Tobacco Control 2000;9:47–63 47

Investing in youth tobacco control: a review of Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from smoking prevention and control strategies

Paula M Lantz, Peter D Jacobson, Kenneth E Warner, JeVrey Wasserman, Harold A Pollack, Julie Berson, Alexis Ahlstrom

Abstract prevention activities have focused on youth, Objective—To provide a comprehensive smoking among adolescents in the United review of interventions and policies aimed States rose throughout most of the 1990s, until at reducing youth cigarette smoking in the declining somewhat in the past two years.2–4 United States, including strategies that Given the epidemiology of smoking have undergone evaluation and emerging initiation, a great deal of policy and innovations that have not yet been programmatic attention has been directed at assessed for eYcacy. youth smoking in the United States.5 In this Data sources—Medline literature article, we synthesise and comment on the bur- searches, books, reports, electronic list geoning literature regarding eVorts to discour- servers, and interviews with tobacco con- age youth from smoking. This article describes trol advocates. a number of youth smoking prevention and Data synthesis—Interventions and policy control strategies, and summarises the state of approaches that have been assessed or the science regarding the impact or evaluated were categorised using a eVectiveness of each strategy. Two previous typology with seven categories (school reports—the US surgeon general’s 1994 report based, community interventions, mass on youth smoking and the Institute of media/public education, advertising re- Medicine’s (IOM) 1994 report Growing up strictions, youth access restrictions, tobacco free—are valuable resources.14We sum- tobacco excise taxes, and direct restric- marise material from these earlier reports, but tions on smoking). Novel and largely also review studies and strategies that have untested interventions were described

emerged since. Our emphasis here is on the http://tobaccocontrol.bmj.com/ using nine categories. youth smoking situation and the state of youth Conclusions—Youth smoking prevention tobacco control science in the United States, and control eVorts have had mixed although we believe that much of what we results. However, this review suggests a present in this review is relevant and salient to number of prevention strategies that are other countries as well. promising, especially if conducted in a We limit our review to youth oriented coordinated way to take advantage of prevention and control strategies and to smok- potential synergies across interventions. ing, recognising that adult interventions and Several types of strategies warrant smokeless tobacco also deserve similar additional attention and evaluation, attention. Note, too, that since very few including aggressive media campaigns, tobacco intervention studies include cost teen smoking cessation programmes, analyses, we cannot oVer specific advice social environment changes, community on September 29, 2021 by guest. Protected copyright. Department of Health regarding the costs of various interventions and Management and interventions, and increasing cigarette the likely returns to these investments. Policy, University of prices. A significant proportion of the Michigan School of Nonetheless, our goal is to provide a cogent resources obtained from the recent settle- Public Health, Ann summary of the main foci of youth tobacco Arbor, Michigan, USA ment between 46 US states and the prevention and control in the United States, an P M Lantz tobacco industry should be devoted to P D Jacobson assessment of the current state of the science, a expanding, improving and evaluating K E Warner description of recent programmatic or policy H Pollack “youth centred” tobacco prevention and J Berson control activities. innovations, and a lengthy reference list to A Ahlstrom (Tobacco Control 2000;9:47–63) which people can turn for additional informa- tion. As such, this review article should be RAND, Santa Monica, Keywords: youth smoking prevention; teen cessation quite useful to tobacco control advocates and California, USA programmes; community interventions; policy J Wasserman policy makers. Although we do not emphasise study design and methodological issues in our Correspondence to: Dr Paula M Lantz, Introduction comments of individual studies, we believe that Department of Health A large body of research shows that, at the this review will be useful to researchers as well. Management and Policy, School of Public Health, present time, very few people initiate smoking We conducted an extensive literature review University of Michigan, 109 or become habitual smokers after their teen and synthesis of published research addressing Observatory, Room M3116, Ann Arbor, MI, 48109-2029, years. In the United States, nearly nine out of interventions to reduce youth smoking. USA; 10 current adult smokers (89%) started their Through Medline, we identified articles [email protected]. habit before the age of 19 years.1 By this age, reporting evaluations of smoking prevention Received 25 April 1999 and most youth who are going to smoke have and control initiatives involving youth. We in revised form 6 September 1999. already become or are in the process of becom- mostly review studies employing experimental Accepted 14 October 1999 ing habitual smokers. Although many tobacco or rigorous quasi-experimental designs. While 48 Lantz, Jacobson, Warner, et al

we reviewed some pre-1994 literature, our educating them on the health and social detri- Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from focus was on what has been learned since 1994 ments of smoking will provide a deterrent. Pro- when both the IOM and surgeon general grammes based on the information deficit or reports were published. rational model have generally been found to be In addition, we collected and reviewed infor- ineVective in deterring initiation or reducing mation on emerging initiatives and interven- volume among current smokers, although tions that have not yet been evaluated or many programmes were not evaluated or only received much attention in the peer reviewed short term impact was assessed. literature. We monitored reports of recent The second major approach to youth strategies distributed through several diVerent tobacco prevention programmes is an electronic mailing lists. We also conducted a “aVective education model” in which the series of informal interviews with tobacco con- programme attempts to influence beliefs, trol advocates in the United States to learn of attitudes, intentions, and norms related to new approaches currently being tried to tobacco use with a focus on enhancing self discourage youth smoking. The purpose of esteem and values clarification. This type of these activities was to identify emerging trends prevention programme emphasises initiation and promising innovations. Our discussion of influences within an individual, recognising recent innovations is neither comprehensive that knowledge deficits are not the only factors nor systematic in a scientific sense. Rather, it is associated with smoking initiation.4 Content an attempt to identify emerging trends and to themes across many of these programmes provide information about some of the new include self esteem and self image and creative interventions that are currently enhancement, stress management techniques, being implemented and evaluated. values clarification, decision making skills, and To organise the wealth of information on the goal setting. Evaluation findings for this type of topic of tobacco prevention and control e orts V intervention generally have suggested a weak or among youth, we categorised eVorts into the insignificant impact. following areas: (1) school based educational The third approach to tobacco prevention is interventions; (2) community interventions; based on a “social influence resistance model”. (3) mass media/public education; (4) tobacco In this model, the programme recognises and advertising restrictions; (5) youth access restrictions; (6) tobacco excise taxes; and (7) emphasises the social environment as a critical direct restrictions on smoking. The published factor in tobacco use. In addition to individual research regarding interventions in these areas factors, influences outside of an individual, is summarised and reviewed. We also describe such as peer behaviour or attitudes (both posi-

a number of novel and largely untested tive and negative), and certain aspects of the http://tobaccocontrol.bmj.com/ interventions. These include: (1) youth oriented environmental, familial, and cultural contexts, smoking cessation programmes; (2) computer are of great importance. As such, this type of based systems; (3) peer based interventions; intervention focuses on building skills needed (4) recent anti-tobacco advertising campaigns; to recognise and resist negative influences, (5) penalties for possession and use; (6) school including recognition of advertising tactics and policies; (7) vendor penalties; (8) restrictions peer influences, communication and decision- 4 on the sale and marketing of tobacco products; making skills, and assertiveness. and (9) interventions to identify youth with a The results of many individual evaluations propensity to use tobacco. We conclude with a and meta-analyses of tobacco and other drug discussion of prevention strategies (both prevention programmes strongly suggest that proven and new) that are promising and programmes based on the social influence resistance model are the most eVective of the warrant further implementation and rigorous on September 29, 2021 by guest. Protected copyright. evaluation. three approaches. The IOM report concluded that evaluations of school based prevention Prevention activities programmes have “consistently demonstrated SCHOOL BASED EDUCATIONAL INTERVENTIONS that a brief school intervention that focuses on Elementary and secondary levels social influences and teaches refusal skills can A large number of school based programmes have a modest but significant eVect in reducing have been implemented during the past three the onset and level of tobacco use”.4 In a meta- decades. Most of these eVorts target analysis of smoking prevention programme elementary school and/or middle school evaluations published between 1974 and 1991, students. As described in the IOM report on Rooney and Murray found that social youth smoking, the majority of these influence programmes could account for programmes have tended to be based on one of reductions in smoking between 5–30% (with three main approaches.4 The first approach is the upper range given as the highest estimate of an “information deficit or rational model” in programme performance under “optimal” which the programme provides information conditions only).6 In meta-analyses of control- about the health risks and negative led studies of drug use prevention programmes consequences of tobacco, most often in a man- for youth, Tobler reported that interactive pro- ner intended to arouse concern or fear. Many grammes and those led by peers that addressed of the early education interventions in youth the social influences of substance use were tobacco control (before the mid 1970s) were most eVective.78 These findings were echoed based on this model. The primary premise of by Black and colleagues, whose meta-analysis this approach is that youth are generally misin- suggested that interactive peer interventions formed about the risks of smoking and that for middle schoolers are superior to Smoking prevention and control strategies 49

