Youth Tobacco Prevention - What Works? Sharon Barbour, MPH Regional Evaluation Specialist UW-Extension

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Overview of session “What works” in general Review of specific interventions and the amount of evidence supporting their effectiveness

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 “Youth Prevention” defined In this presentation, it includes: Preventing youth smoking initiation. Inhibiting progression from experimenter to addicted smoker. …and does not include: Cessation efforts. Reducing exposure to ETS.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Learning from what we currently know… Though evaluation research is still limited, enough exists to provide guidance regarding “what works” in youth tobacco control. As information grows, recommendations may shift. There is still some murkiness and contradiction. Your evaluations help to inform “what works” for your community & other communities. Keep it up!

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 What seems to work? In general… Youth prevention requires a comprehensive approach. There is no “magic bullet.” It requires a long-term commitment to inter-related initiatives that consider: Youth have many social arenas and influences inside and outside of school. Policy changes affect youth as well as adults. Changing social norms regarding tobacco use can make a long- term difference.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 The good news… Community coalitions are well-suited for doing this type of work! You… Are not tied to one issue, one approach, or one organization. Have many arms to reach into the community. Know your community.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Ok, but what do we do? Consider… Initiatives that have at least some proof of effectiveness. What you’re doing already. Interests, experiences, connections, strengths of coalition members. What your community is ready for. What will have greatest impact considering your resources.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Effectiveness research How did we determine the level of effectiveness for the various approaches? Reviewed individual studies. Reviewed analyses of multiple studies. Reviewed recommendations of the Surgeon General, CDC and others. Interviewed state tobacco control experts.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Comprehensive approach - key components appear to be: Cigarette price increases. Intensive media campaigns. Strongly enforced tobacco advertising bans. Strongly enforced bans on smoking in public places. School programs that include a curriculum based on best practices & the social influences approach. “Effectiveness of Comprehensive Tobacco Control Programs in Reducing Teenage Smoking: A Review.” Wakefield M, Chaloupka F, July Surgeon General’s Report 2000, CDC’s Best Practices guidelines 1999

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Effectiveness overview Most proof of effect: Taxes Media Some proof of effect: Smoke free public places Smoke free homes School-based programs IF… Ad bans and restrictions IF…

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Effectiveness overview, continued Promising: Youth led movements/empowerment Inconclusive research: Youth access restrictions Youth possession penalties Proof of no effect: Single events not tied to other program activities School-based curriculum that does not follow “best practices” (to be reviewed)

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Most Proof: Increase price Increase price of tobacco products Youth are most sensitive to price increases 10% increase in price results in an approximately 7% decrease in youth smoking. Guide to Community Preventive Services systematic review, Also: Smokefree Wisconsin website

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Most Proof: Increase price The price to smoking behavior relationship is not linear. A 20% increase in price may lead to closer to a 20% decrease in youth smoking. David Ahrens, Program Manager, Monitoring and Evaluation Program for Wisconsin Tobacco Control

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Price: What you can do Assist SmokeFree Wisconsin’s “Wisconsin Children’s Initiative” to increase excise tax by 85 cents. This represents a 20% increase in cigarette price and could translate to a 14-20% decrease in youth smoking as well as funds for health-related programs in Wisconsin.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Price: What you can do Help build support in your community for the Wisconsin Children’s Initiative. Community Education (letters to editor, educate policy makers, etc.) Recruit endorsing organizations. Your coalition can sign on as an endorsing organization! Note: WTCB funds cannot be used in support of the tax increase.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Price: What you can do Contact Maureen Busalacchi at SmokeFree Wisconsin regarding the initiative at Ask her about upcoming speaker trainings. See the SmokeFree Wisconsin web site: Click on the WI Children’s Initiative logo on the left side bar.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Increase Price: Phillip Morris agrees! “It is clear that price has a pronounced effect on the smoking prevalence of teenagers, and that the goals of reducing teenage smoking and balancing the budget would both be served by increasing the excise tax on cigarettes.” – Phillip Morris - Phillip Morris Research Executive, PM document No , September 17, 1981.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Most proof: Mass media “When combined with other actions,” mass media campaigns can: Reduce tobacco initiation. Median decrease of initiation: 8% Decrease consumption. Median decrease of consumption: 15 packs per capita per year Increase cessation.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Mass media: What you can do Use state media campaign messages to strengthen your media and the state’s media efforts. Use messages in your programs that have been shown to “speak” to youth: industry manipulation: youth as targets and pawns of ‘big tobacco.’ Most youth actually do NOT smoke. Less effective messages are: short and long term health effects (most youth know these).

