OREGON STATE UNIVERSITY

Tobacco Control for Youth: Recent Findings and Recommendations

Brian R. Flay, D.Phil.Department of Public Health

Prepared for TERN meeting, La Jolla, November 19, 2009

Outline

I. Background on Adolescent Tobacco Use II. Industry Anti-tobacco Campaigns III. State and National Campaigns

– State campaigns (including Oregon)– The ‘truth” campaign– ONDCP campaigns

IV. Youth-Focused Prevention Programs– School-based

• Do/Can they work? What works?

– School plus media or community– Comprehensive programs

I’ll highlight some recommendations from the IOM

2007 Report -Some will re-appear in 2010 SGR

Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – U. S.

1900-2004

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Num

ber

of C

igar

ette

s

Source: United States Department of Agriculture

End of WW II

1st Smoking-Cancer Concern

Fairness Doctrine

Messages on TV and Radio

Non-Smokers Rights Movement

Begins

Federal Cigarette Tax

Doubles

Surgeon General’s Report on ETS

1st Surgeon General’s

Report

1st World Conference on Smoking and

HealthBroadcast Ad Ban

1st Great American Smoke-out

OTC Nicotine Medications

Master Settlement Agreement

Great Depression

Trends in Cigarette Smoking Anytime in the Past 30 days by Grade in School – United

States, 1975-2008

0

5

10

15

20

25

30

35

40

45

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

YEAR

PER

CEN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

12th Grade

8th Grade

10th Grade20.4% in 2008

12.3% in 2008

6.8% in 2008

Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Race

– United States, 1977-2008

05

1015202530354045

1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007

YEAR

PERC

ENT

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys; for racial subgroups, data

for the current year and the previous year are combined

White

Black

Hispanic

0

10

20

30

40

50

6019

6519

6719

6919

7119

7319

7519

7719

7919

8119

8319

8519

8719

8919

9119

9319

9519

9719

9920

0120

0320

0520

08

Year

18-24 25-44 45-64 >=65

Per

cent

Trends in cigarette smoking* by age - United States, 1965-2008

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days.Source: various National Health Interview Surveys from 1965 - 2002, National Center for Health Statistics

What about 18-24 year-olds?

II. Industry Anti-Tobacco Campaigns

Brown & Williamson on Brown & Williamson on Nicotine….Nicotine….

““Moreover, nicotine is addictive… We are, Moreover, nicotine is addictive… We are, then, in the business of selling nicotine, an then, in the business of selling nicotine, an addictive drug….”addictive drug….”

Addison Yeaman; General Counsel toAddison Yeaman; General Counsel tothe Brown & Williamson Tobacco the Brown & Williamson Tobacco Company; July 17, 1963.Company; July 17, 1963.

Source: U.S. Food and Drug Administration, 1996.Source: U.S. Food and Drug Administration, 1996.

Philip Morris on Nicotine….Philip Morris on Nicotine….

““Smoke is beyond question the most Smoke is beyond question the most optimized vehicle of nicotine and the optimized vehicle of nicotine and the cigarette the most optimized dispenser of cigarette the most optimized dispenser of smoke.”smoke.”

Dr. William Dunn; Philip Morris Tobacco Company, 1972Dr. William Dunn; Philip Morris Tobacco Company, 1972..

Source: U.S. Food and Drug Administration, 1996.Source: U.S. Food and Drug Administration, 1996.

R. J. Reynolds chimes in….R. J. Reynolds chimes in….

““In a sense, the tobacco industry may be In a sense, the tobacco industry may be thought of as being a specialized, highly thought of as being a specialized, highly ritualized, and stylized segment of the ritualized, and stylized segment of the pharmaceutical industry. Tobacco products pharmaceutical industry. Tobacco products uniquely contain and deliver nicotine, a uniquely contain and deliver nicotine, a potent drug with a variety of physiological potent drug with a variety of physiological effects.”effects.” Claude Teague, R.J. Reynolds Tobacco Company, Claude Teague, R.J. Reynolds Tobacco Company, 1972.1972.

Source: U.S. Food and Drug Administration, 1996.Source: U.S. Food and Drug Administration, 1996.

