Tobacco Control Research on Youth Issues: Scan, Overview and Recommendations [HTML]

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A Report Submitted by Jennifer L. O’Loughlin, Natalie Kishchuk, and Michele Tremblay
to Elizabeth Beckett from the Office of Prevention Cessation and Education of
the Tobacco Control Programme at Health Canada
(Contract Reference Number 4500067371)

September 30, 2004

TABLE OF CONTENTS

I. INTRODUCTION

II. PRIORITY ISSUES IN YOUTH TOBACCO CONTROL

1. Clustering of Youth Risk Behaviours
2. Prevention of Youth Tobacco Use
3. Youth Tobacco Use Cessation
4. Youth Engagement in Tobacco Control Issues
5. Youth Access to Tobacco Products
6. Protection from Exposure to Second-Hand Smoke
7. Effects of Taxation and Pricing on Youth Smoking Behaviour
8. Social Marketing, Denormalization, Mass Media Interventions, Community Mobilization Campaigns
9. Cost-Effectiveness of Youth Tobacco Intervention

III. SUMMARY OF SCAN

INDEX

I. INTRODUCTION

According to the most recent national Youth Smoking Survey conducted in 20021, 23% of Canadian youth in grades five to nine, representing 457,000 young Canadians, have smoked cigarettes. Ten percent (209,000) have tried smoking but have never smoked a whole cigarette, 10% (212,000) have smoked beyond puffing but are not current daily smokers, and two percent (36,000) are daily smokers. There is substantial variation in smoking behaviour across provinces, with the prevalence of ever smoking ranging from 16% in British Columbia to 37% among Quebec youth. Although the proportion of ever smokers nationally in 2002 was substantially lower than the 40% observed in the 1994Youth Smoking Survey, the proportion of young Canadians who smoke remains far too high. In addition, daily smokers smoked more in 2002 (8.1 cigarettes per day on average) than in 1994 (7.4 cigarettes per day).

Children often begin experimenting with cigarette use around age 12 2, although age at initiation can be as early as eight years in some subgroups. 12 Smoking increases sharply with age 3, and some reports suggest that girls smoke more than boys during adolescence. 12,4,5,3 Daily smoking often begins around age 16. 6 The earlier smoking begins, the longer the individual will smoke, the greater the severity of addiction 6,7 and the lower the likelihood of quitting. 8 Teens, especially girls, seem to have more difficulty quitting than adults. 7 While it is commonly believed that physiological dependence develops over 2-3 years 11,6, recent evidence suggests that symptoms of nicotine dependence (ND) occur even during early sporadic smoking 9,10, making earlier prevention of paramount importance, as well as the development of effective cessation programs for young people.

In recognition of the continuing enormous public health burden of youth tobacco use, the Office of Prevention, Cessation and Education of the Tobacco Control Programme at Health Canada called for a scan of the literature on nine established and emerging issues in youth tobacco control, including if and how risk behaviours in youth cluster with tobacco use within the same individual; prevention of youth tobacco use; youth tobacco use cessation; youth engagement in tobacco control issues; youth access to tobacco products; protection of youth from exposure to second-hand smoke; the effects of taxation and pricing on youth smoking behaviour; and the impact of social marketing on prevention.

The specific objectives of the scan were, for each of the nine priority issues, to describe the current knowledge base in the published literature, to summarize the knowledge base, and to identify important gaps in knowledge which clearly need to be addressed. In a preliminary phase prior to undertaking the scan, we validated the list of nine priority issues identified by the Office of Prevention, Cessation and Education of the Tobacco Control Programme with practitioners and policy-makers working in youth tobacco control. Appendix I describes this validation phase. Table 1 below describes specific questions within each of the nine priority issues retained by practitioners and policy makers, for which the literature provides empirical information. As a second supporting task, the Office of Prevention, Cessation and Education of the Tobacco Control Programme requested an inventory of Canadian (and American) researchers working in youth tobacco control. Appendix IV describes the methods used to achieve this objective and includes copies of the Canadian and American inventories.

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TABLE 1

PRIORITY ISSUES IN YOUTH TOBACCO CONTROL IDENTIFIED BY CANADIAN PRACTITIONERS AND POLICY MAKERS

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References For Introduction

1. Manske S et al. 2002 Youth Smoking Survey Technical Report (in preparation).

2. Health Canada. 5. Youth and Young Adults. CTUMS (Canadian Tobacco Use Monitoring Survey), Wave 1, February-June 1999.

3. Perron B, Loiselle J (2003). Enquête québécoise sur le tabagisme chez les élèves du secondaire, 2002. Rapport d’analyse, Québec, Institut de la statistique du Québec, 240 p.

4. Health Canada. National Population Health Survey Highlights. January 1999. No. 1. Smoking Behaviour of Canadians. Cycle 2, 1996/1997.

5. Adlaf EM et al. Drug use among Ontario students, 1977-1999: Findings from the Ontario Student Drug Use Survey. CAMH Research Document Series No.5.

6. Health Canada. 1. Summary of Results. CTUMS (Canadian Tobacco Use Monitoring Survey), Wave 1, February-June 1999.

7. U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2001.

8. Breslau N, Peterson EL. Smoking cessation in young adults: Age at initiation of cigarette smoking and other suspected influences. Am J Public Health 1996;86(2):214-220.

9. DiFranza JR et al. Initial symptoms of nicotine dependence in adolescents. Tob Control 2000;9(3):313-319.

10. O’Loughlin J, DiFranza J, Tyndale R, Meshedjian G, McMillan-Davey E, Clarke P, Hanley J, Paradis G. Nicotine dependence symptoms are associated with smoking frequency in adolescents. Am J Prev Med 2003;25:219-25.

11. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. 1994, 314 p.

12. O'Loughlin J et al. Prevalence and correlates of early smoking among elementary schoolchildren in multiethnic, low-income, inner-city neighborhoods. Ann Epidemiol 1998(a);8(5):308-318.

