the Surgeon
General, CDC and others.
Interviewed state tobacco control experts.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Comprehensive approach key components appear to be:
Cigarette price increases.
Intensive media campaigns.
Strongly enforced tobacco advertising bans.
Strongly enforced bans on smoking in public
places.
School programs that include a curriculum based
on best practices & the social influences
approach.
“Effectiveness of Comprehensive Tobacco Control Programs in Reducing Teenage
Smoking: A Review.” Wakefield M, Chaloupka F, July 1999.
Surgeon General’s Report 2000, CDC’s Best Practices guidelines 1999
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Effectiveness overview
Most proof of effect:
Taxes
Media
Some proof of effect:
Smoke free public places
Smoke free homes
School-based programs IF…
Ad bans and restrictions IF…
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Effectiveness overview,
continued
Promising:
Youth led movements/empowerment
Inconclusive research:
Youth access restrictions
Youth possession penalties
Proof of no effect:
Single events not tied to other program activities
School-based curriculum that does not follow
“best practices” (to be reviewed)
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Most Proof: Increase price
Increase price of tobacco products
Youth are most sensitive to price increases
10% increase in price results in an
approximately 7% decrease in youth
smoking.
Guide to Community Preventive Services systematic
review, 2000. Also: Smokefree Wisconsin website
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Most Proof: Increase price
The price to smoking behavior
relationship is not linear. A 20%
increase in price may lead to closer to a
20% decrease in youth smoking.
David Ahrens, Program Manager, Monitoring and
Evaluation Program for Wisconsin Tobacco Control
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Price: What you can do
Assist SmokeFree Wisconsin’s “Wisconsin
Children’s Initiative” to increase excise tax by
85 cents.
This represents a 20% increase in cigarette
price and could translate to a 14-20%
decrease in youth smoking as well as funds
for health-related programs in Wisconsin.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Price: What you can do
Help build support in your community for the
Wisconsin Children’s Initiative.
Community Education (letters to editor, educate
policy makers, etc.)
Recruit endorsing organizations.
Your coalition can sign on as an endorsing
organization!
Note: WTCB funds cannot be used in support of the tax
increase.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Price: What you can do
Contact Maureen Busalacchi at SmokeFree
Wisconsin regarding the initiative at
mbusalacchi@smokefreewi.org
Ask her about upcoming speaker trainings.
See the SmokeFree Wisconsin web site:
http://www.smokefreewi.org/index.html
Click on the WI Children’s Initiative logo on the left side bar.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Increase Price:
Phillip Morris agrees!
“It is clear that price has a pronounced
effect on the smoking prevalence of
teenagers, and that the goals of
reducing teenage smoking and
balancing the budget would both be
served by increasing the excise tax on
cigarettes.” – Phillip Morris
- Phillip Morris Research Executive, PM document No.
20011255224, September 17, 1981.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Most proof: Mass media
“When combined with other actions,”
mass media campaigns can:
Reduce tobacco initiation.
Median decrease of initiation: 8%
Decrease consumption.
Median decrease of consumption: 15 packs per
capita per year
Increase cessation.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Mass media: What you can do
Use state media campaign messages to strengthen
your media and the state’s media efforts.
Use messages in your programs that have been
shown to “speak” to youth:
industry manipulation: youth as targets and pawns of ‘big
tobacco.’
Most youth actually do NOT smoke.
Less effective messages are:
short and long term health effects (most youth know these).
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Some proof: Clean indoor air public places
This strategy is proven to be effective in
changing adult smoking behavior.
Unfortunately, its effect on youth has
not been studied until very recently. It
appears that clean indoor air is a
powerful strategy for youth as well
as adults.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
“Policy Ecology”
Policy changes such as clean indoor air
policies often lead to multiple impacts.
This web of effects is a welcome
phenomena for those with few resources to
facilitate change!
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Policy ecology example:
Clean indoor air - public places
Effects:
For all: Change social norms
For all: Reduce environmental tobacco smoke
exposure
For adults: Decrease consumption and increase
cessation
For youth: One study - earlier stages of uptake
and less likely to be current smokers
-Wakefield MA. “Effect of restrictions on smoking at home, at school, and in
public places on teenage smoking: Cross sectional study.” British Medical
Journal. 2000:321(7257);333-338).