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

16,000,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

YEAR

DO

LL

AR

S IN

TH

OU

SA

ND

S

All Expenditures

Advertising (All Media)

Consumer Price Discounts

Promotional Allowances

Domestic Cigarette Advertising and Promotional Expenditures for 1980-2003

Tobacco industry counter advertising campaigns

Philip Morris, Dec 98, $100M– Theme: Youths do not need to smoke to

fit in socially with their peers

– “Think. Don’t Smoke.” Lorillard, Jan 2003, $13M

– “Tobacco is Whacko if You’re a Teen” Philip Morris, July 99, targeted parents

– “Talk. They’ll Listen.”

Industry counter ads do not work – and may do damage

Wakefield et al., AJPH 2006 – Methods

• Linked Neilson data on media exposure by youth in 75 major media markets with Monitoring the Future survey data on youth smoking (1999-2002)

• 0ver 103,000 youth, 36% grade 8, 64% grades 10 or 12• 20.8% had smoked in last 30 days, average of 5.43 cigarettes

per day• Average exposure = 4.77 youth-targeted and 1.13 parent-

targeted ads

– Analyses• Regression analyses adjusting for sample weighting, clustering

of students within schools, exposure to other campaigns, overall television viewing, and demographic variables

Industry counter ads do not work – and may do damage

Wakefield et al., 2006 (continued)– Findings

• Covariates had expected effects– E.g., High prices and stronger smoke-free laws associated with lower

levels of smoking• Industry counter ads targeting youth do not work

– Near-zero association with smoking levels– However, for grade 8 students, we observed a negative effect -- exposure

led to stronger intentions to smoke (OR = 1.04)• Industry counter ads targeting parents have negative effects for high

school students– Decreased perceived risk (OR = .93) – Increased intentions (OR = 1.12) and – Increased chances of smoking (OR = 1.12)– Results for grade 8 students in same direction, but smaller.

– Youth are likely to resist messages from authority figures or industry that enlist their parents

– The “forbidden fruit” phenomenon

IOM 2007 Report “Ending the Tobacco

Problem”Recommendation 36

Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. If a tobacco company wishes to support

youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing and evaluating the program.

III. State and National Campaigns

State-sponsored campaigns The Oregon campaign The “truth” campaign ONDCP campaigns Conclusions re campaigns

State-Sponsored Campaigns Have Positive Effects

Emory et al., Archives of Ped and Adol Med, 2005– Similar methods to Wakefield et al (2006), focusing on exposure to

state-sponsored counter ads• By 2002, 35 states had launched anti-tobacco media campaigns

• 1999-2000 Neilson and MTF data used

• Almost 20,000 8th graders

• About 16,000 each of 10th and 12th graders

– Results• Average exposure 5.32 pharmaceutical ads, 7.16 tobacco company

ads, 0.79 industry parent-targeted ads, and 0.90 state-sponsored ads.

• Higher levels of exposure were associated with – Lower estimates of peer smoking (OR = .72)– Higher ratings of perceived harm of smoking (OR = 1.25)– More positive intentions to not smoke (OR = 1.43)– Less likely to have smoked (OR = .74)

State-Wide Campaigns Have Been Effective

Michael Slater recently reviewed for the IOM (2006) Committee on Tobacco Control– See also Wakefield, Flay, Nichter & Giovino, 2003– CA, FL and MA campaigns were particularly well documented– California

• 1990 onwards, $54-140M per year, not youth focused but attacked the industry• Adult smoking dropped from 22.7% to 18% 1989-93 (double the rate in the rest

of the US)

– Massachusetts• 1993 onwards, $43M in 1995, decreased since• Youth (12-15) exposed to the campaign half as likely to progress to regular

smoking (OR = .49). No differences for older youth

– Florida• “truth” campaign initiated 1998• 5% relative decline in youth smoking

These campaigns were all comprehensive – involving counter advertising, education, social marketing, policy and taxation components – so not easy to attribute effects to one component

Traditional (state-based) Tobacco Control Programs WORK!

The Oregon Campaign

42% decrease in per capita cigarette sales 1996-2004 – or a 16% relative (to the nation) decrease

Note loss of momentum when funding was cut

But Oregon youth smoking has paralleled national

trends

The “truth” Campaign is Effective

Derived from the Florida campaign– Started in 2002– Students took an active role in identifying the tobacco

industry as the enemy Evaluations by RTI demonstrate its effectiveness

– Used similar methods to Wakefield et al– About a 6% relative change– For example, change from 25.8% to 18% smoking

This and State-sponsored campaigns also have an agenda-setting effect – keeping the issue salient

ONDCP Campaigns – Suggesting Caution

Recent campaign focused on sensation seeking youth– Derived from the work of Palmgreen and colleagues at University

of Kentucky– Palmgreen et al (AJPH, 2007) reported positive effects of the first

few months of the campaign for high-sensation-seeking youth in two cities

– However, other reports at SPR (Horner, Jacobsohn, Orwin) and from the OMB suggest that the complete campaign (national over 5 years) had no significant effects.

