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.
Conclusion
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.
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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]