Tobacco Control for Youth: Recent Findings and Recommendations

1. Tobacco Control for Youth: Recent Findings and Recommendations Brian R. Flay, D.Phil. Department of Public Health Prepared for TERN meeting, La Jolla, November 19, 2009

2. Outline • I. Background on Adolescent Tobacco Use • II. Industry Anti-tobacco Campaigns • III. State and National Campaigns • State campaigns (including Oregon) • The ‘truth” campaign • ONDCP campaigns • IV. Youth-Focused Prevention Programs • School-based • Do/Can they work? What works? • School plus media or community • Comprehensive programs

3. I’ll highlight some recommendations from the IOM 2007 Report -Some will re-appear in 2010 SGR

4. Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – U. S. 1900-2004 1st World Conference on Smoking and Health Broadcast Ad Ban 1st Surgeon General’s Report 1st Great American Smoke-out End of WW II OTC Nicotine Medications Fairness Doctrine Messages on TV and Radio Master Settlement Agreement 1st Smoking-Cancer Concern Non-Smokers Rights Movement Begins Surgeon General’s Report on ETS Federal Cigarette Tax Doubles Great Depression Source: United States Department of Agriculture

5. Trends in Cigarette Smoking Anytime in the Past 30 days by Grade in School – United States, 1975-2008 12th Grade 10th Grade 20.4% in 2008 8th Grade 12.3% in 2008 6.8% in 2008 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

6. Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Race – United States, 1977-2008 White Hispanic Black Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys; for racial subgroups, data for the current year and the previous year are combined

7. Trends in cigarette smoking* by age - United States, 1965-2008 *Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days. Source: various National Health Interview Surveys from 1965 - 2002, National Center for Health Statistics What about 18-24 year-olds?

8. II. Industry Anti-Tobacco Campaigns

9. Brown & Williamson on Nicotine…. “Moreover, nicotine is addictive… We are, then, in the business of selling nicotine, an addictive drug….” Addison Yeaman; General Counsel to the Brown & Williamson Tobacco Company; July 17, 1963. Source: U.S. Food and Drug Administration, 1996.

10. Philip Morris on Nicotine…. “Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke.” Dr. William Dunn; Philip Morris Tobacco Company, 1972. Source: U.S. Food and Drug Administration, 1996.

11. R. J. Reynolds chimes in…. “In a sense, the tobacco industry may be thought of as being a specialized, highly ritualized, and stylized segment of the pharmaceutical industry. Tobacco products uniquely contain and deliver nicotine, a potent drug with a variety of physiological effects.” Claude Teague, R.J. Reynolds Tobacco Company, 1972. Source: U.S. Food and Drug Administration, 1996.

12. Domestic Cigarette Advertising and Promotional Expenditures for 1980-2003

13. Tobacco industry counter advertising campaigns • Philip Morris, Dec 98, $100M • Theme: Youths do not need to smoke to fit in socially with their peers • “Think. Don’t Smoke.” • Lorillard, Jan 2003, $13M • “Tobacco is Whacko if You’re a Teen” • Philip Morris, July 99, targeted parents • “Talk. They’ll Listen.”

14. Industry counter ads do not work – and may do damage • Wakefield et al., AJPH 2006 • Methods • Linked Neilson data on media exposure by youth in 75 major media markets with Monitoring the Future survey data on youth smoking (1999-2002) • 0ver 103,000 youth, 36% grade 8, 64% grades 10 or 12 • 20.8% had smoked in last 30 days, average of 5.43 cigarettes per day • Average exposure = 4.77 youth-targeted and 1.13 parent-targeted ads • Analyses • Regression analyses adjusting for sample weighting, clustering of students within schools, exposure to other campaigns, overall television viewing, and demographic variables

15. Industry counter ads do not work – and may do damage • Wakefield et al., 2006 (continued) • Findings • Covariates had expected effects • E.g., High prices and stronger smoke-free laws associated with lower levels of smoking • Industry counter ads targeting youth do not work • Near-zero association with smoking levels • However, for grade 8 students, we observed a negative effect -- exposure led to stronger intentions to smoke (OR = 1.04) • Industry counter ads targeting parents have negative effects for high school students • Decreased perceived risk (OR = .93) • Increased intentions (OR = 1.12) and • Increased chances of smoking (OR = 1.12) • Results for grade 8 students in same direction, but smaller. • Youth are likely to resist messages from authority figures or industry that enlist their parents • The “forbidden fruit” phenomenon

16. IOM 2007 Report “Ending the Tobacco Problem”Recommendation 36 • Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. • If a tobacco company wishes to support youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing and evaluating the program.

