Fooyin J Health Sci 2010;2(3−4):72−84 ORIGINAL ARTICLE A Successful Intervention to Reduce Cigarillo Use Among Baltimore Youth Fei-Kai Syu1,2, Ming-Yii Huang3, Joh-Jong Huang4* 1Division of Medical Research, Fooyin University Hospital, Pingtung, Taiwan 2School of Public Health, Johns Hopkins University, Baltimore, United States 3Department of Radiation Oncology, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan 4Department of Family Medicine, Yuan’s General Hospital, Kaohsiung, Taiwan Received: April 15, 2010 Revised: September 7, 2010 Accepted: September 14, 2010 A recent survey demonstrated that in 30 days, almost a quarter (23.9%) of African Americans aged 18−24 years in Baltimore smoked a Black & Mild, a popular cigarillo brand at least once. The theory of reasoned action (TRA) is the best-fitting theoretical model to use for intervention because it has been shown to be a good predictor of smoking behavior among adolescents. We have devised a campaign that involves both active advertising and the creation of an informational website, which can be used to learn about the consequences of cigarillo smoking. Smokers have decreased the number of cigarillos smoked per day by 1, and in particular, there was a dramatic decrease in smokers in Baltimore after the campaign. Particularly, positive impression in both groups tended to have differences in statis- tics before and after the campaign. In conclusion, our results show that the campaign was successful. We intend to expand it to other cities throughout the United States where cigarillo use is prevalent. Key Words: African American; Baltimore; cigarillos; inoculation theory; theory of reasoned action Introduction cigarillo use has been observed among 8th and 9th graders,12−32 and among children as young as 11.25 While not much larger than a cigarette, a cigarillo In fact, middle schoolers are more likely to smoke is classified as a cigar, which is defined as a “roll of Black & Milds than high schoolers.32 Overall, Black & tobacco wrapped in leaf tobacco or in any sub- Milds are the most popular brand of cigars for US stance containing tobacco”.1−11 A recent survey has youths and adults aged 12−25 years.33−35 shown that over a 30-day period, almost a quarter John Middleton Inc., manufacturer of Black & (23.9%) of African Americans aged 18−24 years in Milds, has seen revenue growth of 10% annually Baltimore smoked a Black & Mild, a popular cigarillo since 2002, driven by sales of Black & Milds.2 Even brand, at least once.3 The Baltimore City Health more worrisome, the company was just bought by Department3 has also reported that Black & Milds Philip Morris in November 2007. While announcing are popular among African Americans aged 12−17 the $2.9 billion purchase, Philip Morris CEO Michael years. Although quantitative data have not been col- Szyman czyk said he plans to “accelerate the Black & lected nationally for youths younger than 18 years, Mild brand’s market share growth momentum.”2 *Corresponding author. Department of Family Medicine, Yuan’s General Hospital, No. 162, Chenggong 1st Road, Kaohsiung 802, Taiwan. E-mail: [email protected]. ©2010 Fooyin University Hospital Cigarillos and cigarettes among Baltimore youth 73 Since cigars are made from the same basic mate- times seen in 4 weeks) = 4-week TRPs];30 (5) to show rials as cigarettes, people who smoke cigars are at reductions in self-reported sales of cigarillos from risk for the same health consequences as cigarettes Baltimore City retailers (primarily convenience smokers.22 These health consequences are well- stores) by 1% or higher. documented and include an increased risk of heart disease and stroke, as well as lung, mouth, esopha- Primary theory geal, bladder, and pharyngeal cancers.8 These health problems are associated with high mortality rates The theory of reasoned action (TRA)12 stipulates and result in over 430,000 preventable deaths an- that the intention to engage in a behavior is deter- nually in the US.9 Cigar smokers are have a slightly mined by attitudes towards that behavior and sub- reduced risk compared with cigarette smokers be- jective norms (Appendix A1). Attitude towards the cause they typically do not inhale directly.22 How- behavior is in turn determined by beliefs that the ever, unlike cigar smokers, cigarillo smokers typically behavior leads to certain outcomes and by evalua- inhale;25 therefore, they are likely to have similar, tion of those outcomes. Subjective norms are de- if not greater, health risks than cigarette smokers. termined by beliefs about how specific referents Black & Milds contain 5−12 times the amount of think the person should behave and by the degree nicotine as cigarettes, indicating a serious addiction of motivation to comply with the beliefs of those risk.25 Teens are at much greater risk of addiction referents. than adults because nicotine addiction occurs al- The TRA is the best-fitting theoretical model to most exclusively in adolescence.25 The younger an use for our intervention