non-interactive, didactic programmes led by higher risk for binge drinking and the use of Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from researchers or teachers.9 marijuana, cocaine, and LSD.20 A number of Similarly, in a diVerent meta-analysis of interventions aimed at preventing tobacco, smoking prevention programmes for adoles- alcohol, and other drug abuse have been cents, Bruvold found that the eVects of implemented in both urban and rural colleges interventions with a “traditional” or “rational” and universities, although few have undergone orientation were small and often insignificant.10 rigorous evaluation and few are perceived as In contrast, Bruvold found that those interven- being eVective by those implementing them.21 tions with a social reinforcement orientation (that is, those focusing on the development of Summary skills to recognise and resist social pressures) A large number of individual evaluations and had the largest eVects in terms of attitude and review articles regarding controlled educa- behavioural change. Although not all social tional interventions to reduce youth tobacco influence interventions have been successful, a use have been published.22–26 A wide range of wide body of literature suggests that this evaluation results from experimental and approach has the best track record overall.11 quasi-experimental studies suggest that some One particular intervention that has received of these educational programmes resulted in a a great amount of attention is the “Drug Abuse significant short term reduction in smoking, a Resistance Education” or DARE programme. delay in initiation, or a desirable change in atti- Taught by uniformed police oYcers, DARE tudes toward tobacco use.14 Programmes that combines the building of self esteem, the embrace a “social influences” model tend to be development of resistance skills, and the most eVective, especially when enhanced information about the negative eVects of drug by an extensive community based health use and violence.12 Despite DARE’s popularity education programme. The recent literature and proliferation, few positive results regarding confirms, but does not greatly expand on, the tobacco and other drug use have been revealed 1994 reports. Perhaps more surprisingly, there in numerous individual or combined is not a welter of new evaluations of school programme evaluations.12–14 based programmes, suggesting either that such The long term impact of school based programmes have not changed very much or educational interventions is of concern. It that scholars have been discouraged by appears that the eVects tend to dissipate with previous findings from exploring these time, with eVects generally persisting in the programmes any further. range of 1–4 years.1 The IOM report stated Many of the guidelines for developing and that “while the results of more than 20 research implementing school based tobacco prevention

studies have shown that school based programmes previously issued by the National http://tobaccocontrol.bmj.com/ prevention programmes alone have consist- Cancer Institute and the Centers for Disease ently delayed onset of smoking, lasting eVects Control and Prevention (CDC) are still have only been demonstrated at 2 year follow relevant.422 The CDC’s recommendations up”.4 Programme “boosters” or subsequent include: (1) that the instruction should provide interventions appear to enhance the staying information on the social influences of and power of the intervention eVects, although the peer norms regarding tobacco use in addition most appropriate content of and timing for to information on the short and long term these booster sessions is not known.15 16 physiologic consequences of smoking; (2) pro- gramme specific training for teachers should College level be provided; and (3) that schools should Recent evidence indicates a disturbing increase develop and enforce tobacco free policies, to

in smoking behaviour among college students, make sure prevention programmes are on September 29, 2021 by guest. Protected copyright. suggesting the limits of elementary and implemented in a setting with broad policy secondary school based prevention eVorts. As support.22 Additional information on CDC Wechsler and colleagues showed, the guidelines and specific programmes or prevalence of smoking on college campuses has curricula that the CDC endorses through its increased nationwide.17 Based on longitudinal “Research to Classroom” programme is data from 130 college campuses, these available.27 Recently, Manske and colleagues researchers estimated that the prevalence of recommended testing intervention models that self reported smoking in the past 30 days involve youth developing their own solutions, increased from 22.3% in 1993 to 28.5% in and that examine the interaction between 1997. Recent results from the “Monitoring the school based interventions and other Future” project reveal a trend toward increased community-based activities.23 They also cigarette use among young adults in general.18 recommended that research be conducted to This increase in smoking is believed to reflect better understand why many youth do not the rise in smoking that occurred among smoke. adolescents earlier in the 1990s.17 It is also pos- sible that an increase in smoking initiation COMMUNITY INTERVENTIONS among older teenagers and young adults is also The increased understanding of the combined playing a role. In a study of four universities, eVects of environmental, social, and cultural Naquin and Gilbert found that 10% of conditions on tobacco and other substance use smokers had their first cigarette and 11% has resulted in an emphasis on interventions started smoking on a regular basis after high that include comprehensive, community based school.19 Besides the risks posed by smoking, approaches.28 Such an approach targets young adults who smoke cigarettes are also at a multiple systems, institutions, or channels 50 Lantz, Jacobson, Warner, et al

simultaneously, and employs multiple strate- tax increases (discussed in greater detail Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from gies. In general, community interventions have below), exposure to tobacco education in multiple components, and involve the use of schools, and policies restricting youth access to community resources to influence both tobacco were associated with decreased smok- individual behaviour and community norms or ing and intention to use cigarettes among ninth practices related to adolescent tobacco use. graders (ages 14-15 years). The authors also This includes the involvement of families, observed that the frequency of exposure to schools, community organisations, churches, anti-tobacco advertisements was correlated businesses, the media, social service and health with an increased likelihood of smoking. This agencies, government, and law enforcement, counterintuitive finding was not significant in with intervention strategies generally focused on some of the subanalyses conducted by the making changes in both the environment and authors, and is contradicted by other findings individual behaviour. Although community from the same study, including that the cumu- interventions take a variety of shapes, common lative number of tobacco education classes elements among them include a shared empha- (which include anti-tobacco messages) are sis on altering the social environment or social associated with reductions in smoking context in which tobacco products are obtained behaviour and intentions.39 Some might argue or consumed, and a shared goal of creating a that the paradoxical finding lends credence to social environment that is supportive of the perspective that the strong focus of tobacco non-smoking or cessation.4 Some of the compo- control interventions on youth may uninten- nents of community interventions, such as mass tionally be glamourising tobacco use as an media campaigns and youth access restrictions, adult behaviour and thus have counterproduc- are also implemented as stand alone tive eVects.40 At the present time, however, interventions, as described below. there is little empirical evidence to substantiate While an increasing number of communities this concern. are attempting to influence youth tobacco use Another comprehensive community inter- with multiple component interventions, there vention is the American stop smoking are few published reports of evaluations with intervention study for cancer prevention rigorous designs. The available research results (ASSIST), an eight year programme (1991 to are encouraging in many cases.1 28–32 For exam- 1999) funded by the National Cancer Institute ple, based on the results of a longitudinal trial, in collaboration with the American Cancer Pentz and colleagues reported that a Society and state and local health community intervention involving mass media, departments.41 The overall goal of ASSIST is school based education, parent education, to reduce smoking prevalence to 15% by the

community organising, and health policy com- year 2000 by encouraging smokers to quit and http://tobaccocontrol.bmj.com/ ponents in some of the 15 communities in the by discouraging young people from initiating Kansas City metropolitan area was eVective in the habit. Many local ASSIST coalitions reducing tobacco, alcohol, and illicit drug emphasise the use of public health information use.33 Regarding tobacco use, a significantly and advocacy to denormalise tobacco use in lower rate of smoking was observed in the the community. Some strategies used by intervention group at six months and at two ASSIST communities to prevent and reduce years (when the rates for smoking in the last youth tobacco use include: youth education; month were 19% in the programme group ver- encouraging enforcement of laws restricting sus 29% in the control group).34 In addition, youth access; banning tobacco advertising that the results of a randomised trial conducted by is youth oriented; environmental tobacco Biglan and colleagues in rural Oregon commu- smoke restrictions; and increasing physicians’