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II. PRIORITY ISSUES IN YOUTH TOBACCO CONTROL

The objective of the literature scan was to undertake a census of and to overview recent publications from Canada and the United States in the past five years (1998-2004) for each priority issue in youth tobacco control. To identify publications in each priority area, we searched all relevant electronic databases in the medical and social sciences (PubMed, PsychInfo), we consulted leading tobacco experts across Canada, and we used a snowball approach from the list of references in each publication identified. Publications were then analysed systematically to assess the strength of the evidence, to outline key findings, and to identify gaps in information and knowledge.

Team members then prepared a summary report for each priority issue. Using information collected during our focus group interviews with Canadian youth tobacco practitioners and policy-makers (Appendix I), we designed a format for presentation of this information which met their needs for succinct information presented in an easy-to-read format, that quickly summarized the results of the information to date in the literature, detailed the strength of the evidence on which this information is based, and identified gaps in information.

The next nine sections present the results of the scan. Each section first asks: What questions are addressed in the literature? For each question, the literature is summarized briefly and the strength of the evidence available is rated as weak, weak to moderate, moderate, moderate to strong or strong. Each section then asks: What questions are not addressed in the literature? This analysis in essence identifies gaps in our knowledge base that need to be addressed. Although the results are presented in a user-friendly format, both practitioners and policy-makers expressed, in our preliminary work, the need for more detailed information. For those practitioners who require more detailed information, we included abstracts for each publication reviewed for each priority area in Appendix III. In addition, for priority issues 1-5, we abstracted each article according to its objectives, study design, study population, methods, and results (Appendix III). Abstraction was not completed for priority issues 6-9 due to time limitations. The last section of this report summarizes the scan.

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1. Clustering of Youth Risk Behaviours

1.1 Do risk behaviours including use of alcohol, use of illicit drugs, dieting and body image, and physical inactivity, cluster with tobacco use in youth?

Questions addressed in the literature

(i) Is tobacco use associated with alcohol use in youth?

Most studies that investigate the association between smoking and alcohol use in youth are cross-sectional, and all report a positive association between these two behaviours. It is more common to see drinkers who do not smoke, than smokers who do not drink (Hoffman et al., 2001; Wetzels et al., 2003). Johnson et al. (2000) found that cigarette smoking was associated with binge drinking, especially in males. A positive association has also been observed between cigar smoking and alcohol use (Frazier et al., 2000).

There have been very few longitudinal studies on this topic. Duncan et al. (1998) found that levels of smoking predicted levels of alcohol use two years later, but the converse was not true. In a one-year longitudinal study of 10,170 European adolescents,Wetzels et al. (2003) found that tobacco use at baseline predicted alcohol use, and that this effect was greater in 12-year olds than in 13 and 14 year olds. Also, alcohol use at baseline predicted tobacco use one year later, more so in girls than in boys.

Ellickson et al. (2001) reported that more experimental and established smokers used alcohol weekly five years later than non-smokers, and Chen et al. (2002) found that smoking predicted alcohol use in all ethnic groups studied. As well, smoking in adolescence predicted severe substance use related problems in adulthood, such as drunk driving and being treated in hospital for substance abuse (Riala et al., 2004). In a 15-year longitudinal study, alcohol use in adolescence predicted smoking in adulthood, but smoking in adolescence did not predict alcohol use in adulthood (Paavola et al., 2004).

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(ii) Is tobacco use associated with the use of illicit drugs in youth?

In a longitudinal study of Columbian youth, Siqueira et al. (2003) found that cigarette smoking predicted use of marijuana and other illicit drugs two years later. In addition, cigarette use predicted having drug-related problems at school or at work. These findings were supported in another longitudinal study (Duncan et al., 1998).

A cross-sectional study by Everett et al. (1998) found that smokers were significantly more likely than non-smokers to be past or present users of all illicit substances measured, including marijuana, cocaine, inhalants, LSD, PCP, ecstasy, mushrooms, speed, ice, and heroin. There was a dose-response relationship between smoking and drug use; as the number of days of cigarette smoking increased the odds of having ever used other substances (even just once) increased as well. Even smoking once or twice in the past 30 days significantly increased the likelihood of having ever used illicit substances.

As well, an earlier age at initiation of cigarette use (i.e. before age 13) was associated with an increased odds of marijuana use. Regular smokers were more likely than non-regular smokers to use marijuana as well (Merrill et al., 1999).

In four large cross-sectional studies, Wagner and Anthony (2002) found that smokers and/or drinkers were more likely to encounter an opportunity to use marijuana than non-smokers and non-drinkers, and they were much more likely than non-smokers and non-drinkers to try the drug within the year following this first exposure.

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(iii) Is cigarette use associated with the use of alternative tobacco products such as cigars, bidis, and kreteks in youth?

Bidis are small, thin, hand-rolled cigarettes imported primarily from India and Southeast Asia. Kreteks, also known as clove cigarettes, are imported from Indonesia and contain a mixture of tobacco, cloves and other additives. Both bidis and kreteks have higher concentrations of nicotine, tar and carbon monoxide.

A cross-sectional study by Soldz et al., (2003) demonstrated that most users of alternative tobacco products, including cigars, bidis and kreteks, were also cigarette users. The majority of subjects surveyed had initiated cigarette smoking first. A specific subgroup of youth which had higher grade point averages, and more highly educated parents only smoked cigars,. The researchers suggested that youth from more educated families may be exposed to more positive images of cigars, and view them as more acceptable than cigarettes. Anti-cigar interventions that explicitly target this group may need to be developed and researchers need to examine the attraction of cigar smoking for these young persons.

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(iv) Is tobacco use associated with the presence of symptoms of depression in youth?

Both longitudinal and cross-sectional studies report a positive association between smoking and symptoms of depression. Many longitudinal studies show that smoking predicts the development of symptoms of depression, and that the presence of symptoms of depression predicts smoking initiation or smoking progression (i.e., from light to heavy smoker) (Escobedo et al., 1998; Goodmand and Capitman, 2000; Windle and Windle, 2002). In contrast, whereas Wu et al. (1999) found that smoking was associated with a modest increase in the risk for a first occurrence of depressed mood, depressed mood at baseline was not associated with smoking initiation.