Current campaign focuses on parents– Although careful formative research suggested this might work, the

effects of the industry campaign based on the same approach suggest care is needed.

A media campaign is not a vaccine or a magic bullet

Tobacco Use Prevention Media Campaigns:

Lessons Learned from Youth in Nine Countries

The report indicates that the most effective of these campaigns—– Are part of a comprehensive tobacco control program. – Include ads that provoke strong negative emotions,

such as fear and anger. – Provide new information about health risks to smokers

and nonsmokers. – Engage youth with youth-oriented graphics and

testimonials. – Use multiple strategies and media channels. – Expose youth to messages over significant periods of

time.

Mass media campaigns can work – but tread carefully

Effective campaigns have resulted after long and careful developmental and formative research and pilot message testing– E.g., Worden, Pechmann

Messages that are effective at one time may not be at another time or place– Wear-out

Relevant message properties are many:– Content, medium, messenger, etc.– Execution style and quality– Novelty

Effective media campaigns are cost-effective– Per capita costs are in the range of 50c to $3

IOM 2007 Report “Ending the Tobacco

Problem”Recommendation 36

Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. If a tobacco company wishes to support

youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing and evaluating the program.

IV. Other Youth-Focused Approaches to Prevention

Questions about the effectiveness of school-based prevention programs

Examples of effective school-based programs

Comprehensive content/approaches Adding media or community

components Conclusions

Does school-based prevention have an

important role? Multiple reviews established that school-based prevention

(SBP) can be effective– Black et al 98, Flay 85, IOM 1994, Lantz et al 00, Roona 2000,

Skara & Sussman 03, Tingle et al 03, Tobler 86 92 97 2000– Particularly social influence oriented and active learning

approaches

Several papers found that these effects often did not last through grade 12– Flay et al 89, Murray et al 89, Ellickson & Bell 90

Based on lack of long-term effects, several recent studies and reviews have questioned the value of school-based prevention (SBP)– Glantz & Mandel 05, Peterson et al 2000, Wiehe et al 05

School-based prevention programs can be effective

Include social influences-related content– Educate youth about social influences and correct

misperceptions of normative use among their peers– Teach social (and resistance) skills

Are interactive in their approach, including practice of skills

Include 15 or more sessions in middle school Produce substantial short-term effects Have booster sessions or on-going programming

in high school Flay 2009a & 2009b

Three SBPs with proven long-term effects

TAPP (Hansen et al 88)– Included the above core elements plus

• inoculation against mass media messages, information about parental influences, information about the consequences of use, making a public commitment not to smoke, and peer opinion leaders assisted teachers with program delivery

Life Skills Training (Botvin)– Includes above elements + general social skills– 15-20 sessions in middle school + boosters in HS

Project SHOUT (Elder et al 93, 97)– Included above core elements plus

• health consequences of smoking, celebrity endorsements of nonuse, decision making, resistance skills advocacy (writing letters to tobacco companies, magazines, and film producers; participating in community action projects designed to mobilize them as anti-tobacco activists), a public commitment to not use tobacco, and positive approaches to encouraging others to avoid tobacco or quit

– 18 sessions in MS delivered by college students – Newsletters and phone calls from college students during HS

Averaged 28% relative reduction in smoking onset by end HS

Other SBP programs that show exceptional promise

AAPT (Hansen & Graham 91)– focus on alcohol, showed that normative plus skills training better

than either alone Towards No Tobacco (Sussman et al 93, 95)

– More intensive approach with large effects Know Your Body (Walter et al 88)

– Comprehensive health education with very large effects The Good Behavior Game (Kellam et al)

– Focus on general behavior at grades 1 and 2– Produced 26% relative reduction in grade 8 smoking

Positive Action (Flay & Allred)– Focus on general behavior and character in elementary school– Behavioral effects by grade 5 – >50% relative reduction– Significant long-term effects – 32% RR in MS and 20% in HS