nities demonstrated a reduction in the role in youth tobacco prevention eVorts. on September 29, 2021 by guest. Protected copyright. prevalence of weekly cigarette use in Currently, there are few published articles communities exposed to the intervention evaluating the eVectiveness of ASSIST in gen- (which focused on key social influences of eral, or relative to youth in particular. Manley smoking and included media advocacy, and colleagues reported that interim results anti-tobacco activities for youth, and family regarding the impact of ASSIST suggest that communication activities).35 this programme has led to reduced tobacco School based programmes and community consumption in ASSIST states, and that this interventions involving parents, mass media, eVect reflects more than increased prices from and community organisations appear to have a tobacco taxation.42 Kegler and colleagues stud- stronger impact over time when they work in ied the factors related to coalition eVectiveness tandem rather than as separate, stand alone in 10 ASSIST communities in North Carolina, interventions.4 25 28 36–38 Mobilising parents and but did not evaluate individual programmes for community elements outside of the school eVectiveness in reducing smoking rates.43 They (including the media) is seen as enhancing found that community groups possessing an school based interventions and increasing the articulated plan, including specific goals and potential for a lasting behavioural impact.1 For strategies for implementation, had stronger example, Lewit and colleagues examined the coalitions than community groups lacking impact of tobacco taxes, public smoking these characteristics. ordinances, law regulating youth access, and The eVorts of several community inter- exposure to tobacco messages (both pro and ventions have involved a particular focus on anti) in 21 of the 22 community intervention youth access to tobacco products (as described trial for smoking cessation (COMMIT) below). Numerous other examples of commu- communities.39 These researchers found that nity intervention eVorts related to youth access Smoking prevention and control strategies 51

were reviewed by Forster and Wolfson, includ- paigns in several states, including California, Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from ing the development and implementation of Michigan, Minnesota, and Massachusetts. restrictions regarding cigarette vending However, the impact of media campaigns on machines, restrictions regarding the sale of tobacco use among youth in general or specific “loose” or single cigarettes, restrictions regard- subgroups is unknown. The few existing stud- ing the age of people who can sell cigarettes, ies of the impact of mass media campaigns on and requirements regarding the training of youth smoking have shown varying salespersons.44 All of these are examples of results.1 28 36–38 51–53 Hu and colleagues found attempts to alter the social environment or that both increased taxation and the policy context in which tobacco products are anti-smoking media campaign had an obtained, distributed or consumed. As noted independent and significant impact on overall below, there is little evidence as to the cigarette consumption in California from 1990 eVectiveness of these initiatives in reducing to 1992.51 In addition, Popham and colleagues’ youth tobacco consumption. evaluation of the California media campaign suggested some positive results for youth in Summary grades 4–12 (ages 9-18 years).52 Almost 50% of The results of a small number of controlled tri- students surveyed were able to describe an als of community interventions attest to their advertisement without prompting, and almost ability to have an eVect on youth smoking 90% were able to recall parts of the campaign behaviour. An important finding is that the with a brief description. Although smoking eVectiveness of school based programmes prevalence among students decreased slightly appears to be enhanced when they are in California after the media campaign was included in broad based community eVorts in implemented, this study could not sort out the which parents, mass media, and community eVects of the campaign from the myriad of organisations are involved, and in which the other tobacco control eVorts underway at the social policy or social environment as well as same time. Subsequent data suggest increases individual knowledge, attitudes, and behav- in California youth smoking behaviour during iours are targeted for change.45 However, it is the mid to late 1990s, although the smoking our opinion that broad based community rate there is below the national average.53 interventions alone are not suYcient to bring Flynn and colleagues showed that combin- about a substantial and sustained decline in ing traditional school based prevention eVorts youth smoking. Community eVorts, as with a mass media campaign increases symbolised by COMMIT, ASSIST, and other intervention eVectiveness.36 37 In a study of two interventions, likely need to be combined with communities, the one that received a mass

stronger advocacy, taxation, media interven- media intervention along with the educational http://tobaccocontrol.bmj.com/ tions, and policy formation and programme for four years had an almost 40% implementation.41 45 46 It is also important to lower rate of smoking than the one receiving recognise that the limited number of the educational programme alone. The evaluations with experimental or strong quasi- researchers also found that the media interven- experimental designs seriously limits our tion was particularly eVective among high risk understanding of whether community inter- youth, defined as students who reported ever ventions are eVective and, of equal importance, smoking at baseline (grades 4–6, ages 9-12 which of their components are most useful in years) and had two or more smokers in their reducing youth tobacco use. immediate social or family environment. Based on the evaluation results of Flynn and MASS MEDIA/PUBLIC EDUCATION colleagues, and Worden and colleagues,

Mass media strategies have been used for Secker-Walker and colleagues performed a cost on September 29, 2021 by guest. Protected copyright. broad based public education regarding a vari- analysis of a mass media programme and ety of public health issues, including tobacco found that (in 1996 US dollars) the cost per use prevention and control. Mass media eVorts exposed student was $41, the cost per averted are viewed as particularly appropriate for smoker was $754, and cost per life year gained reaching youth, who are often heavily exposed was $696.36–38 54 If the campaign were to be to and greatly interested in media messages.147 implemented nationwide, the authors argued Further, as Jason48 and Macaskill and that economies of scale would produce signifi- colleagues49 suggested, media based health cant decreases in these costs. Thus, it is promotion eVorts have the potential to reach believed that mass media interventions can large segments of the population, especially have a significant and cost eVective impact on those who are less educated, and to lower bar- youth smoking behaviour. riers to participation in health related Goldman and Glantz recently reviewed programmes. research on the eVectiveness of various It is clear that the tobacco industry is anti-smoking messages and of paid anti- successful in advertising and marketing smoking advertising, and also conducted a pro-tobacco messages for youth. Some have qualitative study of 180 focus groups involving proposed that the “very tools used by the more than 1500 adults and youth.55 They con- tobacco industry to make cigarettes into the cluded that “aggressive” public education single most profitable legal consumer product campaigns that focus on “industry manipula- sold can also be used to combat the smoking tion” (that is, the goal of the tobacco industry pandemic unleashed by tobacco products”.50 to recruit young smokers and the tactics used Young people have been the primary target of to achieve this goal) and the negative eVects of some sophisticated anti-tobacco media cam- second hand smoke are more likely to reduce 52 Lantz, Jacobson, Warner, et al

cigarette consumption and denormalise initiation is influenced by industry advertising Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from smoking. According to these researchers, and marketing.62 incorporating messages of industry manipula- While and colleagues reported that cigarette tion into campaigns resonates with youth in advertising “appears to increase children’s particular because such messages emphasise awareness of smoking at a generic level and that people are not acting independently in encourages them to take up the behaviour, their decision to smoke. Goldman and Glantz beginning with any cigarettes which are also concluded that advertising strategies that available and aVordable”.68 Altman and focus on youth access, the short and long term colleagues found evidence that youth health eVects of smoking, and romantic rejec- awareness of tobacco marketing campaigns, tion have less potential for eVectiveness.55 receipt of free tobacco samples, and receipt of It is important to recognise that the majority direct mail promotional paraphernalia were of “marketing” that has been aimed at smoking found to be associated with susceptibility to and other substance use prevention should tobacco use.69 Consistent with these findings, more accurately be called “social adver- Pierce and colleagues reported that adoles- 56 tising”. There are important diVerences cents who had a tobacco promotional item between mass media or advertising campaigns and/or had an interest in tobacco advertising and social marketing as a structured approach (that is, had a favourite advertisement) were to influencing ideas and behaviours related to significantly more likely to initiate smoking in public health (see reviews by Lefebvre and the following three years.63 Pierce and Flora, Maibach and Holtgrave, and Chapman 57–59 colleagues concluded that a significant portion Walsh and colleagues). Social marketing of youth experimentation with smoking can be employs marketing tools and techniques in a attributed to tobacco promotional activities. rigorous and disciplined approach that involves However, because these promotional items are consumer testing and feedback, and product not randomly distributed, selection bias could responsiveness to this feedback.59 In addition, explain this finding. Logan and Longo argue that it is time to The econometric evidence on the eVects of “rethink” the theoretical approaches to advertising on cigarette consumption has anti-smoking media campaigns, and to devise focused on the aggregate impact on adult a “third generation” of campaigns that encom- pass more of what is known about the smoking. With many studies finding no signifi- behavioural and social dynamics of smoking.60 cant relationship, and many others finding a significant but generally small relationship, this literature is indeterminate on the issue.70 In any Summary