Patton et al. (1998) reported that depression and anxiety significantly predicted smoking onset three years later, especially among youth who had friends who smoked. Albers and Biener (2002) found ever-smoking at baseline predicted symptoms of depression four years later, but once rebelliousness was adjusted for, the relationship became non-significant, suggesting that rebelliousness may have accounted for the association between smoking and symptoms of depression. Some studies have reported differences in this association by ethnicity. Wills et al. (2002) found for example that even though African-Americans and Hispanics had a higher prevalence of negative life events, they had lower rates of increase in smoking. As well, depression has been associated with elevated rates of nicotine dependence (Fergusson et al., 2003).

Rather than depression causing smoking or conversely smoking causing depression, many researchers believe that smoking and depression may have common underlying etiologic factors (Patton et al., 1998; Windle and Windle, 2002; Albers and Biener, 2002; Fergusson et al., 2003). It has been suggested that depressed individuals may smoke as a form of self-medication (Wills et al., 2002).

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(v) Are dieting and body weight/image associated with tobacco use in youth?

Most studies to date are cross-sectional, and the majority focus on the association between tobacco use and weight-related issues in girls. Although the results are not always consistent, some studies report a positive association between smoking and negative weight control behaviours such as bingeing, purging and restriction (Crocker et al., 2001; Winter et al., 2002).

One study found a small but statistically significant relationship between smoking and weight concerns and weight control behaviours in boys (Tomeo et al., 1999). Strauss and Mir (2001) reported that overweight boys who were trying to lose weight were less likely to smoke than overweight boys who were not trying to lose weight.

A study by Baer Wilson et al. (2002) showed that Caucasian teenaged girls who smoked were less likely to consume healthy foods, such as milk, fruit, fruit juice and vegetables, and Strauss and Mir (2001) found that smokers reported eating less fruit and vegetables than non-smokers.

There may also be ethnic or cultural differences in the relationship between smoking and weight loss behaviours. For instance, Baer Wilson et al. (2002) found that the food intake patterns of Hispanic and Caucasian smokers were both dissimilar to African-Americans smokers, who reported a higher consumption of healthy foods. On the other hand, Delnevo et al. (2003) reported no racial/ethnic differences in the use of unhealthy weight loss strategies by smoking status.

Two longitudinal studies suggest that concerns about weight and body dissatisfaction both predict smoking initiation one year later (Stice and Shaw, 2003; Field et al., 2002). The association was strongest in girls. Austin et al. (2001) found that dieting predicted smoking initiation two years later, but only in girls. Also, one study found that girls who valued thinness highly were more likely to progress to becoming established smokers, despite the fact that most girls in the study did not believe that smoking helped control weight (Honjo and Siegel, 2003).

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Several cross-sectional studies suggest a negative association between physical activity and smoking. One study reported a positive association between exercising 8 or more hours per week and being a heavy smoker in girls, although this finding was not statistically significant (Peretti-Watel et al., 2002). In another cross-sectional study, Melnick et al. (2001) reported a positive association between physical activity and the use of chew or dip tobacco.

One longitudinal study found a negative association between high levels of physical activity outside of the school physical education class, and initiation of smoking or progression to a higher level of smoking (Audrain-McGovern et al., 2003).

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One cross-sectional study and one longitudinal study reported an association between tobacco use and school or academic problems, violence, and early pregnancy (Ellickson et al., 2001; Hanna et al., 2001).

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Questions not addressed in the literature

The majority of studies investigating the association between smoking and other risk behaviours in youth are cross-sectional. More longitudinal studies are needed to determine the direction of the associations of interest, to investigate if the association might be causal, and to identify underlying common determinants. Clarification of these issues will help determine if tobacco control programs should target other unhealthy or risky behaviours at the same time as tobacco use, as well as what the best way to combine treatment goals would be.

Some authors suggest that tobacco use acts as a “gateway” to the use of illicit drugs, but the evidence is not conclusive. Therefore it is not clear that if tobacco use is reduced, future illicit drug use will be reduced. Longitudinal studies are needed to address these issues.

It would be useful to know whether treating symptoms of depression in non-smokers prevents smoking initiation, or whether it leads to cessation among smokers. Conversely, would quitting help prevent the development of symptoms of depression? In regard to physical activity, it is unclear if the association with smoking in youth is direct or indirect, whether there is a dose-response relationship between physical activity and smoking, and what specific types of physical activity (i.e., team sports, gym class, free play) might be protective against or associated with the risk of smoking.

Other issues that warrant investigation include whether or not the associations observed vary across subgroups of particular interest to practitioners (i.e. youth of different ethnic origin, sex, socioeconomic status), and whether or not genetic factors might play a role in the observed associations (i.e. for example, the association between depression and smoking could reflect a genetic link).

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1.2 Is there any evidence that interventions targeting multiple risk behaviours are effective at preventing/reducing smoking?

Questions addressed in the literature

(i)What are the effects of interventions that target the use of multiple substances including tobacco?

Most interventions that target tobacco use in the context of multiple substance use programs are school-based, although one intervention tested was home-based. Interventions tested vary considerably in objectives and content; some target smoking and alcohol use, others target smoking, drinking and marijuana use; still others target all drug use. The social influences model is the most common underlying theoretical model on which these interventions are based, one intervention was based on the theory of planned behaviour; and one intervention involved family discussions.

All interventions tested were evaluated in randomized controlled trials, and most used smoking initiation as the outcome. Several studies reported that young persons in the intervention group were less likely to initiate smoking than those in the control group, although the length of follow-up in these studies was short, usually only 1½ years or less (Bauman et al., 2001; Eisen et al., 2002; Ellickson et al., 2003). Two studies found no significant difference in smoking prevalence in the intervention and control groups after three years (Cuijpers et al., 2002; Schinke et al., 2000). Cuijpers et al. (2002) did find a significant difference in the proportion of daily smokers in the intervention and control groups after three years, but the absolute difference was small (50.6% vs 50.7%). One study found a reverse effect on marijuana use (Cuijpers et al., 2002).

