Youth Smoking:

Can it Be Prevented
or Reduced?

Cheryl L. Perry, PhD and Jean L. Forster, PhD

Division of Epidemiology
School of Public Health
University of Minnesota
Fall 2002
 Stage Model of Smoking Acquisition
Ever tried – even a few puffs?

1 No – Never Smoker Yes

Have you ever smoked a whole cigarette?

2 Yes Smoked > 1 whole cigarette?

No – Trier

2 No – Trier Yes

On how many of last 30 days did you smoke?

3 None – < Monthly smoker < 20 days 6 > 20 days – Established smoker

On how many of last 7 days did you smoke?

4 None – Experimental Smoker 5 At least one – Regular Smoker

 Smoking by Age and
Stage of Onset*

AGE
*Source: The MACC Study
 Direction of change in smoking behavior (%)
between senior year of high school and
5 - 6 years later.*

Smoking status 5-6 years later

Senior-year
smoking status
(use in past Number
30 days) Quit Less Use Same Level More Use Weighted

None 85.6 14.4 9,238

< 1 cigarette/day 57.8 14.4 27.8 1,268

1-5 cigarettes/day 29.6 8.8 17.2 44.4 1,058

About 1/2 pack/day 18.8 13.6 21.7 46.0 1,000

> 1 pack a day 13.2 17.7 40.2 29.0 869

*Source: Monitoring the Future Project, United States, 1976 - 1986 senior classes
 Predictive Factors of Youth
Smoking Onset

Socio-Demographic
Low SES
Developmental stage
Environmental
Access to cigarettes
Exposure to marketing
Peer use and support
Sibling use and support
Parental support
Normative expectations

Intra-Personal
Behavioral
Functional meanings of
smoking Academic achievement
Low self-image Behavioral skills
Self-efficacy to refuse offers Prior use of tobacco
Personality factors Other problem behaviors
 Stages of Smoking Onset and
Predictive Factors among Youth
Exposure to advertising, adult/sibling role models
who smoke cigarettes, and low academic
achievement
Peer influences to smoke, the perception that
smoking is normative and functional, and social
access to cigarettes.
Social situations and peers that support smoking,
low self-efficacy and skills to refuse offers to
smoke, and social/commercial access to cigarettes.
Peers who smoke, the perception that smoking has
personal utility, social and commercial access to
cigarettes, and few restrictions on smoking in the
home, school, and community settings.
Number of cigarettes smoked, frequency of
smoking, self-efficacy to refuse offers, peer
support for smoking, and other problem behaviors.
 Types of Prevention Programs
for Youth

■ School-based curricula
■ School environmental changes
■ Parental involvement
■ Teen cessation programs
■ Social and commercial access strategies
■ Mass media campaigns
■ Cigarette advertising and promotional bans
■ Price increases
 Stages of Smoking Onset and Most
Effective Smoking Prevention Programs
School-based curricula
Parental involvement
Mass media campaigns
Cigarette advertising and promotional bans
School-based curricula
School environmental changes
Parental involvement
Social access strategies
Cigarette advertising and promotional bans
Price increases
School-based curricula
School environmental changes
Social and commercial access strategies
Price increases
School environmental changes
Teen cessation programs
Commercial access strategies
Price increases
Teen cessation programs
Commercial access strategies
Price increases
 School-Based Curricula:
Pros and Cons

Pros Cons
Reach 95% of youth Schools resistant to
in schools new programs

Trained professional May not have time

teachers for proper
implementation
Adopted as part of
curriculum Limits on innovation

Part of core school mission

 School-Based Curricula to
Prevent Onset of Smoking

Grades 6-9 Ages 12 - 15 – time of acceleration of onset

Classroom-based Taught by teachers and peer leader

Dose Six to eight session per year over 2-3 years
Content Social influences approach, focusing on why
young people begin to smoke, social
influences, normative expectations, skills to
resist peer influences
Approach
Interactive classroom style, small group
discussions, peer involvement
Outcomes Consistent short-term 2-3-year reductions in
smoking as shown by individual studies and
meta-analyses
 Outcomes of the Life Skills
Training (LST) Program*
LST LST
(with teacher (with video
training) training) Control
Knowledge
Smoking prevalence 1.10d 1.16a .93
Smoking consequences 4.80d 4.60d 4.13
Smoking acceptability 1.49c 1.52d 1.37