event, technical limitations of the dominant http://tobaccocontrol.bmj.com/ Sophisticated mass media campaigns that 71 involve essential elements of social marketing econometric approach combined with a lack and are theoretically driven may well have an of studies on adolescent smoking make this lit- eVect on the attitudes and behaviours of youth erature of little utility in trying to assess regarding tobacco use, although the impact of whether advertising aVects smoking by such campaigns is challenging to evaluate and children. has not yet been demonstrated. The literature Similarly, the potential eVect of restrictions suggests that mass media interventions or bans on cigarette advertising on adolescent increase their chance of having an impact if the smoking behaviour also is unclear. Some states following conditions are met: (1) the campaign and municipalities have implemented restric- strategies are based on sound social marketing tions regarding tobacco advertising. For exam- principles; (2) the eVort is large and intense ple, the state of Utah and several major cities such as San Francisco and Baltimore have enough; (3) target groups are carefully on September 29, 2021 by guest. Protected copyright. diVerentiated; (4) messages for specific target banned tobacco advertising from all billboards groups are based on empirical findings regard- and other objects of display. These types of ing the needs and interests of the group; and bans are too new to have been evaluated yet, (5) the campaign is of suYcient duration.128 and the implementation of similar bans has been delayed because of legal challenges. Nev- TOBACCO ADVERTISING RESTRICTIONS ertheless, the evidence regarding the eVects of Of all consumer products, cigarettes are the cigarette advertising bans is mixed, as diVerent most heavily advertised and marketed. There is statistical analyses have come to opposite con- great concern that tobacco advertising and clusions about whether bans reduce cigarette marketing—including the distribution of consumption.70 SaVer and Chaloupka explain promotional products such as clothing, the inconsistent findings by the fact that partial sporting equipment, and gear for outdoor and complete bans have diVerent eVects, but activities—is positively associated with youth are not clearly distinguished from each other in smoking.61–67 A historical review of tobacco research studies.72 Using both theory and the marketing foci and smoking rates among youth existing empirical evidence, these researchers showed that smoking initiation among females conclude that partial bans have little eVect (but not males) greatly increased at the same because they aVord cigarette companies the time large scale marketing campaigns aimed at opportunity to switch advertising expenditures women were implemented.62 This work to other promotional media and methods. In showed that “major marketing impact contrast, they find that complete bans could occurred in youth smoking initiation only in reduce tobacco consumption by approximately the sex group targeted”, and adds indirect evi- 6%, an amount that may seem small but could dence to the proposition that youth smoking still have an important public health impact. Smoking prevention and control strategies 53 Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from YOUTH ACCESS RESTRICTIONS systems that include licence suspension or In the past decade, the issue of youth access to revocation for violations of state minor access tobacco products has received an explosion of laws.75 attention. Before this time, most intervention Some studies suggest that merchant activities in this area were focused on discour- education regarding youth tobacco access laws aging individual adolescents from smoking. has failed to produce sustained refusal to sell Starting in the late 1980s, when the evidence cigarettes to minors.76 Numerous sting that adolescents have easy access to tobacco operation studies show that illegal tobacco products was mounting, concern and action sales to minors are common, with older minors proliferated regarding broader environmental more able to purchase cigarettes than younger factors aVecting the ability of youths to minors.44 While laws regarding sales to minors purchase or otherwise obtain cigarettes. In a appear to be rather benign in and of recent review article, Forster and Wolfson themselves, what seems to make a diVerence explained that many policies have been imple- regarding illegal tobacco sales to minors is mented at the local, state, and federal levels whether or not the laws are enforced. Upon regarding the distribution and sale of tobacco completion of an extensive study of the products.44 Policy action has been seen in a enforcement and implementation of tobacco number of areas, including regulation of control laws, Jacobson and Wasserman concluded that ongoing enforcement is the key sellers, regulation of buyers, restrictions on the 73 distribution of free products or samples to reducing illegal sales to minors. These researchers stated that “to be eVective, local (including coupons), and regulation of the ordinances must have a graduated penalty means of tobacco sale (where and how it can be structure that starts with a moderate fine for sold).44 The latter includes state and local the first oVense and escalates in severity with e orts to restrict or totally ban vending V each subsequent eVect”. They also concluded machine sales of tobacco. that local licensure and license removal for At the present time, all states prohibit the vendors who sell tobacco products to minors sale and distribution of tobacco products to would further restrict vendors’ willingness to minors through a variety of “youth access sell cigarettes to minors. laws” or policies that involve age restrictions An experimental study of the eVectiveness of for selling tobacco. All 50 states and the an intervention regarding tobacco sales to District of Columbia prohibit the sale of minors was conducted by Rigotti and tobacco products to people under the age of colleagues.77 In this study, three communities 1 18. In contrast, laws banning adolescent in an intervention group enforced tobacco

purchase or possession of cigarettes vary by sales laws, while three matched communities in http://tobaccocontrol.bmj.com/ jurisdiction. Some tobacco control advocates the control group did not. The findings have argued that purchase and possession laws suggested that increased enforcement en- are more diYcult to enforce than restrictions hanced vendors’ compliance with Massachu- on the seller, and are part of an eVort to shift setts’ tobacco sales laws, thus reducing illegal responsibility for tobacco sales from retailers to sales to minors. Similarly, Altman and minors.44 colleagues, after conducting a randomised trial of an intervention to reduce tobacco sales to minors in some California communities, Youth access laws and tobacco sales concluded that “tobacco sales to minors can be Federal Public Law 102-321, commonly reduced through a broad based intervention”.78 referred to as the Synar amendment and Cummings and colleagues evaluated the enacted in 1991, stipulates that states must

impact of an intervention to increase on September 29, 2021 by guest. Protected copyright. enforce laws restricting the sale and compliance with tobacco purchasing laws by distribution of tobacco products to minors and monitoring 319 outlets in six community pairs, must demonstrate success in reducing youth where one of the communities in the pair was tobacco access or risk not receiving the full randomly assigned to an active enforcement complement of block grant funding for the 79 1 programme. Their results showed a dramatic treatment and prevention of substance abuse. increase in compliance with the law in both the Jacobson and Wasserman suggested that the intervention and control communities. The Synar amendment has led to a number of authors believe that their finding of no developments in youth tobacco control, intervention eVect, which is contradictory to including passage of age-of-sale legislation, several other studies, may be explained by increased enforcement eVorts, and the “contamination” from publicity about the increased use of undercover or “sting enforcement intervention and hence almost operations” or undercover studies.73 74 They universal awareness of the project sting opera- also suggested, however, that Synar may be tions among retailers in both the intervention fuelling the growth in the penalising of the pur- and control communities. chasing or possession of tobacco among Some researchers have evaluated the impact minors. Even with the leverage from the Synar of youth access strategies when combined with amendment, it is believed that few jurisdictions other interventions. For example, Feighery and seriously enforce laws regarding the sale of colleagues investigated the eVects of a commu- tobacco to minors.1447374 An objective in the nity education and law enforcement interven- Public Health Services’ draft “Healthy People tion in a two year controlled trial.80 Their 2010 Objectives” is to increase to 100% the primary conclusion was that an educational proportion of states with retail licensure intervention (directed at merchants, law 54 Lantz, Jacobson, Warner, et al