Botvin et al. (1999) evaluated the effectiveness of a drug abuse prevention program on smoking initiation and escalation in inner city, minority girls in 7th grade. The 15 session Life Skills Training program taught social resistance skills to resist use of cigarettes, alcohol and drugs. At the end of 8th grade, the results showed that those who received the intervention were marginally protected against smoking initiation; 23.9% of the control students initiated smoking compared to 19.6% of the intervention students. As well, 9.9% of control students escalated to monthly smoking compared to 6.7% of intervention students. Finally smoking initiation appeared to have been prevented by decreasing risk taking and intentions to smoke, by correcting perceived norms concerning adult and peer cigarette smoking, and by increasing refusal skills and knowledge of smoking consequences.

Skara and Sussman (2003) reviewed 25 long-term adolescent tobacco and other drug use prevention program evaluations. They concluded that social influences programs are effective in preventing or reducing substance use for up to 15 years after exposure to the intervention. However, there were no significant program effects in many studies and the strength of the study design and methodology, as well as generalizability of the results, varied substantially across studies.

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Questions not addressed in the literature

The literature remains unclear as to whether or not targeting youth tobacco prevention in the context of programs that aim at several risk behaviours concurrently, has more potential than targeting tobacco use alone. Should programs target each risk behaviour separately or should the program be directed to the underlying determinants of a cluster of risk behaviours? Although targeting the underlying determinants makes intuitive sense, there is little or no consensus on what these underlying determinants actually are.

It is not clear what the goals of programs targeting multiple risk behaviours should be, nor what the best mix of risk factors to address in a single program might be (i.e., are interventions that target cigarette use and alcohol use more effective than those that target cigarette use and illicit drug use?). From an evaluation methods perspective, much longer follow-ups are needed to determine if initial positive impacts of programs targeting multiple risk behaviours are sustained.

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2. Prevention of Youth Tobacco Use

2.1 What are the best programs that focus on either tobacco only or on multiple factors associated with tobacco use to prevent youth from becoming addicted to tobacco?

Questions addressed in the literature

(i) Are school-based interventions alone effective at preventing smoking among youth?

There is a relatively large literature evaluating smoking prevention programs in youth; the majority of initiatives evaluated are school-based programs, and many are evaluated in randomized controlled trials. Although some did show that persons in the intervention group smoked less than those in the control group, many studies did not follow participants beyond the end of the intervention. More specifically, several studies with follow-ups of 1-year or less reported decreased smoking initiation in the intervention group,in contrast to many studies with longer follow-ups which reported no difference in smoking prevalence between the intervention and control groups. If there was a difference initially, it usually dissipated over time and often did not persist beyond one year post-test (Crone et al., 2003; Dijkstra et al., 1999; Schofield et al. 2003; Unger et al. 2004).

The Hutchison Smoking Prevention Project (HSPP) was evaluated in a randomized controlled trial (Peterson et al., 2000). The intervention involved a social influences approach that attributed desirable and rewarding motivations to non-smoking. It included the 15 “essential elements” for school-based tobacco prevention recommended by a national Expert Advisory Panel and met the guidelines for planning and implementing effective school-based programs for the prevention of tobacco use recommended by the CDC. The HSPP was administered over 10 years (grades 3 through 12) to over 8000 students from 40 school districts in the United States. At 10 and 12 years after implementation of the intervention, there was no effect on smoking initiation, or on other measures of smoking such as cumulative smoking (e.g. total cigarettes smoked), and age at which students first reported monthly, weekly and daily smoking. There was also no evidence of an impact among pre-determined high-risk subgroups. The failure to observe any effect on smoking initiation can only be attributed to the failure of the intervention, as the study was designed and executed with a high degree of rigor. Given that this raises concern about the social influences approach as applied to smoking prevention in a school setting, the authors suggest that more research is needed into the mechanisms of smoking initiation in youth and its prevention.

Cameron et al. (1999) found that the intervention effects depended on the risk level for smoking in specific schools. That is, there was no difference in smoking prevalence between the treatment and control groups in schools at low or medium risk for smoking, whereas in high-risk schools, students in the treatment group smoked significantly less than the control group (16.0% vs 26.9%). After 15 years, Vartiainen et al. (1998) found that, whereas the prevalence of daily smoking did not significantly differ between treatment and control groups, lifetime tobacco consumption was 22% lower in the intervention groups than the control groups.

Noland et al. (1998) conducted a study in a tobacco-producing region, and reported that smoking prevalence in the intervention group was lower than in the control group two years later, after adjusting for baseline tobacco use. The impact appeared to be greater in youth who were involved in raising tobacco, likely because the intervention was tailored towards them.

Interestingly two studies that did find long-term significant effects on smoking initiation involved interventions that targeted early risk behaviours in young children. A study by Storr et al. (2002) evaluated a 1-year classroom centered intervention in first grade that reduced child attention problems and aggressive and shy behaviour. It also evaluated a family-school partnership, which targeted early risk behaviours as well. Six years later, at age 12, significantly fewer youth in the intervention groups (26%) than the control group (33%) had begun smoking. Additional follow-up is needed to determine if the effects persist through the peak years for smoking onset.

Kellam and Anthony (1998) evaluated a two-year intervention that targeted aggressive/disruptive classroom behaviour and poor academic achievement in first and second grade. At age 14, smoking initiation in males who exhibited aggressiveness/disruptiveness at baseline and received the behavioural intervention was significantly lower than among males who did not receive the behavioural intervention. There was no effect in females. These results support the importance of targeting early risk behaviours in boys for reducing the incidence of smoking.

Reverse effects of a prevention program on smoking behaviour have been observed (Renaud et al., 2003). The St-Louis du Parc Heart Health Project was a 5-year heart health promotion program targeting children aged 9-12 years in disadvantaged multiethnic neighborhoods in Montreal, Canada. At two years follow-up, children exposed to the intervention were significantly more likely to initiate and to continue smoking than control children. Hypotheses suggested by the authors to explain the reverse effects include: 1) an unfavorable environment characterized by strong pro-smoking models and resistance to environmental interventions; 2) heightened sensitivity to smoking among children most exposed to the program; 3) defense mechanisms among children stimulated by cognitive dissonance or anxiety; 4) unanticipated effects associated with the health educator who delivered the program; 5) inadequate attention in program development to the diverse cultural origins of the population targeted and 6) intervention content inappropriately targeted to children’s stages of cognitive development. The authors suggest that elementary school-based interventions should aim to develop a clear and coherent social norm about the non-use of tobacco, as a precursor to or in close conjunction with having children as their primary target. Also, program design should ensure that the modes of communication are adapted to the characteristics of the group targeted.