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Some proof: Clean indoor air - public places This strategy is proven to be effective in changing adult smoking behavior. Unfortunately, its effect on youth has not been studied until very recently. It appears that clean indoor air is a powerful strategy for youth as well as adults.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 “Policy Ecology” Policy changes such as clean indoor air policies often lead to multiple impacts. This web of effects is a welcome phenomena for those with few resources to facilitate change!

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Policy ecology example: Clean indoor air - public places Effects: For all: Change social norms For all: Reduce environmental tobacco smoke exposure For adults: Decrease consumption and increase cessation For youth: One study - earlier stages of uptake and less likely to be current smokers - Wakefield MA. “Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: Cross sectional study.” British Medical Journal. 2000:321(7257); ).

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Another web of effect example… Smoke free worksite policy leads to: More quit attempts and fewer adults smoking (= fewer models for youth) More homes with smoking policies Fewer kids smoking

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Clean indoor air - public places: What you can do Contact SmokeFree Wisconsin for assistance with working toward smoke- free environments and click “what works” “How to” info is also available at Americans for Nonsmokers’ Rights:

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Growing proof: Clean indoor air – private homes ONE study showed that teens living in homes with smoking bans were less likely to move through the early stages of smoking – even when the parents were smokers. This effect was stronger than the effect caused by bans in public places. - Wakefield MA. “Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: Cross sectional study.” British Medical Journal. 2000:321(7257); ).

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Smoke-free homes: what you can do Contact American Lung Association of Wisconsin to learn about the “Take it Outside” program Phone: (262)

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Smoke-free homes & pledges… Issues to consider: If you collect smoke-free homes pledges, find out who is pledging – are they already nonsmokers? How do you reach those who smoke? How can you foster community buy-in for the program to increase its effectiveness?

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Clean indoor air & youth cessation An interesting note… Teenagers who are told that environmental tobacco smoke (ETS) harms others are more than twice as likely to quit smoking as teens who are not told of the dangers of ETS. Glantz s and P Jamieson. “Attitudes Toward Secondhand Smoke, Smoking, and Quitting Among Young People,” Pediatrics 106(6): e82 (December 2000)

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Some proof: Ad bans and restrictions…IF… There is a complete BAN that is strongly ENFORCED, it may reduce total tobacco consumption by 6%. Note: Ad bans are currently illegal. Youth-specific estimates appear to be quite small. Partial bans are likely ineffective as they allow industry to shift ad dollars to other forms of promotion. The research is very mixed. - Jacobson PD, P Lantz, K Warner, J Wasserman, H Pollack, A Ahlstrom. Combating Teen Smoking: Research and Policy Strategies. University of Michigan Press,

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Ad bans and restrictions: What you can do Consider participating in “Community Ad Watch” and inventory tobacco ads in your community. It’s a good way to monitor the industry, involve youth and educate and mobilize your community. Contact: Erich Mussak at UW Comprehensive Cancer Center for a manual and info:

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Some proof: School-based curriculum IF… You follow “best practices” guidelines Are most effective when they are: part of comprehensive school program connected to community initiatives

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 School-based curricula More details follow regarding school-based initiatives because today’s topic is youth, most coalitions are already doing this work, and schools are an important part of a comprehensive tobacco control program. However, remember that school-based initiatives alone are not as effective as some other approaches. In fact, they have been historically ineffective.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Reasons why school-based programs have been historically ineffective Programs “that work” are not necessarily the most used and not taught as designed. There is a shortage of “linking agents: persons or groups that have a strong incentive for maintaining a program and promoting its continuation” - US Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Office on Smoking and Health, 2000, p. 84.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Reasons why school-based programs have been historically ineffective Youth operate in a “larger classroom” outside of school which has powerful spheres of influence. Curriculum may impact those at the lowest risk of becoming addicted smokers.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Curriculum Best Practices Programs based on the social influences model are most effective. The main goal of the model is to “equip younger adolescents with specific skills and other resources that would help them resist direct and indirect social influences to try smoking…” - US Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Office on Smoking and Health, 2000.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Social influences, examples Environmental Tobacco use in public places and home, advertising, peers Cultural Acceptance and rates of smoking vary by cultural groups. Familial Parents’ smoking status and attitudes