Normative Expectations
Adult smoking 3.92a 3.95a 4.22
Peer smoking 3.80a 3.77a 3.92

Personality Measures
Self-esteem 34.25a 34.07 33.65
Self-efficacy 19.27 19.20 19.26
Social anxiety 28.71b 29.36 29.92

Smoking Behavior 1.46c 1.50b 1.63

a = p <.05; b = p <.01; c = p <.001; d = p <.0001

*Adjusted third-year follow-up mean for smoking-related knowledge,

expectations, personality measures, and behavior.
 “ 2 Smart 2 Smoke”

A theater production to encourage non-smoking

among elementary school-age children.

Key themes:
■ Smoking has short- and long-term consequences
■ Most people don’t smoke
■ Smoking is not “cool”
■ There are lots of ways to refuse offers to smoking

Play themes:
■ Ages 5 - 9: The Big, Bad Wolf is a smoker
■ Ages 10 - 12: Planet Tramsos – the new youth market
 “ 2 Smart 2 Smoke”Outcomes
■ 17 school randomized to “intervention” and “delayed
intervention control”

■ Intervention:
◆ Play
◆ Follow-up classroom activities
◆ Follow-up home activities

■ Questionnaire measured Knowledge, Attitudes, Intentions

■ Outcomes: Students were significantly less likely to say they
would NEVER smoke in both young and older groups.

Source: Perry, Komro et al., 1999

 School Policy/Environment
■ School policy on tobacco use should:
◆ Prohibit tobacco use by students, staff, visitors
➨ School property, off-site school functions
◆ Prohibit tobacco advertising in publications, at functions
◆ Prohibit items with tobacco logos on school property
◆ Include provisions for communication and enforcement
◆ Provide access and referral to cessation programs
■ 34 states prohibit smoking by anyone at school
◆ Rarely enforced
■ When enforced, bans on smoking in school
◆ Reduce smoking prevalence
◆ Reduce monthly consumption
◆ Prevent progression to regular smoking
■ No enforcement, no effect
 Parental Involvement

Pros Cons

Most potent Hard to reach

intervention
Need community support
Natural role models for
teens Have many issues to
address
Opportunity to punish,
reinforce, monitor
 Home Smoking Bans Are More
Effective with Teens than
Smoking Bans in Public Places

Odds Ratios for Association of Smoking

Restrictions with 30-Day Smoking Prevalence, High
School Students
OR 95%CI P value

Total Home Ban 0.79 0.67 - 0.91 <.001

Some Home Restrictions 0.85 0.74 - 0.95 <.01
School Ban 0.99 0.85 - 1.13 .86
Enforced School Ban 0.86 0.77 - 0.94 <.001
Other Public Restrictions .03
0.91 0.83 - 0.99
Source: Wakefield et al, 2000
Parental Involvement Programs:
Dissemination Knowledge by
Behavioral Postcards

Source: Perry, Komro et al., 2000

Teen Cessation: What Works?
 Teen Cessation: What Works?