Thomas (2002) completed a systematic review of school-based programs for preventing smoking which found that, of the 15 most valid studies of social influences interventions, eight showed some positive effect on smoking prevalence. Seven failed to detect any effect. Thomas also reported that there is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programs that include community interventions.

A review by Backinger et al. (2003) concluded that school based curricula alone have been generally ineffective in the long term in preventing smoking, but that they are effective when combined with other approaches, such as media and smoke-free policies.

Using a best practice approach, Manske and Dobbins (2002) published a report indicating that, of 55 Youth Tobacco Use Prevention Interventions, 5 were recommended as best practices, 35 were promising and 13 were not recommended. Promising practices include school based programs focusing on multiple factors excluding policy initiatives and community component, as well as community programs focusing on raising understanding of tobacco issues, including community activities and school-based activities. This supports contentions by Farrelly et al. (2003) and Friend and Levy (2002) that a combination of different approaches might generate better results than interventions that focus on one approach alone (i.e. school-based programs combined with another prevention approaches might be more successful).

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(ii) Are interventions in home and office settings effective at preventing smoking in youth?

Other settings for prevention interventions that have been evaluated include the home and the office. Curry et al. (2003) evaluated a 20-month home-based intervention that involved a mailed parental smoking prevention kit, outreach follow-up telephone calls to parents by a health educator, child materials, medical record cues for physicians to deliver prevention messages and a parent newsletter. There was no effect on smoking behaviour, but the intervention was associated with a modest but statistically significant increase in parent-child discussion of smoking-related topics. Despite the disappointing results, the authors concluded that development and evaluation of innovative approaches to tobacco use prevention should continue, and that parents and health care systems are too important as channels to abandon as vehicles for prevention messages.

Two studies evaluated office-based interventions. In one intervention, orthodontists provided preteens with pre-printed “prescriptions” indicating reasons not to start smoking as well as counseling (Hovell et al., 2001). In the other intervention, youth were asked by their dentist about smoking, shown photographs of the harmful effects of smoking on the teeth, allowed to examine their own mouth with a mirror, and counseled in accordance with their answer to the question on smoking habits (Kentala et al., 1999). Neither intervention resulted in significant effects on initiation.

Fidler and Lambert (2001) evaluated an intervention in which information about smoking was sent to 10-15 year old youth under the signature of his/her general practitioner, as well as certificates and posters intended to reinforce non-smoking behaviour. After one year, the prevalence of smoking was 7.8% in the control group and 5.1% in the intervention group (5.2% VS 2.4% among boys and 10.0% VS 7.5% among girls).

A systematic review by Christakis et al. (2003) found limited evidence that pediatric smoking prevention interventions delivered by care providers are efficacious or effective over the long-term. Only one of four studies demonstrated a significant effect on smoking initiation after 1 year and none of the studies had follow-up periods greater than 3 years.

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(iii) Are community interventions effective at preventing smoking in youth?

Biglan et al. (2000) evaluated “Project SixTeen,” a community program which was implemented in conjunction with a school-based program. The community program included media advocacy, youth anti-tobacco activities, family communications about tobacco use and reduction of youth access to tobacco. After five years, smoking prevalence in the control group (who received the school-based program only) increased significantly, whereas there was no significant change in the intervention group. The results suggest comprehensive community wide interventions can improve on the effects of a school-based program.

Very few studies evaluated the effectiveness of a community intervention alone. One Australian study evaluated a community program which involved formation of community committees and utilization of access-point networks to initiate and maintain intervention strategies. After two years, there was no significant effect on smoking initiation in 13-16 year old students, and the intervention group was not significantly more aware of anti-smoking activities than the control group. The authors could not recommend community action alone as a tool to decrease adolescent smoking (Hancock et al., 2001).

Bruce and van Teijlingen (1999) reviewed the effectiveness of 60 established UK and Irish Smokebusters clubs. Smokebusters is a community-based smoking prevention initiative for young children. Only three of the clubs had conducted long-term outcome evaluations; there was no evidence of sustained change in smoking behaviour.

Sowden et al. (2000) conducted a systematic review of 17 community interventions for preventing smoking and found limited support for the effectiveness of such interventions. The authors concluded that when planning future community programs, that the following characteristics should be considered: 1) build upon elements of existing programs that have been shown to be effective rather than repeating methods that have achieved limited success; 2) programs need to be flexible to the variability between communities so that the components of a given program can be modified to achieve acceptability; 3) developmental work with representative samples of those individuals to be targeted should be carried out so that appropriate messages and activities can be implemented; 4) program messages and activities should be guided by theoretical constructs about how behaviours are acquired and maintained; and 5) community activities must reach the intended audience if they are to stand any chance of success of influencing the behaviour of that audience.

Based on their comprehensive review of a small number of controlled trials of community interventions, Lantz et al. (2000) concluded that community interventions can have an effect on youth smoking behaviour, and that the effectiveness of school-based programs appears to be enhanced when they are included in broad based community efforts. Also, in the opinion of the authors, community interventions alone are not sufficient to produce a significant decline in smoking in youth that is sustainable.

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Questions not addressed in the literature

Many school-based prevention programs have been evaluated, many with no long-term effect on decreasing smoking initiation. After the disappointing results of the Hutchison trial, Peterson et al. (2000) suggest that research is needed to: 1) identify risk factors that are highly predictive of subsequent smoking by children; 2) identify those highly predictive risk factors that are theoretically modifiable; 3) assess the extent to which changing these risk factors might be expected to reduce smoking acquisition among youth and 4) critically re-evaluate current behaviour change strategies, together with the development and testing of new strategies for changing the identified predictive risk factors and reducing smoking among youth.

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3. Youth Tobacco Use Cessation

3.1 Why and how do youth quit smoking spontaneously?

Questions addressed in the literature

(i) What are the determinants of successful smoking cessation in youth?