because it has been shown adolescent begins smoking, the more likely he or to be a good predictor of smoking behavior among she will have a strong addiction to nicotine,34 making adolescents.23 In fact, the TRA and modified versions future cessation more difficult. are also very accurate in explaining components of why adolescents initiate and continue smoking.24 The TRA has also been shown to be accurate in Materials and Methods predicting smoking behavior cross-culturally.13 Not only is the TRA a good predictor of smoking The goal of our intervention was to reduce the preva- among adolescents, but many effective anti-smoking lence of cigarillo use in African-American youth campaigns have used it to form the theoretical in Baltimore aged 12−17 years by 0.75% over an basis of their interventions. Although the use of 18-month period. We expected the baseline preva- specific theories is not explicitly stipulated in most lence to be approximately 23.9% of adults aged 18−24 anti-smoking campaigns, the use of the TRA is years. As a reference point to determine what change implicit in many of them.16 For example, Hersey is feasible, the American Legacy Foundation’s “truth” and colleagues16 argue that the successful “truth” campaign has been credited with a 1.6% reduction in counter-tobacco media campaigns in California, youth cigarette smoking over 3 years.10 While behav- Massachusetts and Florida all employed the TRA in ioral effects may not show a linear effect over time, developing their intervention goals and message con- we believe that a 0.75% reduction in 18 months is tent. For example, in the “truth” campaigns, mes- achievable. This time period was chosen as the time sages were chosen to increase negative beliefs about frame based on the Centers for Disease Control’s the tobacco industry. This created a social inoculation (CDC) recommendation to allow 18 months for a to- effect, changing attitudes toward smoking, reducing bacco media campaign to show effects on behavior.30 receptivity toward industry advertising, thus reduc- Our objectives (over the 18-month time frame) ing smoking intention and behavior.16 The TRA has included the following: (1) To determine the inci- also been shown to be effective in marijuana in- dence of cigarillo use among African-American youth terventions, especially when messages focus on the and reduce the baseline incidence by a factor of attitude-intention component of the TRA.29 As cig- 20%; (2) to increase awareness that cigarillos are arillo and marijuana smoking populations may signifi- not associated with a reduced risk of negative cantly overlap, this study further indicates that the health consequences by a factor of 50% of baseline; TRA is an appropriate model for our intervention. (3) to increase awareness of tobacco industry tar- It is important to note that although subjective geting of African-American youth by a factor of 30% norms play an important role in youth smoking of baseline; (4) following CDC recommendations, to initiation,15 the CDC does not recommend using reach 80% of Baltimore City youth aged 12−17 years interventions to change smoking norms because per quarter of a year, with 4-week target rating these interventions can be difficult to implement points (TRPs) of 400 or higher in the introductory and have not been found to be effective.30 We phase and 200 or higher throughout the rest of the hypothesize that youth likely trust the norms they campaign [(% of target audience seeing ad) × (no. of actually see around them more than those they 74 F.K. Syu et al are told about in advertisements. For these rea- outlining best practices based on evaluations of sons, we chose to focus on the attitude branch of previous state and national campaigns. In terms of the TRA for our intervention. An application of the content, the CDC report found that focusing on the attitudinal branch of TRA toward cigarillo use re- negative health effects of smoking and on the to- duction via emphasis on health risks and industry bacco industry’s practices of deception are the most targeting is shown and described in Appendix B. remembered and effective topics.30 These content We chose the TRA over the newer theory of areas are core components of the American Legacy planned behavior (TPB).1 Based on our literature Foundation’s national version of the “truth” ad review, research showed that although both theo- campaign, which has been found to be responsible ries are accurate and reliable in predicting behavior, for an estimated 22% of the youth smoking decrease the TRA or a modified version of the TRA is more among students in grades 8−12, down from 25.3% effective in planning youth smoking prevention pro- in 1999 to 18.0% in 2002.10 The effectiveness of the grams, whereas the TPB is more effective in plan- “truth” campaign agrees with our understanding ning smoking cessation programs.7,24 Given that our that addressing the attitude change aspect of TRA intervention is prevention-focused, we opted to use is a strong approach.