Hawaii RCT: Lifetime Prevalence of Substance Abuse, Violent Behaviors, & Sexual Activity: 5th grade (all

significant, no significant interactions) (Beets et al., AJPH, 2009)

0

5

10

15

20

25

TobaccoUsage

Alcohol Been Drunk Any IllicitDrug Use

Been High onDrugs

Carried aknife or razorto use to hurt

someone

Threatened tocut or stabsomeone

Cut orstabbed

someone onpurpose tohurt them

Carried a gun Shot atsomeone

Voluntary sexwith someone

of theopposite sex

Lif

etim

e P

reva

len

ce (

%)

Control Positive Action

Substance Abuse Violent Behaviors Sexual Activity

--------------SUBSTANCE ABUSE------- ---SERIOUS VIOLENT BEHAVIORS--- SEX

% Ever Used Sustances and % Reduction by Condition:Grade 5 Chicago Randomized Trial

13.2%

36.2%

10.7%

39.9%

9.4%

28.3%

5.1%

32.1%

28.2%

21.7%

52.2%

19.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Ever smoked/usdtobacco

Ever drank alcohol Ever gotten drunk Ever usedtobacco, alcohol

or drugs

Pe

rce

nt

C PA % reduction

Chicago:(Li et al., in review)

SBP programs with media or community components

Three with reported long-term effects reviewed by Flay for IOM– North Karelia, Minnesota 89, Midwestern Prevention

Project, Vermont mass media project– Average 31-40% relative reduction through HS

One other promising program– Project 16 (Biglan et al 2000)

• Included 5-session social influences curriculum (7th and 9th grades) plus a community program, which included:

• media advocacy, youth anti-tobacco activities, family communications about tobacco use, and reduction of youth access to tobacco

• Relative reduction in smoking onset of 21% at the end of the program and 28% one year later

Youth Prevention of Tobacco Use Can Be Effective

Important elements include:– Social influences (norms and skills) plus other content

• Should be highly interactive, including practice of skills

– Include 15 or more lessons at middle school plus some kind of booster on on-going programming at HS

– Can be accomplished within comprehensive health education or character education programming

– Including mass media or other community components is likely to increase effectiveness

– Student advocacy/activism is an important component• Shown in mass media, school-based and community examples

Take care to avoid negative effects

IOM 2007 Report“Ending the Tobacco

Problem”Recommendation 13

School boards should require all middle schools and high schools to adopt evidence-based smoking prevention programs and implement them with fidelity. They should coordinate these in-school programs with public activities or mass media programming, or both. Such prevention programs should be conducted annually. State funding for these programs should be

supplemented with funding from the U.S. Department of Education under the Safe and Drug-Free School Act or by an independent body administering funds collected from the tobacco industry through excise taxes, court orders, or litigation agreements.

IOM 2007 Report“Ending the Tobacco

Problem”Recommendation 1

Each state should fund state tobacco control activities at the level recommended by the CDC. – A reasonable target for each state is in the

range of $15 to $20 per capita, depending on the state’s population, demography, and prevalence of tobacco use.

– If it is constitutionally permissible, states should use a statutorily prescribed portion of their tobacco excise tax revenues to fund tobacco control programs.

Estimated adult smoking prevalence assuming no change in the tobacco control environment

0

5

10

15

20

25

2005 2010 2015 2020 2025

Years

Adu

lt sm

okin

g pr

eval

ence

(%

of

tota

l pop

ulat

ion)

Business as usual will not get to us to the HP2010 goal of 12% prevalence

What is at stake!

Cigarette Sales and Real Cigarette Prices, US, 1970-2003

1.3

1.8

2.3

2.8

3.3

3.8

4.3

1970 1974 1978 1982 1986 1990 1994 1998 2002

Year

Pri

ce (i

n F

Y03

do

llars

)

19000.00

21000.00

23000.00

25000.00

27000.00

29000.00

31000.00

Sal

es (m

illio

ns

of p

acks

)

Price Sales

Source: Tax Burden on Tobacco

The clear relationship between cigarette prices and consumption

IOM 2007 Report“Ending the Tobacco Problem”

Recommendation 3 The federal government

should substantially raise federal tobacco excise taxes, currently set at 39 cents a pack. Federal excise tax rates should

be indexed to inflation.

Report available at

www.nap.edu

Early Warning Sign