Many adolescents smokers want to quit smoking - more than 60% have serious intentions to quit, and the majority has made at least one quit attempt (Burt and Peterson, 1998; Myers and MacPherson, 2004; Grimshaw et al, 2003). However, few young smokers are able to quit successfully (Burt and Peterson, 1998).

Both cross-sectional and longitudinal studies have identified determinants of successful cessation in youth. Personal characteristics influence the likelihood of quitting in youth, including anti-tobacco beliefs (Sussman 2002) and attitudes (Engels et al., 2002), self-efficacy (Engels et al., 2002; Tucker et al., 2002), school performance (Tucker et al., 2002; Hu et al., 1998), feeling hopeful about life (Sussman 2002), having an intact nuclear family (Tucker et al., 2002; Ellickon et al., 2001), and not having symptoms of depression (Zhu et al., 1999).

Quitting successfully is also associated with intentions not to smoke in the future and with frequency of smoking (Tucker et al., 2002; Ellickson et al., 2001; Sargent et al., 1998). Occasional smokers are more likely to quit than regular smokers (Zhu et al., 1999; Sargent et al., 1998). In a 4-year longitudinal study, past quit attempts that lasted longer than two weeks predicted cessation, as did having no past quit attempts (Zhu et al., 1999). The smoking-related environment seems to play a key role in the cessation process: adolescents are more likely to succeed in quitting if they have fewer friends or family members who smoke (Sussman 2002; Tucker et al., 2002; Ellickson et al., 2001; Paavola et al., 2001). Also, the perception of less parental approval of smoking is a predictor in some studies (Tucker et al., 2002; Ellickson et al., 2001).

In a 13-year longitudinal study that monitored smoking behaviour beginning at age 15, Paavola et al. (2001) found that, compared to their male counterparts, cessation rates were consistently higher among females who smoked daily or occasionally. Also, cessation rates were higher among married, employed and white-collar workers. It was lower among persons who consumed fatty milk, reported less leisure-time physical activity, and consumed more alcohol. One-third of all teenaged smokers had stopped smoking by age 28. A two-year longitudinal study of smokers in grade 10 reported that there were sex differences in three of the predictors of quitting success studied (Ellickson et al., 2001). Lower levels of delinquency, poorer grades and higher peer support were associated with a greater likelihood of quitting for girls, whereas higher levels of delinquency, better grades and lower peer support were associated with greater likelihood of quitting for boys.

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Questions not addressed in the literature

More well-designed longitudinal studies are needed to address this issue. The role of nicotine dependence in self-initiated cessation relative to known predictors of cessation in youth should be investigated; dependence likely explains why heavy smokers are less likely to quit on their own, and why those with a history of failed quit attempts are less able to stop smoking.

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3.2 What are the best programs to help young smokers quit?

Questions addressed in the literature

(i) Which school-based programs are best for tobacco use cessation in youth?

The most common setting for youth cessation interventions is the school. In many studies evaluating school-based cessation programs, the effectiveness of the intervention could not be determined because of methodological weakness including small sample sizes, lack of a control group, and short-term follow-up. In addition there is considerable variation in the length, intensity and content of interventions studied.

Of ten studies with adequate study designs and methods, three reported no effects on cessation (Aveyard et al., 1999; Brown et al., 2002; Robinson et al., 2003), six reported positive effects on cigarette smoking and one reported positive effects on spit tobacco use.

The six studies that reported positive program effects evaluated two interventions: Project EX (Sussman et al., 2001) and Not-On-Tobacco (N-O-T) (Horn et al., 1999; Dino et al., 2001a; Dino et al., 2001b; Horn et al., 2003; Horn et al., 2004). Project EX is a 6-week clinic which includes enjoyable, motivating activities to enhance quit rates among youth. Five months after the appointed “quit day,” 17% of those who received the intervention had quit smoking, compared to 8% in the control group.

N-O-T is a 10-week intervention conducted in gender-specific groups that involves a total health approach. 6.2 months after the “quit day,” 29.6% of females who received the intervention and 8.9% of females in the control group had quit. In contrast, 14.4% of males who received the intervention and 15.9% of males in the control group had quit (Dino et al., 2001a). These results suggest that the N-O-T intervention had a differential effect on boys and girls. The researchers conclude that gender-specific interventions are warranted.

Walsh et al., (2003) evaluated a cessation intervention for spit tobacco use in male athletes, and found a positive effect on cessation after brief counseling and screening for oral cancer.

In a 2002 review of cessation interventions, Sussman (2002) concluded that the most effective interventions were those carried out in school classrooms, and those based on motivational enhancement and contingency-based reinforcement (i.e. techniques that reward participants for being abstinent). In a later review by McDonald et al. (2003), the only approach that the review panel endorsed was the use of cognitive-behavioural approaches.

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(ii) Are programs in other settings effective for tobacco use cessation in youth?

Numerous studies evaluate cessation interventions for youth in home, research office, clinic, hospital, and youth summer program settings, using randomized controlled trial designs. Two hospital-based interventions using brief motivational interviewing reported positive results on cessation (Brown et al., 2003; Colby et al., 1998). The effectiveness of other interventions cannot be ascertained because the methods used in the evaluations were weak. These include a home-based intervention where the parent/caregiver received instructions and advice via mailed booklets and phone calls from health educators (Bauman et al., 2000), and a clinic-based intervention where youth received a 45-minute consultation with a nicotine-dependence counselor who developed an individualized treatment plan (Patten et al., 2001). Laser acupuncture has been evaluated for its effect on cessation in youth, but the results were not superior to placebo (Yiming et al., 2000).

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Questions not addressed in the literature

Cessation as it pertains to youth needs to be better conceptualized and measured in studies of youth cessation. Biochemical validation (CO or cotinine) of reported non-smoking is important in this population.

In general the literature that evaluates the effectiveness of cessation interventions for youth is underdeveloped. More studies with rigorous methodology (i.e. randomized controlled trials using validated measures of cessation with long-term follow-up) are needed.

