Youth Tobacco Prevention - What Works? Sharon Barbour, MPH Regional Evaluation Specialist...
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Youth Tobacco Prevention - What Works? Sharon Barbour, MPH Regional Evaluation Specialist UW-Extension
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Youth Tobacco Prevention - What Works?
Sharon Barbour, MPHRegional Evaluation Specialist
UW-Extension
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Overview of session“What works” in general
Review of specific interventions and the amount of evidence supporting their effectiveness
Monitoring and Evaluation ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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 long-term difference.
Monitoring and Evaluation ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Effectiveness researchHow 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 ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Effectiveness overviewMost proof of effect:
TaxesMedia
Some proof of effect:Smoke free public placesSmoke free homes School-based programs IF…Ad bans and restrictions IF…
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Effectiveness overview, continued
Promising:Youth led movements/empowerment
Inconclusive research:Youth access restrictionsYouth possession penalties
Proof of no effect:Single events not tied to other program activitiesSchool-based curriculum that does not follow “best practices” (to be reviewed)
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Most Proof: Increase price
Increase price of tobacco productsYouth 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Most Proof: Increase priceThe 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Price: What you can doAssist 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 ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Price: What you can doContact Maureen Busalacchi at SmokeFree Wisconsin regarding the initiative [email protected] 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Policy ecology example:Clean indoor air - public
placesEffects:
For all: Change social normsFor all: Reduce environmental tobacco smoke exposureFor adults: Decrease consumption and increase cessationFor 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 ProgramUniversity 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 policiesFewer kids smoking
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Clean indoor air - public places: What you can do
Contact SmokeFree Wisconsin for assistance with working toward smoke-free 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 ProgramUniversity 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 ProgramUniversity 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: [email protected]
Monitoring and Evaluation ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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: [email protected]
Monitoring and Evaluation ProgramUniversity 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 programconnected to community initiatives
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
School-based curriculaMore 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Reasons why school-based programs have been historically
ineffectivePrograms “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 ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Curriculum Best PracticesPrograms 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Social influences, examples
EnvironmentalTobacco use in public places and home, advertising, peers
CulturalAcceptance and rates of smoking vary by cultural groups.
FamilialParents’ smoking status and attitudes
Monitoring and Evaluation ProgramUniversity 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-smokerCorrect 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 ProgramUniversity 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 continuingCurricula 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 ProgramUniversity 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 ProgramUniversity 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/tob-curric.htm
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Other recommended curricula and elements of comprehensive
school-based program
See “Resources for School Tobacco Programs: A Selected List”
Distributed by Wisconsin Department of Public Instruction, 2001
Monitoring and Evaluation ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Comprehensive school-based programs
CDC recommends strengthening school-based curriculum by using a multifaceted approach:
Tobacco-free policiesTeacher trainingParental involvementCessation servicesLink 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Promising: Empowerment/Youth-Led
MovementsMay help change social normEncourages activism in tobacco controlNo evaluative data yet: See American Legacy Foundation reports for updates on their evaluation efforts:
http://www.americanlegacy.org/
Monitoring and Evaluation ProgramUniversity 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 ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Inconclusive Youth access restrictions
Regulation of sellers & buyersRegulation of where & how soldRegulation of free product distribution
Youth possession penalties
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Proof of no effectSingle events not tied to program.
School-based curriculum that does not follow “best practices.
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
SummaryMost effective:
Cigarette price increasesMedia – counteradvertising
Probably effective:Enforced Smoke Free EnvironmentsEnforced ad bans and restrictionsComprehensive school-based programs
Promising:Youth-led movements
Monitoring and Evaluation ProgramUniversity of Wisconsin-Extension, Cooperative Extension
Copyright 2002
Summary, cont.Inconclusive
Youth access restrictionsYouth possession penalties
No effectSingle events not tied to programSchool-based curriculum that does not follow “best practices”
Monitoring and Evaluation ProgramUniversity 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 ProgramUniversity 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
JournalsTobacco ControlJournal of American Public Health Assoc.Pediatrics
