Tobacco Control Interventions for Youth and Young

1. Tobacco Control Interventions for Youth and Young Matthew C. Farrelly, Ph.D.

2. Evidence for Tobacco Control • Many evidence-based interventions available • Smoke-free air laws and ordinances • Increasing the price of tobacco • Multi-component quitlines • Reducing client out-of-pocket costs for effective cessation therapies • Provider reminder systems, w/ and w/out provider education • Mass media campaigns • Studies show that increases in funding for state TCPs • Decrease the prevalence of smoking among youth and adults • Decrease per capita cigarette sales • Promote cessation (not yet published)

3. Common strategies • Media campaigns • Truth campaign • Correcting misperceptions • Price/tax increases • Experimentation • Progression to regular/established smoking • School-based tobacco prevention • Short-term vs. long-term effects • Coordinated with other interventions (e.g., media) • Community mobilization • Community Education • Policy change • Changing adult norms

4. Evidence base for media • NCI monograph makes it clear that media can work • What’s more elusive is understanding “active ingredients” in successful campaigns • Comprehensive evidence that the truth® campaign has been successful. Demonstrated impact on • Awareness • Attitudes, beliefs, intentions and perceptions of use • Particularly salient for 18-24 “straight-to-work” subgroup • Prevalence and initiation • Little evidence (in my opinion) of true synergies with other interventions despite push for “comprehensive” approaches

5. truth® • Launched in 2000 • Modeled after Florida campaign • Current campaign “Do you have what it takes?” • Mock interviews in a Stephen Colbert style • Points out how tobacco is like no other industry

6. Correcting Misperceptions-Vermont’s 8 out of 10 Campaign • In 2000, 46% of middle school students thought that 55% or more of high school students smoke • By 2008 this dropped to 16%.

7. North Carolina TRU • Graphic and emotional testimonial style that available evidence suggests may be the most effective strategy for adult cessation. • Awareness high among youth (71% in 2007) • Good receptivity

8. Ohio Stand • Give a voice to youth in making informed decisions • Embody a social movement against tobacco • Promising to make a difference in the lives of important people around you • Inoculating youth from tobacco • Offering an alternative to smoking: a nonsmoking teen lifestyle. • Awareness reached over 50% • Influenced attitudes.

9. Washington State-No Stank You • Aimed at youth 12-14 • Short-term health effects • Yellow teeth • Bad smelling clothes • Wrinkles • Hairy tongue • Research has shown that younger children relate to these messages • No evidence that it reduces smoking

10. Mississippi’s Generation Free • Tobacco, drug, and alcohol messages under one umbrella campaign • High production value • Novel messages • Positive, but not hokey • Humorous • Clever

11. Essential elements for effective media • Understand your audience well • Target at-risk youth • Ensure that a meaningful percentage of the target audience is consistently exposed to your message • Not clear if there is any one theme or strategy that works best with youth • Strong support for truth approach from Florida and the U.S.

12. Price/tax • Higher prices prevent progression to regular use, but do little to prevent experimentation • Many youth obtain cigarettes from social sources (initially) • Reasonably large effects for young adults • Effects significantly larger than for other adults • Effects may be decreasing over time in the US • Need to have a comprehensive tax policy that includes all forms of tobacco to encourage unintended effects (e.g., roll your own, compensation)

13. School-based tobacco prevention education • Systematic reviews have generally concluded that these programs do not produce long-term effects • Long-term Hutchinson study viewed by many in tobacco control as definitive evidence that these programs are not effective • I agreed until I read Brian Flay’s recent review of reviews (in Tobacco Induced Diseases, 2009) • Flay re-examined the recent systematic reviews and concluded they suffered from methodological problems

14. School-based tobacco prevention education • He concludes that school-based smoking prevention programs can have long-term effects if they are: • Interactive social influences or social skills programs • Involve 15 or more sessions up to at least 9th grade • Produce substantial short-term effects • Include the use of peer leaders rather than adults exclusively • Include community components • Implementing an effective program is challenging • Many lists of “evidence-based” programs include programs that do not meet rigorous standards of evidence • Programs need to be implemented with fidelity • Teachers need training • Demanding accountability is often challenging

15. New Twist on Peer-led Smoking Prevention in Schools • Peer-led approach, with careful selection of influential peers (e.g., good leaders, looked up to) (Campbell et al, 2008, The Lancet) • Engage in informal conversations with peers about the effects of smoking and benefits of not smoking • 10-week intervention period in schools in west of England and southeast Wales • Randomised (it was in the UK) trial with 29 control and 30 intervention schools • Results: reasonably consistent effects on youth smoking

16. Community-based interventions • US Centers for Disease Control and Prevention recommends focusing on promoting “durable changes in social norms” through policy change. • This strategy is favored over “individually focused educational and clinical approaches with a smaller span of impact.” • Implement policies that have the greatest population impact on tobacco use (e.g., smoke-free air laws, excise taxes) • Community coalition efforts are needed to effect policy change in all settings, including “homes, work sites, schools, places of worship, places of entertainment, health care settings, civic organizations, and other public places.”

17. Youth Advocacy Groups • Many states have programs • American Legacy Foundation funded several states in the early 2000s, several continue with state support • Mixture of policy advocacy and community education • Some focus on youth empowerment as a goal and less on achieving concrete tobacco control outcomes • Anti-industry focus still common • Smoking in movies appears to be an emerging topic of interest

18. Mississippi: Generation Free • Website description of youth activism program: • Express your individuality • Voice your opinion • Communicate with your peers and others • Make a difference • Get FREE gear • Media Campaign by same message

19. Colorado’s Get Real • Reminding retailers not to sell cigarettes to kids. • Organizing events to educate youth and adults. • Promoting tobacco control.

20. Other Examples Maine Indiana Kansas

21. Youth Advocacy in Practice • Often focus too much on community education rather than policy change • Youth-oriented interventions preach to the converted • “Goody goody” kids are not credible messengers for at-risk youth • Florida’s SWAT • News media coverage of SWAT associated with the passage of tobacco product placement ordinances (Niederdeppe, Farrelly, Wenter, 2007) • Newspaper coverage of youth advocacyefforts in FL contributed to observed declines in current smoking (Niederdeppe et al, 2007)

22. Youth Advocacy in Practice • Focus on policy change likely to be the most productive use of resources • Product placement/point-of-sale ordinances • Tobacco-free schools (focus on smoke-free grounds) • Tobacco advertisement-free magazines • Integrate with adult coalitions to focus on other advocacy issues

23. Social norm changes • Some states have focused efforts on adults (18+ or 25+), betting on a trickle down effect • Some evidence to support this • Perception that prevention is challenging with fluid youth trends and preferences • May lead to slower change among youth and young adults