Cessation interventions for youth should be evaluated in different contexts. More specifically we need to identify the most appropriate settings for youth cessation programs. What is the best format? How intense should cessation programs be to achieve success? Should interventions be gender-specific? Who (teachers, peers, nurses, etc.) is best-placed to deliver cessation interventions for youth?

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3.3 Do nicotine replacement therapy (NRT) and bupropion (Zyban) work in youth?

Questions addressed in the literature

(i) Is nicotine replacement therapy effective for tobacco-use cessation in youth?

Three studies have been published recently on the effectiveness of nicotine patch for smoking cessation in youth. However two of the three studies did not include a control group (Hurt et al., 2000; Smith et al., 1996). The third study (Hanson et al., 2003), did not detect a significant effect of NRT on cessation. Although this study was a randomized controlled trial, both recruitment and retention were inadequate. The study did report that participants treated with the nicotine patch experienced a significantly lower craving score, as well as a lower overall withdrawal symptom score than participants on the placebo patch. Stotts et al., (2003) found no benefit of the nicotine patch over placebo for spit tobacco cessation in youth.

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(ii) Is bupropion effective for tobacco-use cessation in youth?

Only two pilot studies have been published on the effectiveness of bupropion (O’Connell et al., 2004; Upadhyaya et al., 2004). Both were limited by a small sample size and neither had a control group. Therefore no conclusions can be drawn.

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Questions not addressed in the literature

Based on the studies to date it is not possible to determine whether or not NRT and Zyban are effective in helping youth quit. Evaluations with rigorous study designs and methods are needed. These studies should be designed to attain adequate sample sizes, include control groups, demonstrate adherence to treatment, investigate possible adverse effects, and assure long-term follow-up. It should be determined which youth in terms of sex, age, and smoking status, might benefit most from NRT and Zyban.

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4. Youth Engagement in Tobacco Control Issues

4.1 Is there any evidence that youth engagement in tobacco control issues affects tobacco use?

Questions addressed in the literature

(i) Does youth engagement in tobacco control influence tobacco use?

There is only one recent publication that addresses this issue (Winkleby et al., 2004). In a randomized controlled study involving youth in grades 11-12, regular smokers (defined as smoking more that one pack of cigarettes per week) who participated in community advocacy activities addressing environmental influences of cigarette smoking, were more likely to reduce or quit smoking than those in the control group. The prevalence of regular smoking decreased from 25.1% to 20.3% in the intervention group while it decreased from 25.6% to 25.2% in the control group. The difference observed was maintained after six months. There was no effect on light smokers (defined as those who smoked less than a pack of cigarettes a week).

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Questions not addressed in the literature

Evidence is needed on whether or not participation in tobacco advocacy and tobacco control activities prevents smoking initiation, if participation reduces smoking in occasional and regular smokers, and if it helps young smokers quit. There is no information on age at which participation in tobacco control issues might be most beneficial.

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4.2 What strategies have been successful at engaging, involving and supporting youth in tobacco control activities (smokers and non-smokers)?

Questions addressed in the literature

(i) What factors are associated with participation in anti-tobacco activities?

Carver et al. (2003) measured the attitudes and self-perceptions of a group of high school students attending a tobacco advocacy conference regarding anti-tobacco advocacy. Overall, they were moderately positive about anti-tobacco advocacy. Girls had more positive attitudes than boys. Participants strongly believed in their ability to resist peer pressure to use tobacco, as well as their willingness to speak to others personally about not using tobacco. On the other hand, they were only moderately confident in their abilities for activism. The researchers suggest that community coalitions that include youth may need to focus on building their skills for activism.

Lee et al. (2001) studied factors associated with participation and willingness to participate in anti-tobacco community activities, among students in grades 4 to 7. Parental smoking status and participation in student government activities were associated with participation in anti-tobacco activities. Exposure to anti-tobacco television campaigns, liking school and several tobacco-related knowledge and attitudinal questions were related to willingness to participate in anti-tobacco activities. Several factors were associated with both actual participation and willingness to participate, including parental discussion of tobacco use, exposure to school courses with anti-tobacco curricula, and a belief that youth could convince their friends to stop smoking.

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Questions not addressed in the literature

Studies are needed to determine why youth participate in anti-tobacco activities, and to ascertain if the determinants of participation differ between smokers and non-smokers. Identification of these predictors will allow development of anti-tobacco interventions that are more likely to attract young people, and that have a positive impact on their attitudes and behaviours towards smoking, as well as those of their peers. It may be useful to incorporate modifiable factors such as parental discussion of tobacco use into interventions aimed at engaging, involving and supporting youth in tobacco control activities. These factors could increase interest among youth in anti-tobacco advocacy.

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5. Youth Access to Tobacco Products

5.1 Does retail access to tobacco products influence smoking initiation and cessation in youth?

Question addressed in the literature

(i) Are tobacco sales laws and retailer compliance with these laws associated with smoking prevalence and/or initiation in youth?

Most studies addressing this issue evaluate retailer compliance with youth access laws, rather than the impact of access laws on smoking prevalence in youth. Several studies compared smoking rates between towns with and without access laws. However the results from these studies suffer from inadequate control of potentially confounding differences between towns.

Two cross-sectional studies reported that youth access laws and degree of compliance with the laws were associated with lower smoking prevalence and initiation among young people (Forster et al., 1998; Pokorny et al., 2003). Several studies have found that the effects of youth access laws appear to act through denormalization of smoking rather than through reduced cigarette sales to youth (Forster et al., 1998; Gilpin et al., 2004; Siegel et al., 1999).

One longitudinal study followed two cohorts of 12-15 year-old never-smokers in California for three years (Gilpin et al., 2004). The earlier cohort (1993-1996) was studied before, and the later cohort (1996-1999) after, implementation of the Stop Tobacco Access to Kids Enforcement (STAKE) Act in 1994, which increased enforcement of youth access laws. The authors documented transition to any smoking according to the perception that cigarettes are easy or hard to get. Transition to any smoking in the earlier cohort did not differ according to young persons’ perceptions of the difficulty getting cigarettes. However adolescents in the later cohort who thought that cigarettes were hard to get were significantly less likely to start smoking than those who thought that cigarettes were easy to get. These results suggest that adolescents’ perceptions that cigarettes are hard to get may be in part a social normative factor that indirectly deters youth from taking up smoking. The authors concluded that concerted enforcement of laws prohibiting the sale of tobacco to minors may be warranted as part of a comprehensive tobacco control program that seeks to denormalize tobacco use.

