Smoking Prevention and Control Strategies for Youth

Investing in Youth Tobacco Control: A Review of Smoking Prevention and Control Strategies
Paula M Lantz, Peter D Jacobson, Kenneth E Warner, Jeffrey Wasserman, Harold A Pollack, Julie Berson and Alexis Ahlstrom
March 30, 2000 / Tobacco Control 2000;9:47-63


To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy.

Data sources
Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates.

Data synthesis
Interventions and policy approaches that have been assessed or evaluated were categorized using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories.

Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programs, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating "youth centered" tobacco prevention and control activities.


School-Based Prevention
Some educational programs have had positive short term effects on smoking behavior and tobacco-related attitudes among middle school students; however, program effects dissipate within 1-4 years. Programs that focus on the social influences to smoke (i.e. media, peer, family) and teach refusal skills tend to be the most effective especially when enhanced by an extensive community-based health education program. Guidelines issued by the National Cancer Institute and the Centers for Disease Control and Prevention (CDC) are still relevant. CDC's recommendations include:

(1) instruction should provide information on the social influences of and peer norms regarding tobacco use in addition to information on the short and long term physiologic consequences of smoking;
(2) program-specific training for teachers should be provided; and
(3) schools should develop and enforce tobacco free policies, to make sure programs are implemented in a setting with broad policy support.

Community Interventions
The results of a small number of controlled trials of community interventions attest to their ability to have an effect on youth smoking behavior. An important finding is that the effectiveness of school based programs appears to be enhanced when they are included in broad based community efforts in which parents, mass media, and community organizations are involved, and in which the social policy or social environment as well as individual knowledge, attitudes, and behaviors are targeted for change. Broad based community interventions alone are not sufficient to bring about a substantial and sustained decline in youth smoking. Community efforts likely need to be combined with stronger advocacy, taxation, media interventions, and policy formation and implementation.

Mass Media / Public Education
Mass media campaigns may have an effect on the attitudes and behaviors of youth regarding tobacco use, although the impact is difficult to evaluate and has not yet been demonstrated. The literature suggests that mass media interventions increase their chance of having an impact if the following conditions are met:

(1) the campaign strategies are based on sound social marketing principles;
(2) the effort is large and intense enough;
(3) target groups are carefully differentiated;
(4) messages for specific target groups are based on empirical findings regarding the needs and interests of the group; and
(5) the campaign is of sufficient duration.

Youth Access Restrictions
More evidence, in the form of controlled trials of interventions, is needed to support the intense growth of activity in the area of youth access restrictions. Youth access interventions can lead to a general reduction in illegal sales of cigarettes to minors. Whether this will translate into reduced and sustained reductions in youth tobacco use remains to be seen.

Tobacco Excise Taxes
The evidence on the degree to which teenagers are responsive to changes in cigarette prices is mixed, but the general consensus is that higher prices are an effective deterrent to youth smoking. Because cigarette price increases have been relatively small (under a dollar and, in many cases, just a few cents), it is difficult to predict with confidence the impact that a large price increase -- such as a dollar or more per pack -- would have on teenage cigarette consumption. The effects might be expected to be proportionately greater than those of a small tax increase.

Smoking Cessation
The impact of smoking cessation interventions among adolescents is not well understood. Given the cost effectiveness of smoking cessation interventions for adults, and the large number of addicted teenagers, research on programs tailored to youth should be a high priority.

Anti-Tobacco Advertising
There is no agreement on the best approach to media counter advertising, and states are using various models for their anti-tobacco advertisements. The current ads in California continue previous anti-industry messages. In a slightly different approach, Florida focuses on youths asking the industry to be truthful. Arizona offers the message that smoking is neither cool nor healthy, while Massachusetts concentrates on adverse health effects. It is too soon to tell whether the heightened awareness of these ads will lead to lower youth smoking rates.

Other Innovations
Other recent innovations in tobacco prevention and control include computer-based systems, peer-based interventions, penalties for possession and use, school policies, vendor penalties, clean indoor air laws, and interventions that focus on adolescent risk taking or problem behaviors. Little empirical support currently exists for the effectiveness of these approaches.

Invest in Program Evaluation
One possible explanation for the mixed results of programs for youth is inadequate program evaluation. One of the most significant barriers to implementing effective prevention programs is translating a successful, but small scale and tightly controlled, intervention to the community. Once the intervention has reached the community it is often assumed to be effective without further evaluation. The failure to evaluate youth prevention programs is a serious deficiency in being able to defend additional investments in youth tobacco control efforts. Many new innovations appear promising. However, they need rigorous program evaluation in order for us to understand better the magnitude of the effects, whether or not different groups of youth respond differently to the intervention, the costs involved, and the barriers and facilitators to program implementation.

The most obvious conclusion is that adolescent smoking prevention efforts have had mixed results. No one approach is likely to reverse that finding. Despite recent research and innovative prevention strategies, we cannot say that there are any new revelations about the effectiveness of these programs beyond the conclusions reached by the Surgeon General and the Institute of Medicine in 1994. As a result, advocating for a focus on youth smoking prevention and control is somewhat controversial. Some policy analysts have suggested that the focus of public policy should be to reduce teenage smoking initiation rates. Others have suggested that the focus on children will undermine the broader and likely more fruitful initiatives and programs needed to attack smoking and to promote cessation among adult habitual smokers.

Editorial Note
We concur with most conclusions reached in this review of the literature about the effectiveness of smoking prevention and control strategies for youth. Although promising strategies exist, we have much to learn if we hope to mount large-scale programs that effectively reduce the incidence and prevalence of tobacco use among youth. Unfortunately, agencies that run such programs often feel threatened by rigorous program evaluation and may try to bias evaluation results. When agencies conceal program implementation problems and exaggerate program effectiveness, they undermine the potential effectiveness of their programs, and they impede our ability to learn from our mistakes. Based upon our experiences in California, we would underscore the need for rigorous and INDEPENDENT program evaluation. In some instances, this may require having a different agency sponsor the evaluation than the one that is sponsoring the program.
[Joel Moskowitz, Center for Family & Community Health, School of Public Health, UC Berkeley]

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