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Another web of effect
example…
Smoke free worksite policy leads to:
More quit attempts and fewer adults
smoking (= fewer models for youth)
More homes with smoking policies
Fewer kids smoking
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Clean indoor air - public places:
What you can do
Contact SmokeFree Wisconsin for
assistance with working toward smokefree environments.
608-268-2620
www.smokefreewi.org/ and click “what works”
“How to” info is also available at Americans
for Nonsmokers’ Rights: www.no-smoke.org
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Growing proof: Clean indoor
air – private homes
ONE study showed that teens living in homes
with smoking bans were less likely to move
through the early stages of smoking – even
when the parents were smokers. This effect
was stronger than the effect caused by bans
in public places.
-Wakefield MA. “Effect of restrictions on smoking at home, at
school, and in public places on teenage smoking: Cross sectional
study.” British Medical Journal. 2000:321(7257);333-338).
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Smoke-free homes: what you
can do
Contact American Lung Association of
Wisconsin to learn about the “Take it
Outside” program
Phone: (262) 703-4200
Email: amlung@lungwisconsin.org
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Smoke-free homes & pledges…
Issues to consider:
If you collect smoke-free homes pledges,
find out who is pledging – are they already
nonsmokers? How do you reach those
who smoke?
How can you foster community buy-in for
the program to increase its effectiveness?
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Clean indoor air & youth
cessation
An interesting note…
Teenagers who are told that
environmental tobacco smoke (ETS)
harms others are more than twice as
likely to quit smoking as teens who
are not told of the dangers of ETS.
Glantz s and P Jamieson. “Attitudes Toward Secondhand Smoke, Smoking, and Quitting
Among Young People,” Pediatrics 106(6): e82 (December 2000)
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Some proof: Ad bans and
restrictions…IF…
There is a complete BAN that is strongly
ENFORCED, it may reduce total tobacco
consumption by 6%. Note: Ad bans are currently
illegal.
Youth-specific estimates appear to be quite small.
Partial bans are likely ineffective as they allow
industry to shift ad dollars to other forms of
promotion.
The research is very mixed.
- Jacobson PD, P Lantz, K Warner, J Wasserman, H Pollack, A Ahlstrom.
Combating Teen Smoking: Research and Policy Strategies. University of
Michigan Press, 2001. 158-9.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Ad bans and restrictions:
What you can do
Consider participating in “Community
Ad Watch” and inventory tobacco ads in
your community. It’s a good way to
monitor the industry, involve youth and
educate and mobilize your community.
Contact: Erich Mussak at UW
Comprehensive Cancer Center for a manual
and info: mussak@uwccc.wisc.edu
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Some proof: School-based
curriculum IF…
You follow “best practices” guidelines
Are most effective when they are:
part of comprehensive school program
connected to community initiatives
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
School-based curricula
More details follow regarding school-based
initiatives because today’s topic is youth,
most coalitions are already doing this work,
and schools are an important part of a
comprehensive tobacco control program.
However, remember that school-based
initiatives alone are not as effective as some
other approaches. In fact, they have been
historically ineffective.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Reasons why school-based programs
have been historically ineffective
Programs “that work” are not necessarily the
most used and not taught as designed.
There is a shortage of “linking agents:
persons or groups that have a strong
incentive for maintaining a program and
promoting its continuation”
-US Department of Health and Human Services. Reducing Tobacco
Use: A Report of the Surgeon General. Office on Smoking and
Health, 2000, p. 84.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Reasons why school-based programs
have been historically ineffective
Youth operate in a “larger classroom” outside
of school which has powerful spheres of
influence.
Curriculum may impact those at the lowest
risk of becoming addicted smokers.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Curriculum Best Practices
Programs based on the social influences
model are most effective.
The main goal of the model is to “equip
younger adolescents with specific skills and
other resources that would help them resist
direct and indirect social influences to try
smoking…”
-US Department of Health and Human Services.
Reducing Tobacco Use: A
Report of the Surgeon General. Office on Smoking and Health, 2000.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Social influences, examples
Environmental
Tobacco use in public places and home,
advertising, peers
Cultural
Acceptance and rates of smoking vary by
cultural groups.
Familial
Parents’ smoking status and attitudes
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Social influences model Include four areas of learning:
Emphasize the short term effects of
smoking (yellow teeth, bad breath) &
advantages of remaining non-smoker
Correct misperceptions: Most importantly,
teach that most teens do not smoke.
