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Youth have long been the focus of tobacco prevention and intervention efforts. In a study reported by the U.S. Department of Health and Human Services in 1994 smokers in their 30s were asked when they began smoking, 89% reported starting before the legal age of 18. The Centers for Disease Control and Prevention report that once smokers are hooked, they have less than a 3% chance of quitting. Many studies suggest that if one has not begun smoking by the age of 21, then risk of addiction is low. Therefore, the best intervention is prevention at an early age.
Risk-taking of all kinds peaks in the adolescent years in part because youth tend to have the idea that they are indestructible. Even when exposed to information about the harmful effects of tobacco and alcohol, it is hard to impress upon them that these things do not just happen to other people. The health risks of tobacco are cumulative. The chronic disease morbidity and mortality associated with tobacco use are manifest in the middle adult years. Thus teenagers are less likely than adults to appreciate that smoking could result in health problems for themselves later in life.
What factors influence youth to initiate this habit? One of the most acknowledged influences is peer. Research shows that youth are much more likely to smoke if they have friends that smoke. However, there seems to be some dispute as to whether young people begin to smoke because of peer influence or if they seek out other friends with common interests, including smoking. As one might expect, a first experience with tobacco is also most likely to occur in the presence of one’s peers. However, one report published in Addictive Behaviors analyzed its population by gender and found that the social influence to smoke and initiating the habit was only true for boys.
Adolescents’ ideas about smoking norms are related to their own tobacco use. Youth who begin smoking are more likely to believe it is normal and also have more friends that smoke. If youth believe that more than 50% of adults and children smoke, they themselves are more likely to engage in the behavior.
Another important influence on young people is advertising. Advertising is not restricted to magazines and billboards. Tobacco companies sponsor athletic events and concerts for the youth market to say nothing of the appeals through the film industry. Philip Morris is reported to have paid over $42,000 to have the Marlboro logo appear in the movie Superman II. Liggett and Philip Morris also spent $350,000 for their cigarettes to appear in the movie License to Kill.
In short, it is not just one factor influencing children to use tobacco. There are many factors, and therefore, many paths for programs in prevention and intervention.
Informational Approaches
Since the first report by the surgeon general was published in 1964, prevention programs have changed dramatically. In the beginning, interventions were aimed at adults who were already addicted to nicotine. It was thought that if smokers knew of the harmful effects of their habits, they would voluntarily quit. However, the strength of the physiological addiction and the social pressure to smoke were not fully considered. Although the necessity to prevent the habit before it was formed was clear, information about the health risks of tobacco were not sufficient to dissuade adolescents
Psychosocial Approaches
Later, prevention programs started to emphasize more than just the health consequences of smoking. As awareness of the psychosocial correlates of youth initiation of tobacco use grew, projects in the late 1970s began to address peer pressure, modeling, and advertising pressure. Adolescents were taught to say no and how to say it. They were given tools with which to combat pressure from both the media and their own friends. While these programs have shown some success, optimism is not warranted. According to Center for Disease Control and Prevention, smoking has increased 32% among high school students from 1991 to 1997. Whether this increase is due to the inability to reach those most at risk for smoking, (i.e. school dropouts) or if the programs themselves are just ineffective or if insufficient duration is not clear.
Besides the health consequences of tobacco use, prevention efforts have also emphasized the social consequences of tobacco use. In a study published in Addictive Behaviors in 1983, seventh graders were shown videos of peers’ negative reactions to smoking in an effort to change their attitudes and intentions to smoke. Measures collected immediately after the video and a month later showed limited success. Females showed a more favorable response than males as did youth who had already experimented with tobacco. The latter group indicated that they did not intend to smoke in the future.
In contrast to other work which has looked at negative peer pressure, this study looks at peer pressure as a possible deterrent from smoking.