■ Few programs evaluated or show positive

outcomes

■ American Lung Association: Not on Tobacco

(NOT)
◆ Non-school settings
◆ Small, same gender groups, 10 sessions
➨ Motivational issues

➨ Physical, psychological, social

consequences of smoking
➨ Skills for quitting, coping with family/peers

➨ Other healthy lifestyle behaviors

◆ Increases quit rate, decreases amount smoked

Teen Cessation: What Works? (Continued)

■ AMA-CDC protocol for healthcare settings

◆ 4 brief, clinic-based, 1-on-1 sessions with health
professional
◆ Content tailored to teen’s motivation, factors that
influence use
➡ Coping skills, awareness of tobacco use, quit
date

■ Follow-up through quitting process

■ Evaluation not completed
 Restrictions on Social &
Commercial Access to Tobacco

Pros Cons
Sends a message that the May draw attention away from
community considers teen other important tobacco
smoking a serious issue policies

Holds adults in many sectors Effectiveness depends on

responsible for preventing enforcement, resource
teen smoking intensive

Consistent with the serious Focus on youth may imply that

health consequences of adult tobacco use is
tobacco use acceptable

Politically controversial
 Flow of Tobacco to Youth

Illegal
sales
to < 18
youth

Legal Provision
Commercial sales Youth
outlets to 18+ smokers
adults Acquisition

Theft
by < 18
youth

Source: Forster et al, 1999

Sources of MOST RECENT Cigarette:
Past Month Smokers, Grades 8-10

Source: Forster et al, under review. N = 3991

Social Exchange of Cigarettes (Past
Month Smokers)
Smoking Level
<Daily Daily
N=1801 N=2207
Ever stolen cigarettes, not from a store: 20% 36%
Number of different teens you got tobacco
from, past month: None 16% 6%
1 24% 6%
2-5 51% 45%
>5 9% 43%

Number of different teens you gave

tobacco to, past month: None 44% 10%
1 19% 6%
2-5 30% 37%
>5 7% 45%

Ever sold tobacco to another teen: 28% 69%

Source: Forster et. al., under reivew

 Teens are more likely to get
cigarettes from and give cigarettes
to their friends if…

■ Siblings, most friends smoke

■ They smoke more

■ They perceive that their parents and the

community don’t care if they smoke

■ They usually BUY their own cigarettes

 Restricting Youth Access to
Commercial Sources of Tobacco

Local ordinance or state law that requires:

• Licensure
• License fee high enough to pay for checks
• Administrative penalties for licensee & seller
• Annual compliance checks
• No self-service of tobacco products
• Age 18 to sell tobacco
 Tobacco Policy Options for
Prevention Study: TPOP

■ Design:
Randomized community intervention study, N=14
■ Intervention goal:
Adoption of local ordinances restricting youth
access to commercial tobacco
■ Intervention methods:
Community organizing to promote mobilization in
support of ordinance
■ Outcome:
Youth smoking rate in communities
 TPOP Community Organizing Plan

Goal:
Reduce commercial availability to youth by
changing local policies and practices

■ Interview community members

■ Form strategy team
■ Educate for action, develop supporters
■ Present ordinance to city council
■ Ensure enforcement of ordinance
 Teen Smoking in Intervention and
Control Communities before and after
Intervention: TPOP Study

30

25
1993
20 1996
Percent

15

10

0
I C I C I C
Daily Smoking Weekly Smoking Monthly Smoking
net difference = -4.9% net difference = -5.6% net difference = -6.7%
p = .0275 p = .0705 p = .1009
 Mass Media Strategies
Aimed at Youth

Types: Television counter-advertising, radio ads,

print media, internet

Pros Cons
Reach large numbers Message may not be
of teens relevant
Can change social norms Superficial prevention
message
Can be linked to more
intensive interventions Expensive on primary
networks
Needs frequent updating
 Mass Media Campaign Message
Themes
Consequences of Smoking:
■ Short-term
■ Long-term
■ Family-related
■ Addiction
Social Norms and Imagery:
■ De-glamorization of smoking
■ Smoking not normative
Role Models:
■ Smoker is negative role model
■ Celebrities promote non-smoking
Industry and Product Focus:
■ Tobacco industry documents
■ Chemicals in cigarettes
Adapted from Farrelly
Second-Hand Smoke et al., 2002
 Smoking prevalence in University of
Vermont program using mass media to
prevent adolescent smoking
School program only
School program and media ca
30
Weekly smoking prevalence (%)