17. III. State and National Campaigns • State-sponsored campaigns • The Oregon campaign • The “truth” campaign • ONDCP campaigns • Conclusions re campaigns

18. State-Sponsored Campaigns Have Positive Effects • Emory et al., Archives of Ped and Adol Med, 2005 • Similar methods to Wakefield et al (2006), focusing on exposure to state-sponsored counter ads • By 2002, 35 states had launched anti-tobacco media campaigns • 1999-2000 Neilson and MTF data used • Almost 20,000 8th graders • About 16,000 each of 10th and 12th graders • Results • Average exposure 5.32 pharmaceutical ads, 7.16 tobacco company ads, 0.79 industry parent-targeted ads, and 0.90 state-sponsored ads. • Higher levels of exposure were associated with • Lower estimates of peer smoking (OR = .72) • Higher ratings of perceived harm of smoking (OR = 1.25) • More positive intentions to not smoke (OR = 1.43) • Less likely to have smoked (OR = .74)

19. State-Wide Campaigns Have Been Effective • Michael Slater recently reviewed for the IOM (2006) Committee on Tobacco Control • See also Wakefield, Flay, Nichter & Giovino, 2003 • CA, FL and MA campaigns were particularly well documented • California • 1990 onwards, $54-140M per year, not youth focused but attacked the industry • Adult smoking dropped from 22.7% to 18% 1989-93 (double the rate in the rest of the US) • Massachusetts • 1993 onwards, $43M in 1995, decreased since • Youth (12-15) exposed to the campaign half as likely to progress to regular smoking (OR = .49). No differences for older youth • Florida • “truth” campaign initiated 1998 • 5% relative decline in youth smoking • These campaigns were all comprehensive – involving counter advertising, education, social marketing, policy and taxation components – so not easy to attribute effects to one component

20. Traditional (state-based) Tobacco Control Programs WORK!

21. The Oregon Campaign • 42% decrease in per capita cigarette sales 1996-2004 – or a 16% relative (to the nation) decrease • Note loss of momentum when funding was cut

22. But Oregon youth smoking has paralleled national trends

23. The “truth” Campaign is Effective • Derived from the Florida campaign • Started in 2002 • Students took an active role in identifying the tobacco industry as the enemy • Evaluations by RTI demonstrate its effectiveness • Used similar methods to Wakefield et al • About a 6% relative change • For example, change from 25.8% to 18% smoking • This and State-sponsored campaigns also have an agenda-setting effect – keeping the issue salient

24. ONDCP Campaigns – Suggesting Caution • Recent campaign focused on sensation seeking youth • Derived from the work of Palmgreen and colleagues at University of Kentucky • Palmgreen et al (AJPH, 2007) reported positive effects of the first few months of the campaign for high-sensation-seeking youth in two cities • However, other reports at SPR (Horner, Jacobsohn, Orwin) and from the OMB suggest that the complete campaign (national over 5 years) had no significant effects. • Current campaign focuses on parents • Although careful formative research suggested this might work, the effects of the industry campaign based on the same approach suggest care is needed. • A media campaign is not a vaccine or a magic bullet

25. Tobacco Use Prevention Media Campaigns:Lessons Learned from Youth in Nine Countries • The report indicates that the most effective of these campaigns— • Are part of a comprehensive tobacco control program. • Include ads that provoke strong negative emotions, such as fear and anger. • Provide new information about health risks to smokers and nonsmokers. • Engage youth with youth-oriented graphics and testimonials. • Use multiple strategies and media channels. • Expose youth to messages over significant periods of time.

26. Mass media campaigns can work – but tread carefully • Effective campaigns have resulted after long and careful developmental and formative research and pilot message testing • E.g., Worden, Pechmann • Messages that are effective at one time may not be at another time or place • Wear-out • Relevant message properties are many: • Content, medium, messenger, etc. • Execution style and quality • Novelty • Effective media campaigns are cost-effective • Per capita costs are in the range of 50c to $3

27. IOM 2007 Report “Ending the Tobacco Problem”Recommendation 36 • Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. • If a tobacco company wishes to support youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing and evaluating the program.

28. IV. Other Youth-Focused Approaches to Prevention • Questions about the effectiveness of school-based prevention programs • Examples of effective school-based programs • Comprehensive content/approaches • Adding media or community components • Conclusions

29. Does school-based prevention have an important role? • Multiple reviews established that school-based prevention (SBP) can be effective • Black et al 98, Flay 85, IOM 1994, Lantz et al 00, Roona 2000, Skara & Sussman 03, Tingle et al 03, Tobler 86 92 97 2000 • Particularly social influence oriented and active learning approaches • Several papers found that these effects often did not last through grade 12 • Flay et al 89, Murray et al 89, Ellickson & Bell 90 • Based on lack of long-term effects, several recent studies and reviews have questioned the value of school-based prevention (SBP) • Glantz & Mandel 05, Peterson et al 2000, Wiehe et al 05