enforcement agencies, and the community at issue. Intervention communities organised to Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from large) alone had a limited eVect on reducing enact local ordinances, change retail mer- illegal sales to minors, but that education plus chants’ behaviour, and promote enforcement enforcement significantly reduced illegal of illegal sales to minors. Although youth over-the-counter sales. Biglan and colleagues81 smoking rose in both intervention and control used a multiple time series design to assess the communities, the rate of increase was much impact of an intervention involving community smaller in intervention communities. The mobilisation, merchant education, changing authors concluded that “this study provides consequences for clerks, publicity about clerks evidence that a community mobilisation inter- refusing to sell, and feedback to store owners vention resulting in policy adoption and and managers about sales to youth in rural enforcement to reduce youth access to tobacco Oregon. Their analyses suggested that the can aVect adolescent smoking rates”; they were intervention led to a significant (62%) careful to note that the results reflect only short reduction in sales in the intervention term eVects.86 communities. If the only or primary way in which youth In response to public pressure, the tobacco gained access to cigarettes was through illegal industry has embarked on a highly publicised sales, then we might expect the enforcement of campaign to reduce youth smoking behaviour. youth access laws to have a powerful eVect on The eVects of the Tobacco Institute’s “It’s the smoking behaviour. However, youth cite a Law” campaign—which is a public relations number of “social sources” (such as family, eVort purportedly designed to eliminate the friends, or even strangers) for their cigarettes as sale of tobacco products to minors—appear to well as illegal purchase.87 88 Forster and be minimal. A survey of tobacco retailers colleagues found that, in the 14 communities revealed that less than 5% of retail respondents in their intervention trial, youth who reported were participating in the programme, and that ever smoking were very likely to cite social there was no diVerence between participating sources for cigarettes, although older youth and non-participating retailers in terms of their and those reporting weekly smoking also willingness to sell cigarettes to minors (86% v reported purchasing their own tobacco.89 The 88%).82 In another study, DiFranza and literature to date appears to suggest that youth colleagues found that vendors participating in obtain tobacco products from a wide variety of the “It’s the Law” programme were just as sources, including social sources. likely to make sales to minors as non- participating vendors.83 Summary It is undeniable that the current state of regula-

Youth access laws and smoking behaviour tory, judicial, and legislative pressure on the http://tobaccocontrol.bmj.com/ While several studies suggest that the enforce- tobacco industry and tobacco retailers ment of youth access laws can lead to represents an unprecedented and concentrated reductions in illegal sales to minors, the assault on youth access to tobacco products. evidence that this actually translates into Forster and Wolfson have stated that although reduced tobacco consumption is limited. “it seems reasonable to assume that reducing Several studies failed to look at the impact of the number of retailers that sell tobacco to enforcement interventions on smoking behav- minors illegally will reduce minors’ access to iour. In studies that looked at both sales and tobacco, which will in turn reduce youth behaviour, the two did not always go hand in smoking rates, it is surprising how little hand. For example, the study by Rigotti and evidence is available to support those colleagues cited above found that reduced sales assumptions”.44 More evidence, in the form of

to minors were not accompanied by changes in controlled trials of interventions, is needed to on September 29, 2021 by guest. Protected copyright. adolescents’ perceptions of their access to ciga- support the intense growth of activity in the rettes or in their smoking behaviour.77 area of youth access restrictions. Furthermore, Similarly, Altman and colleagues concluded it is clear that in the face of increased enforce- that, while interventions to reduce tobacco ment of youth access laws, tobacco remains an sales to minors can be eVective, multiple alluring and addictive substance of great supply and demand focused strategies are appeal to youth. What can be said with the evi- needed to actually reduce tobacco use.78 dence at hand is that youth access In contrast, in an observational study of the interventions can lead to a general reduction in impact of anti-smoking legislation in one illegal sales of cigarettes to minors.90 Whether suburban community, Jason and colleagues this will translate into reduced and sustained found that both merchant sales and adolescent reductions in youth tobacco use remains to be smoking behaviour were reduced after the pas- seen. sage of the law.84 Data from their student In 1997, the Food and Drug Administration surveys suggested that both experimentation (FDA) implemented a number of regulations and habitual use of cigarettes decreased by regarding youth access to tobacco. These regu- over 50% between the pre- and post-test lations make it a violation of federal law to sell observations; subsequent inquiry suggested tobacco products to anyone under the age of that a reduction in use was still apparent after 18 years and to fail to request an identification seven years.84 85 card for anyone appearing to be under 27 Forster and colleagues conducted a years. In addition, the regulations establish a randomised community trial in 14 Minnesota minimum cigarette pack size of 20 cigarettes, communities.86 The goal of the intervention ban free samples of cigarettes and smokeless was to make youth access a community wide tobacco, prohibit cigarette sales through Smoking prevention and control strategies 55

vending machines (with some exceptions), and light of the addictive nature of smoking, long Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from ban self service displays of tobacco products. term adult smokers are likely to adjust less At the present time, it is not clear if the FDA quickly to changes in price than teenagers who will have the resources necessary to enforce have been smoking for a relatively short time, if these regulations.44 More significantly, the at all. In addition, peer behaviour is likely to be tobacco industry challenged these regulations much more influential for youths, multiplying as being beyond the FDA’s scope of authority. the eVects of price on youth smoking. That is, In the case of Brown & Williamson Tobacco an increase in cigarette price directly reduces Corp v FDA, the Fourth Circuit Court of youth smoking and then again indirectly Appeals agreed with the industry and ruled reduces it through its impact on peer smoking. that the FDA could not promulgate most of the Grossman and Chaloupka oVered two regulations. That case is now on appeal to the additional reasons.94 First, the fraction of US Supreme Court, with a decision expected disposable income a young smoker spends on by mid 2000. cigarettes is likely to exceed that spent by an adult smoker. Second, compared to adults, TOBACCO EXCISE TAXES youths are more likely to be oriented toward In this section, we review the evidence regard- the present than the future. ing the impact of tobacco excise taxes on youth The conclusion that youth cigarette demand smoking. Much of what we report here was is more price elastic than adult demand was taken, with permission, from previous work of widely accepted until 1991 when Wasserman Chaloupka and Warner.70 Tobacco products and colleagues published a study indicating are taxed by the federal government, states, that prices did not have a significant impact on and a few local governments. While generating youth smoking.95 They attributed this result to revenue, tobacco taxation is also a policy that the inclusion in their models of an index of creates an economic disincentive to use restrictions on smoking. These restrictions, tobacco. Theoretically, increasing the price of which they note are positively correlated with cigarettes through taxation could reduce price, had not been included in most previous adolescent cigarette consumption through studies of cigarette demand. Moreover, three mechanisms: some adolescents would Chaloupka found that the price elasticity of quit smoking; some would reduce the amount demand for young adults (that is, individuals that they smoke; and some would not start between 17–24 years of age) was also smoking in the first place.1 The extent to which insignificant.96 higher cigarette taxes will achieve these However, a recent study of the impact of objectives depends upon how responsive cigarette price increases on young adults

smokers, and prospective smokers, are to price (college age students) challenges these results. http://tobaccocontrol.bmj.com/ increases. Chaloupka and Wechsler estimated price elas- The addictive nature of cigarettes suggests ticities ranging from −0.906 to −1.309, with that teenagers could indeed be more approximately half of the response caused by responsive than adults to changes in cigarette the impact of price on smoking prevalence and prices, as it is easier to start smoking than to the remaining half caused by the impact of quit. Thus, any factor that can deter or reduce price on the number of cigarettes smoked by consumption, especially in older adults (who smokers.97 Noting that their sample was not a are established smokers), is likely to have a random sample of all young adults, Chaloupka larger eVect on teenagers who are initiating the and Wechsler suggested that the price elasticity habit. Studies of the elasticity of demand for of cigarette demand by college students may be cigarettes have followed a long tradition, dating even higher, given the evidence that cigarette 91