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Social influences model - Include four areas of learning: Emphasize the short term effects of smoking (yellow teeth, bad breath) & advantages of remaining non-smoker Correct misperceptions: Most importantly, teach that most teens do not smoke. Discuss social influences on decision to smoke. Provide training in refusal skills.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Also important for effectiveness… Number of contacts the program makes The use of booster sessions, even telephone contacts seem to help sustain the effect on smoking initiation. Starting early and continuing Curricula often begin in the 6 th or 7 th grade. It is important to continue contacts through high school, even if only with booster sessions.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Two “Programs that Work” CDC’s “Programs that work” initiative highlights two school-based programs: Project Toward No Tobacco Use (Project TNT) Life Skills Training (LST)

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 For more info… Go to CDC site for more on curriculum and evaluation findings for both programs: curric.htm

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Other recommended curricula and elements of comprehensive school- based program See “Resources for School Tobacco Programs: A Selected List” Distributed by Wisconsin Department of Public Instruction, 2001

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 What about Teens Against Tobacco Use (TATU)? TATU seems to be very popular. However, there is no evaluative data on its effectiveness. Content and implementation varies. In order to increase its effectiveness, incorporate best practices.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Comprehensive school-based programs CDC recommends strengthening school-based curriculum by using a multifaceted approach: Tobacco-free policies Teacher training Parental involvement Cessation services Link to community coalition work and statewide counteradvertising campaigns - Centers for Disease Control and Prevention (CDC). Best Practices for Comprehensive Tobacco Control Programs. August, 1999.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 School programs: what you can do Your most effective role is to work with schools as change agents, not as direct student educators. That is, help schools choose curricula that follow best practices or modify existing curricula. Help them expand their programs to be more comprehensive. Acting as direct student educators is probably not an effective role for coalitions.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 What you can do, con’t. Link school-based programs to other community tobacco control activities. Why? Because even successful school-based programs may not be effective in the long run beyond delaying smoking initiation. This is likely because of the cumulative influences outside of school. Thus, keep working at the community level and tie that work with the schools or youth in general.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Where is Philip Morris on this one? The tobacco industry has generally been supportive of school programs. Why? According to PM: ‘anti-smoking attitudes the [children] have learned in school and elsewhere can be unlearned or replaced by pro-smoking norms held by others their own age or a little older.’ – Phillip Morris document

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Promising: Empowerment/Youth- Led Movements May help change social norm Encourages activism in tobacco control No evaluative data yet: See American Legacy Foundation reports for updates on their evaluation efforts:

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 What we do know.. We don’t know how effective youth-led initiatives are but we do know that including youth in your planning and implementation will make your programs more appropriate for your target audience: youth! Youth can add credibility, insight and energy!

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Inconclusive Youth access restrictions Regulation of sellers & buyers Regulation of where & how sold Regulation of free product distribution Youth possession penalties

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Proof of no effect Single events not tied to program. School-based curriculum that does not follow “best practices.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Summary Most effective: Cigarette price increases Media – counteradvertising Probably effective: Enforced Smoke Free Environments Enforced ad bans and restrictions Comprehensive school-based programs Promising: Youth-led movements

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Summary, cont. Inconclusive Youth access restrictions Youth possession penalties No effect Single events not tied to program School-based curriculum that does not follow “best practices”

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 Phillip Morris (mostly) agrees again! “It is said…that three things threaten our tobacco business: Taxation, Marketing Freedoms and ETS.” Phillip Morris Document Bates # Note: Quote made before initiation of intensive counteradvertising campaigns.

Monitoring and Evaluation Program University of Wisconsin-Extension, Cooperative Extension Copyright 2002 What you can do - stay informed… The Community Guide (CDC) Reviews of youth access restrictions, school-based initiatives, and tobacco industry & product restrictions slated for summer Journals Tobacco Control Journal of American Public Health Assoc. Pediatrics