Discuss social influences on decision to
smoke.
Provide training in refusal skills.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Also important for
effectiveness…
Number of contacts the program makes
The use of booster sessions, even
telephone contacts seem to help sustain
the effect on smoking initiation.
Starting early and continuing
Curricula often begin in the 6th or 7th
grade. It is important to continue contacts
through high school, even if only with
booster sessions.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Two “Programs that Work”
CDC’s “Programs that work” initiative
highlights two school-based programs:
Project Toward No Tobacco Use (Project
TNT)
Life Skills Training (LST)
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
For more info…
Go to CDC site for more on curriculum
and evaluation findings for both
programs:
http://www.cdc.gov/nccdphp/dash/rtc/tobcurric.htm
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Other recommended curricula and
elements of comprehensive schoolbased program
See “Resources for School Tobacco
Programs: A Selected List”
Distributed by Wisconsin Department of
Public Instruction, 2001
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
What about Teens Against
Tobacco Use (TATU)?
TATU seems to be very popular.
However, there is no evaluative data
on its effectiveness.
Content and implementation varies.
In order to increase its
effectiveness, incorporate best
practices.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Comprehensive school-based
programs
CDC recommends strengthening school-based
curriculum by using a multifaceted approach:
Tobacco-free policies
Teacher training
Parental involvement
Cessation services
Link to community coalition work and statewide
counteradvertising campaigns
-
Centers for Disease Control and Prevention (CDC). Best Practices for
Comprehensive Tobacco Control Programs. August, 1999.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
School programs: what you
can do
Your most effective role is to work with
schools as change agents, not as direct
student educators. That is, help schools
choose curricula that follow best practices or
modify existing curricula. Help them expand
their programs to be more comprehensive.
Acting as direct student educators is probably
not an effective role for coalitions.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
What you can do, con’t.
Link school-based programs to other
community tobacco control activities.
Why? Because even successful school-based
programs may not be effective in the long run
beyond delaying smoking initiation. This is
likely because of the cumulative influences
outside of school. Thus, keep working at the
community level and tie that work with the
schools or youth in general.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Where is Philip Morris on this one?
The tobacco industry has generally
been supportive of school programs.
Why? According to PM: ‘anti-smoking
attitudes the [children] have learned in
school and elsewhere can be unlearned
or replaced by pro-smoking norms held
by others their own age or a little older.’
– Phillip Morris document
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Promising: Empowerment/YouthLed Movements
May help change social norm
Encourages activism in tobacco control
No evaluative data yet: See American
Legacy Foundation reports for updates
on their evaluation efforts:
http://www.americanlegacy.org/
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
What we do know..
We don’t know how effective youth-led
initiatives are but we do know that
including youth in your planning and
implementation will make your
programs more appropriate for your
target audience: youth!
Youth can add credibility, insight and
energy!
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Inconclusive
Youth access restrictions
Regulation of sellers & buyers
Regulation of where & how sold
Regulation of free product distribution
Youth possession penalties
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Proof of no effect
Single events not tied to program.
School-based curriculum that does not
follow “best practices.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Summary
Most effective:
Cigarette price increases
Media – counteradvertising
Probably effective:
Enforced Smoke Free Environments
Enforced ad bans and restrictions
Comprehensive school-based programs
Promising:
Youth-led movements
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Summary, cont.
Inconclusive
Youth access restrictions
Youth possession penalties
No effect
Single events not tied to program
School-based curriculum that does not
follow “best practices”
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Phillip Morris (mostly) agrees again!
“It is said…that three things threaten
our tobacco business: Taxation,
Marketing Freedoms and ETS.”
-
1993 Phillip Morris Document Bates #2022977856
Note: Quote made before initiation of intensive
counteradvertising campaigns.
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002
What you can do - stay
informed…
The Community Guide (CDC)
Reviews of youth access restrictions, school-based
initiatives, and tobacco industry & product
restrictions slated for summer 2002.
http://www.thecommunityguide.org/home_f.html
Journals
Tobacco Control
Journal of American Public Health Assoc.
Pediatrics
Monitoring and Evaluation Program
University of Wisconsin-Extension, Cooperative Extension
Copyright 2002