back more than half a century. Most of these demand is relatively less elastic for more on September 29, 2021 by guest. Protected copyright. studies have focused on the adult, or overall, educated or higher income individuals.96–99 demand for cigarettes, with comparatively few Recent studies by Farrelly and colleagues,100 focused on teenage cigarette demand. After Lewit and colleagues,39 and Tauras and reviewing the relevant literature, a 1993 Chaloupka101 provide additional support for National Cancer Institute expert panel the inverse relationship between price sensitiv- concluded that most estimates of the adult ity and age. elasticity of demand have clustered around In general, researchers examining the eVects −0.40.92 This implies that a 10% increase in of price on smoking participation using the price of cigarettes will reduce the number individual level data from cross sectional of cigarettes demanded by 4%. The panel fur- surveys have assumed that much of the price ther found that prices influence teenage eVect estimated for youth reflects the impact of cigarette consumption “at least as much as price on smoking initiation, while the estimate adult consumption”. Yet the dearth of studies for adults is largely capturing the eVects of devoted to calculating teenage cigarette price price on smoking cessation. A few recent stud- elasticities prevented the panel from arriving at ies have attempted to examine directly the a more precise estimate. impact of cigarette prices on smoking In one of the early studies in this area, Lewit initiation. Douglas and Hariharan found that a and colleagues estimated elasticities for teens’ number of socioeconomic and demographic likelihood to smoke and the quantity of factors had a significant eVect on smoking ini- cigarettes smoked by continuing smokers to tiation, but their estimates for cigarette prices −1.19 and −1.44, respectively.93 These were insignificant.102 These results were researchers suggested that youths should be supported by DeCicca and colleagues, raising more price sensitive than adults because, in doubts about the hypothesis that higher 56 Lantz, Jacobson, Warner, et al

cigarette prices lead to significant reductions in Recent innovations in youth smoking Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from youth smoking.103 prevention and control Re-examining the longitudinal data used by The purpose of this section is to identify DeCicca and colleagues, Dee and Evans found emerging trends and promising innovations in a negative and significant impact of cigarette policy and programmatic responses to youth taxes on smoking initiation.104 They argued smoking. In considering programmes to inves- that DeCicca and colleagues’ finding that price tigate further and to implement, tobacco has no impact on smoking initiation was largely control advocates and policy makers might the result of the way in which their sample was want to be familiar with emerging programmes that have received little to no evaluation atten- constructed. Their estimated price elasticity of tion to date. We stress that this section provides smoking onset is −0.63, consistent with several neither a comprehensive nor systematic review. other recent studies of youth smoking employ- Rather, this section represents an attempt to ing cross sectional data. Clearly, the use of provide information about major themes that longitudinal data to examine the impact of are referred to in published reports and in the cigarette tax and price changes on smoking media, that recur in reports on the internet of initiation and cessation is an important current tobacco control activities, and have advance. The findings from studies using rela- emerged in our interviews and interactions tively longer panels that control for unobserved with tobacco control advocates and profession- state and/or individual factors aVecting als. In addition, it is important to emphasise demand100 101 are consistent with the findings that the majority of strategies described below that price sensitivity is inversely related to age. have received no or only cursory evaluations. Evans and Farrelly recently examined a phe- Thus, while some of these approaches may be nomenon not previously studied by econo- compelling or appear to have promise, there is mists: the compensating behaviour by smokers little to no empirical evidence to support in response to tax and price changes.105 Specifi- claims about their worth or eVectiveness at this cally, they found consistent evidence that, point in time. although smokers reduced daily cigarette con- sumption in response to higher taxes, they also SMOKING CESSATION INTERVENTIONS The results of a number of descriptive studies compensated in several ways. In particular, and focus group studies suggest that many teen smokers in high tax states consumed longer smokers are motivated to quit smoking. It has cigarettes and those that are higher in tar and been estimated that 74% of occasional teen nicotine, with young adult smokers also most smokers and 65% of daily users have a desire to

likely to engage in this compensating quit, although some studies suggest that the http://tobaccocontrol.bmj.com/ behaviour. As a result, they argued that the success rate among those who do attempt to perceived health benefits associated with quit is low.106 107 Sargent and colleagues found higher cigarette taxes are likely to be somewhat that smoking cessation rates among adoles- overstated. Given this compensating behav- cents were comparable to adult rates, and var- iour, Evans and Farrelly suggested that if ciga- ied according to smoking status (46.3% among rette taxes are to be used to reduce the health occasional smokers, 12.3% among daily smok- consequences of smoking, then taxes based ers of 1–9 cigarettes, and 6.8% among daily 108 on tar and nicotine content would be smokers of > 10 cigarettes). appropriate.105 This is a controversial idea, An important conclusion of several studies however, that can be criticised on other of adolescent smoking is that it is important to grounds.70 Concerns include: that such a policy intervene to keep occasional smokers from

becoming daily smokers. Yet,the results from a on September 29, 2021 by guest. Protected copyright. conveys the impression that low tar and large focus group study of high school smokers nicotine cigarettes are less hazardous, although suggest that adolescents are unfamiliar with this is not at all clear; that as people shift to low the concept of a smoking cessation programme tar and nicotine brands their daily or with other tools or methods that support consumption may increase to compensate; and quit attempts.109 Participants were not that if such a tax varied across states, it might interested in seeking help or assistance from increase cigarette smuggling. any professional person or service in attempting to quit, including physicians. Concerns about confidentiality and parental Summary The evidence on the degree to which teenagers involvement were strongly voiced. Unfortunately, as Sussman and colleagues are responsive to changes in cigarette prices is documented in a recent review article, there mixed, but the general consensus is that higher have been very few controlled trials of eYcacy prices are an eVective deterrent to youth smok- regarding adolescent smoking cessation.110 ing. Because cigarette price increases have Brief oYce interventions delivered by health been relatively small (under a dollar and, in care professionals hold great promise as a ces- many cases, just a few cents), it is diYcult to sation strategy among smokers, especially predict with confidence the impact that a large those who are not yet addicted to nicotine. price increase—such as a dollar or more per There is a clear need for training regarding pack—would have on teenage cigarette smoking cessation interventions among consumption. The eVects might be expected to clinicians serving adolescent patients. Frank be proportionately greater than those of a small and colleagues reported that while over 50% of tax increase. adult smokers who had seen a physician in the Smoking prevention and control strategies 57 Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from past year were counselled to quit smoking, only Peer based interventions 14% of smokers aged 12–17 had received ces- A major trend in school based interventions is sation advice.111 Similarly, data from the 1993 the use of peer education programmes like Teenage Attitudes and Practices survey Teens Against Tobacco Use (TATU), which showed that only 25% of 10–22 year olds has had programmes in many states. These report that a healthcare provider had discussed programmes, sponsored by the American Lung cigarette smoking with them.112 Research has Association, train older students to become shown that most pediatricians feel confident positive role models for middle and elementary and prepared to address issues regarding envi- school students. TATU interventions include ronmental tobacco smoke with their patients, multiple, intensive sessions during the first yet fewer feel comfortable advising paediatric phase, with “boosters” in subsequent years. patients and their parents on how to stop Prevention programmes often include a media literacy component (for example, teens learn smoking.113–115 A number of materials (included how the tobacco industry’s advertising savvy guidelines and quick reference guide) in has manipulated and distorted information support of clinician based interventions about tobacco). regarding smoking cessation are available from the Agency for Health Care Research and Recent anti-tobacco advertising campaigns Quality (formerly the Agency for Health Care 116 As a result of the perceived success of the hard Policy and Research) or the CDC. hitting anti-tobacco advertisements in Califor- In summary, the impact of smoking nia, several states have begun a new generation cessation interventions among adolescents is of anti-tobacco advertising. These ads can be not well understood.110 Until recently, formal characterised as youth oriented—high energy, smoking cessation programmes were aimed aggressive, fast paced, and in turn angry, exclusively at adults. An important recent sarcastic, and irreverent. They are also now trend, however, is an increase in the number of being youth influenced, with teens being part such smoking cessation programmes now of the production process under the available for youth. Given the cost eVectiveness assumption that teens best know how to appeal of smoking cessation interventions for adults, to other teens. For example, as a result of its and the large number of addicted teenagers, 1997 settlement with the tobacco industry, research on cessation programmes tailored to Florida launched the “Truth” ads, which were youth is an important area and should be a meant to “demonise” the tobacco industry. high priority.117 118 The Truth/SWAT (Students Working Against Tobacco) messages were partially designed by

teens and specifically aimed at teens. Initial http://tobaccocontrol.bmj.com/ Computer based systems evaluation reports indicate that the ads reached An important emerging trend is the use of 92% of teens and significantly increased computer based systems to communicate mes- their negative attitudes toward tobacco sages about tobacco to teens. Some of these companies.122 innovations have been evaluated, but because There is no agreement on the best approach most are in various stages of development and to media counter advertising, and states are implementation we consider them under the using a variety of models for their anti-tobacco category of new innovations. For instance, advertisements.123 The current anti-smoking Innovative Training Systems is developing a ads in California continue previous anti- computer game designed to educate children industry messages. In a slightly diVerent about the harms from tobacco products.119 approach, Florida ads focus on youths asking