30. School-based prevention programs can be effective • Include social influences-related content • Educate youth about social influences and correct misperceptions of normative use among their peers • Teach social (and resistance) skills • Are interactive in their approach, including practice of skills • Include 15 or more sessions in middle school • Produce substantial short-term effects • Have booster sessions or on-going programming in high school • Flay 2009a & 2009b

31. Three SBPs with proven long-term effects • TAPP (Hansen et al 88) • Included the above core elements plus • inoculation against mass media messages, information about parental influences, information about the consequences of use, making a public commitment not to smoke, and peer opinion leaders assisted teachers with program delivery • Life Skills Training (Botvin) • Includes above elements + general social skills • 15-20 sessions in middle school + boosters in HS • Project SHOUT (Elder et al 93, 97) • Included above core elements plus • health consequences of smoking, celebrity endorsements of nonuse, decision making, resistance skills advocacy (writing letters to tobacco companies, magazines, and film producers; participating in community action projects designed to mobilize them as anti-tobacco activists), a public commitment to not use tobacco, and positive approaches to encouraging others to avoid tobacco or quit • 18 sessions in MS delivered by college students • Newsletters and phone calls from college students during HS • Averaged 28% relative reduction in smoking onset by end HS

32. Other SBP programs that show exceptional promise • AAPT (Hansen & Graham 91) • focus on alcohol, showed that normative plus skills training better than either alone • Towards No Tobacco (Sussman et al 93, 95) • More intensive approach with large effects • Know Your Body (Walter et al 88) • Comprehensive health education with very large effects • The Good Behavior Game (Kellam et al) • Focus on general behavior at grades 1 and 2 • Produced 26% relative reduction in grade 8 smoking • Positive Action (Flay & Allred) • Focus on general behavior and character in elementary school • Behavioral effects by grade 5 – >50% relative reduction • Significant long-term effects – 32% RR in MS and 20% in HS

33. Hawaii RCT: Lifetime Prevalence of Substance Abuse, Violent Behaviors, & Sexual Activity: 5th grade (all significant, no significant interactions) (Beets et al., AJPH, 2009) --------------SUBSTANCE ABUSE------- ---SERIOUS VIOLENT BEHAVIORS--- SEX

34. Chicago: (Li et al., in review)

35. SBP programs with media or community components • Three with reported long-term effects reviewed by Flay for IOM • North Karelia, Minnesota 89, Midwestern Prevention Project, Vermont mass media project • Average 31-40% relative reduction through HS • One other promising program • Project 16 (Biglan et al 2000) • Included 5-session social influences curriculum (7th and 9th grades) plus a community program, which included: • media advocacy, youth anti-tobacco activities, family communications about tobacco use, and reduction of youth access to tobacco • Relative reduction in smoking onset of 21% at the end of the program and 28% one year later

36. Youth Prevention of Tobacco Use Can Be Effective • Important elements include: • Social influences (norms and skills) plus other content • Should be highly interactive, including practice of skills • Include 15 or more lessons at middle school plus some kind of booster on on-going programming at HS • Can be accomplished within comprehensive health education or character education programming • Including mass media or other community components is likely to increase effectiveness • Student advocacy/activism is an important component • Shown in mass media, school-based and community examples • Take care to avoid negative effects

37. IOM 2007 Report“Ending the Tobacco Problem”Recommendation 13 • School boards should require all middle schools and high schools to adopt evidence-based smoking prevention programs and implement them with fidelity. They should coordinate these in-school programs with public activities or mass media programming, or both. Such prevention programs should be conducted annually. • State funding for these programs should be supplemented with funding from the U.S. Department of Education under the Safe and Drug-Free School Act or by an independent body administering funds collected from the tobacco industry through excise taxes, court orders, or litigation agreements.

38. IOM 2007 Report“Ending the Tobacco Problem”Recommendation 1 • Each state should fund state tobacco control activities at the level recommended by the CDC. • A reasonable target for each state is in the range of $15 to $20 per capita, depending on the state’s population, demography, and prevalence of tobacco use. • If it is constitutionally permissible, states should use a statutorily prescribed portion of their tobacco excise tax revenues to fund tobacco control programs.

39. Estimated adult smoking prevalence assuming no change in the tobacco control environment Business as usual will not get to us to the HP2010 goal of 12% prevalence

40. What is at stake!

41. The clear relationship between cigarette prices and consumption Source: Tax Burden on Tobacco

42. IOM 2007 Report“Ending the Tobacco Problem”Recommendation 3 • The federal government should substantially raise federal tobacco excise taxes, currently set at 39 cents a pack. • Federal excise tax rates should be indexed to inflation.

43. Report available at www.nap.edu

44. Early Warning Sign