Marketing and Media Strategies
Mass media campaigns may show some progress in lowering youth smoking rates. However, their effectiveness is limited if they are not used in conjunction with other methods such as school-based programs. In order for antismoking advertisements to be effective
1) they must target fifth through tenth graders,
2) new ads must be created each year,
3) ads must be coordinated with school programs,
4) the emphasis must be on the short-term effects of smoking,
5) they must include tobacco refusal strategies, and
6) ads must explain that smoking is not common.
Between 1987-1993, Canada used a “Break Free” marketing campaign to combat the use of tobacco. This campaign used television, radio, posters, magazine advertisements as well as other youth activities to get out the message that being smoke-free is positive and popular. A survey reported in Social Marketing: Theoretical and Practical Perspectives found positive results for 11 to 17 year olds during the last year of the campaign: “For nonsmokers, the ads were reportedly successful in helping 39% of ex smokers not to smoke and 19% not to start smoking. Among smokers, 15% reported the ads helped them to cut down the amount they smoked, whereas 4% agreed the ads make it easier to quit.” A new campaign targeted at both youth and adult populations in Canada emphasizes both the health consequences to the smoker as well as the negative effects of secondhand smoke on people nearby.
In April 1998, Florida initiated a youth-led media campaign that seems to be showing some success. The campaign involves irreverent advertisements ridiculing the tobacco industry and the methods the industry uses to attract youth into smoking. According to the Center for Disease Control, surveys done in February 1998 and February 1999 have shown a significant decrease in smoking among Florida school students who smoked. While these initial results are encouraging, it is still difficult to say whether or not the decrease is due to the advertisements themselves or to the increased price of cigarettes.
School-based prevention programs
A meta-analysis published in The American Journal of Public Health in 1993 evaluated 94 separate school-based prevention programs. The programs were classified as rational, developmental, social norms, and social reinforcement approaches. Rational programs used a traditional informational approach with lectures on health effects, etc. The behavioral and attitudinal effects of these programs were small. Developmental programs used an affective education approach including lecture, discussion, problem solving, and role playing. These programs focused on increasing self-esteem and self-reliance and showed a moderate effect on behaviors and attitudes. Social norms approaches encouraged participation in community projects, vocational training, and recreational activities. Their aims were to reduce alienation and increase self-esteem. These programs also showed a moderate effect on behavior and attitude. Social reinforcement programs used a social pressures approach; that is, discussion, behavior modeling, and role playing. These programs aimed to develop youths’ abilities to resist social pressure and identify immediate social and physical consequences of using tobacco. The largest behavioral and attitudinal effects were found for those programs which were not based on rational knowledge but on the social consequences of tobacco use. In other words there is some value to being able to demonstrate that if you smoke, you will have bad breath and nobody will like you rather than saying, “If you smoke you might die of a smoking-related illness 40 years from now.” Perhaps a focus on the immediate consequences combined with community participation were key in convincing adolescents not to smoke.
The study published in The American Journal of Public Health concluded that social reinforcement, social norms, and developmentally orientated programs were promising school-based tobacco prevention programs. The success of these methods was likely due to the links the programs made between attitudes towards smoking, social norms regarding smoking, and to perceived behavioral control towards smoking.
Community Coalition Approaches
The most successful school-based programs also involve parents and the larger community. Changing social norms is one of the primary objectives of prevention programs and community coalitions. These coalitions work to raise awareness in the community, involve youth in prevention efforts, and work with schools to improve programs. Coalitions generally consist of different groups rather than just individuals working together. The advantage is that the ideas, resources, and commitment of the coalition is more than just the sum of the whole. In other words, when organizations pool their resources, they are more effective, visible, and efficient in reaching shared goals. Some community coalitions have been working closely with youth focusing on the problem of tobacco as a public problem. However, few studies have been published evaluating these community programs and none have investigated children’s conceptions of rights and responsibilities around tobacco.
More recent prevention research is exploring the possibility of youth responding to a positive peer pressure idea in which youth are encouraged to look out for their friends rather than told to “Just say no.” It is too soon to say if this approach will be successful, but the data is encouraging.
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