Former surgeon general C Everett Koop is the industry to be truthful. Arizona ads oVer on September 29, 2021 by guest. Protected copyright. developing a similar system.120 The advantages the message that smoking is neither cool nor of these eVorts, if successful, are their low cost healthy, while ads in Massachusetts concen- and adolescent receptivity to computer based trate on adverse health eVects. At this point, it information. is too soon to tell whether the heightened As an example of a recently evaluated awareness of these ads will lead to lower youth programme, Pallonen and colleagues described smoking rates. two new computerised self help smoking cessation programmes for adolescents.121 In the Penalties for possession and use. A controversial initiative that has emerged first intervention, the authors adapted a recently is the increasing willingness of policy computer system based on a model of adult makers to fine underage youth for using smoking behaviour change to adolescents. For tobacco products. Until recently, policy makers the second intervention, they used a teen focused on penalising the vendor for an illegal smoking cessation clinic programme developed sale to minors as opposed to the user.90 Under by the American Lung Association. The results pressure from retail merchants’ associations, suggested reasonable cessation attempts and and perhaps out of frustration that “supply initial success (14–20%), but decreasing cessa- side” policies have not adequately discouraged tion rates (6%) after the six month follow up youth tobacco consumption, policy makers survey. The authors noted that the technology have begun to enact laws that fine minors for and approach are at an early stage of develop- smoking in public or possessing tobacco prod- ment, but that this study supports the feasibil- ucts. Tobacco control advocates have ity of using computer based systems in adoles- vociferously protested this approach as an cent smoking cessation interventions. attempt to shift attention away from vendors 58 Lantz, Jacobson, Warner, et al Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from who sell tobacco products to minors. Vendor penalties Regardless, this shift appears to be gaining There do not appear to be any significant inno- momentum. As with many of the more well vations regarding actions against retail vendors established prevention strategies, we have no who sell tobacco products to minors, but there information on whether user fines will discour- are some nascent trends to watch. For age youth from smoking. example, one trend may be local licensure of Minors caught smoking or in possession of tobacco vendors and increasing penalties for cigarettes can face a variety of penalties, illegal sales to minors. Fines in Utah start at ranging from a ticket or fine to an appearance $250 and go up to $10 000. Despite the poten- in smoking courts, suspension from school, tial financial penalty for non-compliance, the denial of a driver’s license, or any combination volume of violations was so great that a tobacco of these. Fines diVer widely in severity, some court was instituted in 1998. Local licensure is important because municipalities are more starting as low as $25, and increase with repeat likely to monitor compliance and threaten violations. Fines can also be combined with licensure removal than state agencies.90 tobacco education or cessation classes. Some areas allow for the removal or denial of the Restrictions on the sale and marketing of tobacco oVender’s driver’s licence. For example, products minors in Florida may lose their licence or be One way to restrict youth access to tobacco legally prohibited from attaining one if found products is to remove the products from areas in violation of the state’s 1997 possession law. where youth can go. For example, recent Driver’s licence suspension or denial appears restrictions on vending machines have been to be reserved for repeat oVenders; licences are eVective in removing them as a source of ciga- usually reinstated within a period of three to six rettes for minors. An emerging trend is to months. restrict self service displays of cigarettes. An important innovation to watch is the use Vendors oppose such restrictions because self of teen smoking courts. Florida, Indiana, Utah, service displays enhance sales. Another area of and various counties in other states are experi- marketing restrictions involves billboard adver- menting with teen smoking courts, where teens tising. The issue of billboard tobacco advertis- must appear with their parents. The experience ing was addressed in the 46 state tobacco is more like a prevention programme than a settlement, which stipulates the removal of traditional court. In Plantain, Florida, a trip to billboard advertisements by April 23, 1999. the teen smoking court includes a lecture by a Even before that, several communities had throat cancer survivor, an anti-smoking video, banned or restricted the use of billboard adver- and an appearance in front of the judge. The tising. Most restrictions concern the area in http://tobaccocontrol.bmj.com/ smoking court in Linn County, Oregon “tries” which the ads are located. first time oVenders using teen prosecutors and teen juries in an attempt to stop tobacco use Direct restrictions on smoking. Policy eVorts to restrict public smoking have before the transition to routine or addicted 125 smoker. proliferated since the 1980s. Such eVorts include state and local restrictions on smoking in public facilities and outdoor spaces, in School policies worksites, in hospitals, in restaurants and bars, Schools may have their own smoking policies, in hotels and motels, and on airline which can apply even to those students over 18 flights.73 126 127 Brownson and colleagues years old. Penalties for violations include fines, concluded that public smoking bans appear to

smoking education and cessation classes, be eVective in reducing non-smokers’ exposure on September 29, 2021 by guest. Protected copyright. informing the student’s parents, and suspen- to environmental tobacco smoke, and that sion and/or expulsion. In 1997, Jacobson and work site bans do influence the intensity of 126 Wasserman reported that schools were not very smoking among workers. Such bans may also aggressive in enforcing no smoking rules and have a positive impact on quit rates. considered it to be a low priority.73 It appears, Some econometric studies of teenage and however, that schools are increasingly willing to young adult smoking behaviour found evidence that clean indoor air laws may reduce develop, implement, and enforce no smoking teenage cigarette consumption. Wasserman policies. Recently developed school smoking and colleagues found that imposing strict regu- policies seem to use a combination of lations on smoking in public places can signifi- punishments, rather than just fining or cantly reduce the number of cigarettes suspending students. Pentz and colleagues consumed by teenagers.95 Similarly, Chaloupka found, in a study of 23 schools in California, and Grossman, using data from the that schools with smoking policies with four Monitoring the Future project, found that components (that is, a smoking prevention restricting smoking in public places signifi- education plan is in place and students ae cantly reduced the prevalence of youth restricted from smoking on school grounds, smoking, and that restricting smoking in when leaving school grounds, and when near schools, in particular, reduced the average school grounds) had lower rates of self reported number of cigarettes smoked by young smoking among the students.124 Although not a smokers.128 Finally, Chaloupka and Wechsler controlled study, these results suggest that found that laws restricting smoking in strong school smoking policies are associated restaurants and schools significantly lowered with decreased rates of youth smoking. college students’ smoking participation rates.97 Smoking prevention and control strategies 59

