Smoking Prevention

Brian A. Primack, MD, EdM Assistant Professor of Medicine and Pediatrics University of Pittsburgh School of Medicine

Composite Theoretical Model
Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES

Positive Attitudes, Expectations

Intention

Smoking

Sense of Norms

Outline ‡ ‡ ‡ ‡ ‡ Increase cigarette price? Education campaigns? Reduce youth access? Reduce advertising/promotion? School-based programs? .

Increasing the Unit Price for Tobacco Products? .

Increasing the Unit Price for Tobacco Products? Yes! (Strong Evidence) .

Expectations Intention Smoking Sense of Norms .Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes.

Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes. Expectations Price Increases Intention Smoking Sense of Norms .

Price ‡ Higher prices for tobacco products reduced consumption ‡ 10% price increase 4% consumption decrease ‡ Data primarily comes from 13-25 year old age group ‡ Best way: excise tax ‡ Challenge: requires passing legislation .

Price Studies ‡ More effect among African Americans than Caucasians ‡ More effect among males than females ‡ More effect among younger than older .

Kinds of Excise Tax ‡ Federal ‡ State ‡ Local .

46) WA ($2.02) AZ ($2) ME ($2) MI ($2) AK.35 (#15) .57) RI ($2.State Excise Tax ‡ Mean: 80 cents ‡ Highest rates ± ± ± ± ± ± ± NJ ($2. HI ($2) later this year ‡ Lowest excise taxes ± ± ± ± ± ± ± ± NC (35¢) FL (34¢) KY (30¢) VA (30¢) TN (20¢) MS (18¢) MO (17¢) SC (7¢) ‡ PA: $1.

50 TN. 1¢ to 6¢ IL.Other Excise Taxes ‡ Local ± ± ± ± ± ± AL. 1¢ VA. 10¢ to 15¢ MO. 4¢ to 7¢ NYC $1. 2¢ to 15¢ ‡ Federal ± Increased to 39¢ in 2002 ± ALA and others seek $2 increase .

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28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.23 .

Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.23 .

12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.23 .28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.

23 .Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.

28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.23 .

23 .28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.

23 .Anatomy of Cigarette Price ‡ Illinois ± Factory Price: $2.28 ± Federal Excise Tax: 39¢ ± Retailer markup: $1.12 ± State Excise Tax: 98¢ ± Sales Tax: 29¢ ± TOTAL: $5.

Mass Media Education Campaigns? .

Mass Media Education Campaigns? Yes! (Strong Evidence) .

Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes. Expectations Intention Smoking Sense of Norms .

Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes. Expectations Education Campaigns Intention Smoking Sense of Norms .

Massachusetts. Minnesota ‡ Hard to control for other factors . all aimed at adolescents ‡ Compare smoking rate changes in different communities ‡ Florida.Mass Media Education Campaigns ‡ PSA¶s: Print. TV. Radio ‡ 12 studies.

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Shards O Glass Light .

4% (absolute) ‡ Most effective: >2 years ‡ Those that combined education campaigns with other interventions worked better ± Contests ± Community education ± School-based programs ‡ Effects decrease over time .Mass Media Education Campaigns ‡ Decrease by about 2.

Youth Access? .

Youth Access? Maybe .. ..

Expectations Intention Smoking Sense of Norms .Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes.

Expectations Youth Access Intention Smoking Sense of Norms .Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes.

Photographic ID Required .Minimum Age.

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Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes. Expectations Youth Access Intention Smoking Sense of Norms .

Clerk Intervention .

Free Distribution/Samples .

Vending Machines .

Other Access Issues ‡ ‡ ‡ ‡ Packaging Graduated Penalties Random Inspections Statewide Enforcement .

8% .³Recommended´ ‡ ³Community Mobilization When Accompanied by Additional Interventions´ ‡ Absolute reductions as much as 5.

³Insufficient Evidence´ ‡ ‡ ‡ ‡ Sales laws directed at retailers alone Laws directed at minor purchase alone Active enforcement of sales laws alone Retailer education alone .

Reduce Smoking Promotions? .

Reduce Smoking Promotions? Yes! (and no ..) ..

Expectations Intention Smoking Sense of Norms .Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes.

Expectations Reduce Promotion Intention Smoking Sense of Norms .Composite Theoretical Model Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES Positive Attitudes.

Smoking Promotions Definitely Increase Smoking ‡ Tobacco Promotion and the Initiation of Tobacco Use: Assessing the Evidence for Causality ‡ DiFranza. Wellman. 117: e1237-e1248 . Sargent et al ‡ Pediatrics 2006.

Films .

Advertisements .

Flexibility of the Industry ‡ ‡ ‡ ‡ TV Movies Billboards Concerts. other promotions ± ³Kool Mixx´ tour ± ³Stir the Senses´ tour ‡ Free products .

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Camel ³Seven Pleasures of the Exotic´ .

School-Based Programs? .

School-Based Programs?
Unknown ...

Composite Theoretical Model
Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES

Positive Attitudes, Expectations

Intention

Smoking

Sense of Norms

Composite Theoretical Model
Personal Factors Rebelliousness Sensation Seeking Grades Environmental Factors Parental/Sibling Peer Media Demographics Gender/Age Race/Ethnicity SES

Positive Attitudes, Expectations

School-Based Programs

Intention

Smoking

Sense of Norms

‡ 20 school districts got the program. effects on body.HSPP (JNCI. 2000) Curriculum for youth. high implementation fidelity ‡ ‡ ‡ ‡ . resisting peer influence. 3rd-10th grades 47. etc. 20 did not ‡ 94% follow up.25 hours total ³Social Influences´ approach How to say no. self esteem.

Results of HSPP ‡ No difference in smoking at 12th grade ‡ No difference in smoking 2 years after high school ‡ No difference among boys or girls ‡ No difference among people of other subgroups (such as family risk for smoking) .

Depends on the Kind of Program ‡ ³Life Skills Training´/³Social Influences´ ± Self esteem ± Refusal ‡ ³Media Literacy´ ± Analysis of tobacco advertisements/promotions ± Understanding of marketing and industry .

Summary ‡ Price Increases ‡ Comprehensive Mass Media Education Campaigns ‡ Youth Access ‡ Reduction of Advertising ‡ School & Community Based Programs .

edu .bprimack@pitt.

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1999 Gruber 2004 Lewit 1981. 1997 Ohsfeldt 1994.Price References ‡ ‡ ‡ ‡ ‡ ‡ CDC 1998 Chaloupka 1996. 1997. 1997 Wasserman 1991 .

1994 . 1999 Flay.Media Campaign References ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Bauman. 1994 Murray. 1987. 1991 CDC. 1997 Hafstad. 1995 Flynn. 1997 Johnson. 1990 Kaufman.

9% ‡ Cost per smoker averted: $6069 ‡ Program cost/QALY: $333 .4% vs.Economic Analysis ‡ 4 year study from MT. NY. 25. VT ‡ 5-10th grade students followed for 2 years ‡ Mass media campaign and school-based program ‡ Smoking 20.