25

20

15

10

0
1 2 3 4 5 6

Study Year
Source: Adapted from Flynn et al. (1992)
 Cigarette Use Among Florida Teens
After the “Truth” Campaign

1998 1999

30 27.4
25.2
25
18.5
20
Percent

15
15

10

0
Middle School Students High School Students
Trial Exhibit 12,865

“Our attached recommendation to

expand nationally the successfully
tested “Meet the Turk” ad
campaign and new Marlboro-type
blend is another step to meet our
marketing objective: To increase
our young adult franchise. To
ensure increased and longer-term
growth for CAMEL FILTER, the
brand must increase its share
penetration among the 14-24 age
group which have a new set of
more liberal values and which
represent tomorrow’s cigarette
business.”
 Restrictions on Tobacco
Advertising and Promotion
Pros
Advertising works - provides an
identity that teens find
attractive
The tobacco industry has
saturated the market with
advertising
1st Amendment protections of
advertising less stringent
Cons
May be seen as violating
the right to free speech
Very difficult to be proactive;
the industry continually creates
new promotion strategies
Potential negative consequences
not always obvious
 Cigarette Advertising and
Promotions to Youth After the
Master Settlement Agreement (MSA)

■ After MSA billboard ban (1998) advertising inside and

outside gas stations, convenience stores increased
■ After MSA ban on magazine ads targeting teens, >80%
of teens exposed to ads for youth brands of cigarettes
■ Offer of gift with cigarette purchase more likely in
states with comprehensive tobacco control program
■ Overall expenditures on cigarette advertising and
promotion continues to increase after MSA
■ Cigarette smoking in movies higher in the 1990s than in
the 1960s
Tobacco Advertising Continues
in Youth-Oriented Magazines
 Further Restrictions on
Cigarette Advertising and
Promotions Are Possible

■ Enforce current law to remove logos and ads from auto racing
on TV
■ Give Food and Drug Administration authority over tobacco
products
■ Tax tobacco advertising
■ Make movies that include smoking R-rated
■ Ban use of tobacco logos in advertising of non-tobacco
products
■ Require larger and more graphic warnings on tobacco
advertisements and products
 Cigarette Price Increase
City, County, State, and
Federal Taxes

Pros Cons
Reduces prevalence of Encourages smuggling
smoking
Can be reversed
Reduces onset of
Disproportionately affects
smoking
low income
Provides monies for
tobacco control Effect diminishes unless
tax continually increased
C e n te r f o r T o b a c c o - F r e e K id s , 2 0 0 1
Center for Tobacco-Free Kids, 2001
 Trial Exhibit
C87-04530

“. . . the 1982-83 round of price

increases caused two million
adults to quit smoking and
prevented 600,000 teenagers
from starting to smoke . . . this
means that 700,00 of those adult
quitters had been PM and
420,000 of the non-starters would
have been PM smokers . . . We
don’t need to have that happen
again.”
 A Comprehensive Approach
Reduces Youth Tobacco Use
■ Adopt and enforce local and statewide policies
◆ School policies
◆ Tobacco tax increases
◆ Restrictions on commercial access to tobacco by youth
◆ Smoke-free public places

■ Use evidence-based anti-tobacco curricula in grades K-12

■ Counter pro-tobacco norms through a high-quality media campaign
■ Encourage parents to establish no-smoking expectations and home
policies
State Comprehensive Programs =
Reductions in Youth Smoking

■ Florida, 1998-2000
◆ 18.5% --> 11.1%, middle school students
◆ 27.4% --> 22.6%, high school students

■ California, 1998-2000
◆ 5.8% --> 3.4% 12-17 year olds

■ Massachusetts, 1995-1999
◆ 35.7% --> 30.3%, high school students

■ Mississippi, 1999-2001
◆ 31.5% --> 23.6%, high school students

■ Maine, 1997-2001
◆ 39.2% --> 25%, high school students

■ Oregon, 1996-2001
◆ 22% --> 12%, 8th grade
◆ 28% --> 19.6%, 11th grade