Although the reasons why such laws may be Equally important, there is great potential for Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from eVective in reducing youth smoking are these interventions to be cost eVective. Even unknown, one could speculate that they simply modest gains from prevention and cessation reduce the opportunities available for smoking. eVorts could lead to substantial reductions in Alternatively, or perhaps in conjunction with the morbidity and mortality costs of these reduced opportunities, clean indoor air smoking.135 Our assessment and recommenda- laws may be a useful vehicle for creating a cul- tions are similar to those of the CDC regarding tural norm that suggests smoking is socially “best practices” for comprehensive tobacco unacceptable. control programmes.136 We recommend that significant attention be given to the following Interventions that focus on adolescent risk taking strategies. in general and/or on problem behaviours Youth smoking occurs in a web of social MEDIA CAMPAIGNS relations that foster many types of adolescent Evidence from hard hitting state sponsored experimentation and that also may foster prob- anti-tobacco campaigns suggest that a lem behaviours. Because of this social context, sustained media campaign against smoking youth smoking arises from some of the same can be a successful strategy. At this point, we family, peer, and community influences that are not prepared to recommend a particular are also important to sexual risk taking, crime media strategy among those now being tried. and violence, and the initiation of harmful According to the available evidence, one shot alcohol and illicit substance use.129 130 Existing campaigns are not likely to change behaviour. prevention research regarding other adolescent Rather, a plan for a multi-year campaign that problem behaviours therefore has potentially utilises a strong social marketing approach— important implications for the design and and also incorporates a rigorous evaluation evaluation of programmes to curb youth smok- component—should be developed and imple- ing. Such interventions for older adolescents mented. In addition, more research is needed are often focused on improving academic skills. to examine whether and how tobacco advertis- Many are also aimed at creating a sustained ing has been successful in reaching children relationship with adult advisors or mentors and convincing them to use tobacco products. who can provide social and emotional support Once more information is learned, these while reinforcing appropriate social norms marketing techniques can be used to the regarding substance abuse and other advantage of anti-tobacco groups and state behaviours.130 131 An additional approach organisations in developing eVective media involves “family focused” interventions. Biglan messages.

purported that there is a “great deal” of http://tobaccocontrol.bmj.com/ evidence supporting the eYcacy of family TEEN CESSATION PROGRAMMES focused interventions regarding substance Almost all of the attention on smoking abuse, including interventions that address the cessation has focused on adults.110 Our review multiple factors aVecting family functioning.132 suggests that eVorts to develop and implement A small, but potentially interesting literature adolescent smoking cessation programmes for policy makers to consider examines the should be accelerated. It is particularly impor- eVectiveness of interventions designed to deal tant to target adolescents who are just at the with behaviour that indicates a propensity to transition point before or after habitual use tobacco products. For example, Kellam and smoking begins. The evidence at hand suggests Anthony conducted a randomised prevention that, although the processes by which nicotine trial to determine whether interventions target- dependence develops in adolescence are not

ing aggressive or disruptive classroom well understand, teenagers certainly can and on September 29, 2021 by guest. Protected copyright. behaviour—an early antecedent to smoking— do become addicted to nicotine.137–139 There is would reduce adolescent use of tobacco.133 a need to reconsider the use of nicotine Using the “good behaviour game” or the “mas- replacement therapy for adolescents. Cur- tery learning curriculum” as the behavioural rently, these therapies are unavailable legally to intervention, the authors found that tobacco persons under 18, and very few studies have initiation for disruptive boys who were assigned assessed eYcacy and safety in adolescents.139–141 to the intervention was lower than the control As Patten concluded in a recent review article, group. There were no diVerences for girls. The much research is needed to evaluate the authors conclude that these results suggest tar- benefits of nicotine replacement therapies in geting early risk factors for tobacco use as a adolescent smokers, and to assess adjuvant complement to subsequent prevention activi- behavioural interventions tailored to adoles- ties. This finding is consistent with Hu and col- cents’ unique developmental and psychosocial leagues, who found that higher academic characteristics.141 performance is associated with a lower probability of smoking and that policies CHANGING THE ENVIRONMENT directed toward improving academic perform- Although the focus of this article and of the ance may also reduce adolescent tobacco use.134 recommendations is on adolescents, it is important for tobacco control advocates to Discussion consider how to change the overall Our review suggests a number of prevention environment that induces adolescents to strategies that are promising, especially if con- initiate tobacco use. One problem with ducted in a coordinated way to take advantage targeted prevention strategies is that a single of potential synergies across interventions. programme cannot always or perhaps even 60 Lantz, Jacobson, Warner, et al Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. Downloaded from often prevent smoking if the environment sur- INCREASING CIGARETTE PRICES rounding the child encourages tobacco use. Raising excise taxes and increasing the price of Cigarette advertising, easy access to tobacco cigarettes is likely to have an observable impact products, and tolerance toward smoking are on youth smoking. Adolescents are price sensi- only some of the issues that may contribute to tive. Even if adolescents still have access to high rates of youth smoking. We believe that an cigarettes through friends and family, higher aggressive approach to changing the social prices are likely to result in fewer routine context of smoking would include: (1) an smokers and perhaps fewer cigarettes emphasis on smoking cessation among adults consumed by occasional smokers. Therefore, in an attempt to reduce the amount of smoking eVorts to increase state and federal tobacco among adult role models for children; (2) the excise taxes should continue. expansion of state and local clean indoor air laws; and (3) rigorous enforcement of illegal INVEST IN PROGRAMME EVALUATION tobacco sales to minors. One possible explanation for the mixed results of smoking prevention and control pro- grammes for youth is inadequate programme SCHOOL AND COMMUNITY BASED EFFORTS evaluation. One of the most significant barriers Despite the mixed results of previous school to implementing eVective prevention pro- based eVorts, prevention programmes based on grammes is translating a successful, but small a social influence model have shown to have scale and tightly controlled, intervention to the short term eVects on middle school students, community.46 142 Once the intervention has the time when students are most likely to initi- reached the community it is often assumed to ate smoking. Unfortunately, little is known be eVective without any further evaluation. about the eVect of these interventions when Our review suggests that the failure to evaluate they are removed from a highly controlled youth prevention programmes is a serious defi- research setting and implemented on a large ciency in being able to defend additional scale in schools. We suggest that policy makers investments in youth tobacco control eVorts. should focus on taking advantage of synergies Many new innovations appear promising. between diVerent strategies, especially school However, they all need rigorous programme and community based programmes. One possi- evaluation in order for us to understand better bility for expanding school based interventions the magnitude of the eVects, whether or not is to combine them with community based pro- diVerent groups of youth respond diVerently to grammes that use a social influences model and the intervention, the costs involved, and the also target the familial environment and the barriers and facilitators to programme

overall sociopolitical context of the community. implementation. http://tobaccocontrol.bmj.com/ We recognise that tobacco use is not the only risk taking behaviour in which many Conclusions adolescents engage. Thus, it is important in the The most obvious conclusion from this review is development of new interventions to view ado- that adolescent smoking prevention eVorts have lescent smoking in the context of broader had mixed results. It is also clear that no one developmental issues, and to recognise that, for approach is likely to reverse that finding. Despite some youth, smoking serves as a marker for a considerable amount of additional research other behavioural problems. and a wide range of new and innovative preven- School and community based interventions tion strategies, we cannot say that there are any should also explore the use of computers in new revelations about the eVectiveness of these their programmes. Adolescents represent a programmes beyond the conclusions reached by 14

perfect audience for using emerging computer the surgeon general and the IOM in 1994. As on September 29, 2021 by guest. Protected copyright. based anti-smoking strategies. The develop- a result, advocating for a focus on youth ment and expansion of computer based smoking prevention and control is somewhat systems presents a unique opportunity to take controversial. Some policy analysts have advantage of technology that most adolescents suggested that the focus of public policy should are comfortable with and to adapt be to reduce teenage smoking initiation anti-smoking messages to individual needs and rates.1473 Others have suggested that the focus circumstances. on children will undermine the broader and Our review suggests that most school based likely more fruitful initiatives and programmes prevention programmes target students in the needed to attack smoking and to promote ces- elementary and junior high school, while high sation among adult habitual smokers.40 school students are often ignored. High school From a practical perspective, these diVerent students may receive “booster” sessions, but policy views are not mutually exclusive. Both these sessions are often unconnected to the can be implemented simultaneously, and should interventions received in junior high. High be considered as complementary rather than school students are also excellent candidates competing strategies. From a public health per- for participating in sting operations, lobbying spective, we are appropriately concerned that for anti-smoking legislation, and becoming the prevalence of youth smoking remains high peer educators for children in their despite the amount of resources already devoted community. Interventions using peer educators to this problem and the wide array of should be evaluated both for their impact on interventions that have been tried. Yet, it is pos- the children receiving the programme and for sible that without these interventions, rates of the eVect of reinforcing non-smoking both experimental and habitual smoking among behaviour on the teens themselves. youth would be even higher. Smoking prevention and control strategies 61 Tob Control: first published as 10.1136/tc.9.1.47 on 1 March 2000. 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