In a 4-year prospective study, Siegel et al., (1999) found that youth aged 12-15 years living in towns with tobacco sales ordinances were significantly less likely than youth living in towns without an ordinance to progress to established smoking (i.e., lifetime consumption of at least 100 cigarettes). This effect was strongest among youth at the earliest stages of smoking initiation. Also there appeared to be a dose-response effect - youth in towns with weak ordinances were more likely than those in towns with strong ordinances (but less likely than those in towns without ordinances) to take up smoking. However none of these results were statistically significant. Interestingly youth living in towns with laws governing youth tobacco sales perceived no greater difficulty obtaining cigarettes, and were no more likely to believe that there were penalties for selling tobacco to minors or for purchasing tobacco if underage. The investigaotrs proposed two explanations for their results. First, the adoption and implementation of local sales ordinances could result in a change in social norms with regards to smoking. Second, local tobacco sales ordinances could be a proxy for other factors that distinguish communities that adopt such ordinances.

Altman et al., (1999) examined the effectiveness of a community intervention to reduce tobacco sales to minors on consumption among youth in grades 7, 9 and 11 in a randomized controlled trial. Over a 34-month intervention period, the proportion of stores that sold tobacco to minors declined from 75% to 0% in treatment communities. Among 7th graders, those in the intervention communities were significantly less likely to have smoked in the past 30 days than those in the control communities, but this difference persisted only 11/2 years. No significant difference in smoking prevalence was observed for 9th and 11th graders.

In several cross-sectional studies, restrictions on retail availability of tobacco seemed to be unrelated to smoking initiation, when cigarettes were readily available in the home (Pokorny et al., 2003). Finally, in states with a strong tobacco economy, the effect of policies on youth smoking seemed to be limited (Luke et al., 2000).

A systematic review by Stead and Lancaster (2000) found that many community interventions in place to deter shopkeepers from making illegal cigarette sales to underage youth were able to achieve large decreases in sales, but none of them achieved complete, sustained compliance. The investigators suggest that without complete, sustained compliance, there will always be a commercial source of cigarettes for underage youth. They conclude that this is the reason for the limited evidence from controlled trials that reducing youth access to cigarettes will reduce actual use.

Another review by Fichtenberg and Glantz (2002) concluded that youth access interventions are not associated with consistent positive effects on youth smoking prevalence, and that there is no evidence that increased compliance is associated with decreased prevalence. They suggest that the reason for this is that only about half of teen smokers use commercial sources as their usual source of cigarettes and the rest obtain cigarettes from parents, friends and strangers, or steal them. Given the limited resources available for tobacco control, the investigators advise against using this strategy for reducing youth tobacco use.

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Questions not addressed in the literature

Results to date suggest that tobacco sales laws can be an effective part of tobacco control programs that use a combination of approaches. However more well-designed long-term studies that use smoking prevalence in youth as the outcome are needed. These studies should be conducted in a wide variety of communities.

Studies are needed to identify differential effects of youth access enforcement efforts in subgroups based on gender, ethnicity, and type of smoker (i.e., sporadic versus regular smokers).

The mechanism by which access laws prevent and/or reduce smoking (if in fact they do) should be further studied. Are the effects of access laws truly mediated through denormalization? How do access laws influence where youth get their cigarettes? When strict enforcement laws are in place, do youth turn to other sources to obtain cigarettes? What is the role of cigarette smuggling?

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5.2 What are the best interventions to reduce youth access to cigarettes through friends, older youth, and adults?

Questions addressed in the literature

(i) What can be done to reduce youth access to cigarettes from friends, other youth and adults?

The literature provides evidence that youth acquisition of cigarettes from non-commercial social sources including friends, family members, and adult strangers, is quite common and quite easy (Castrucci et al., 2002; Forster et al., 2003; Harrison et al., 2000; Robinson et al., 1998; Loiselle, 1999; Perron, 2003). Females, younger adolescents, and experimental smokers acquire cigarettes more often from social sources than males, older adolescents, and regular smokers. To date there are few publications that describe interventions to reduce access to tobacco through these non-commercial social sources.

Post et al. (1999) provided suggestions for developing a community response to this problem: they recommendedcreating messages that target teens who smoke regularly, to influence their attitudes and behaviours related to distributing cigarettes. They also recommended point-of-purchase initiatives which address adults and older youth who supply cigarettes to people who are known to them (e.g. under aged friends and family), not just to strangers. Lastly they suggest that general knowledge and awareness about the Tobacco Control Act, need to be improved. More specifically, teenagers, adults, and parents need to know that it is illegal to supply tobacco to anyone underage.

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Questions not addressed in the literature

To date research related to youth acquisition of cigarettes has focused on characterizing non-commercial social sources of cigarettes. Studies are needed to identify innovative approaches that prevent adolescents from acquiring cigarettes from the people close to them including friends, older youth, and adults. Strategies that deter these social sources from providing cigarettes to underage youth also need to be evaluated.

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6. Protection from Exposure to Second-Hand Smoke

6.1 Are indoor and outdoor smoking bans effective in reducing children’s exposure to second-hand smoke?

Questions addressed in the literature

Indoor smoking bans

(i) Do interventions aimed at parents who smoke reduce their children’s exposure to second hand smoke (SHS) in the home?

One focus of the literature on indoor smoking bans has been interventions aimed at parents who smoke to reduce exposure to SHS in the home in their young children. The study endpoints for SHS exposure have been child cotinine levels (considered the best available biomarker of SHS) and air nicotine levels. Parental carbon monoxide (CO) levels and smoking rates and intensities were often measured as well. Parents’ self-reported smoking practices are reasonably valid proxies for physiological measures (Wong et al., 2002).

There has been some limited success in reducing SHS exposure in children through interventions to increase indoor smoking bans. Several studies designed to reduce parental smoking found no effects of these interventions on children’s cotinine levels, although several reported effects on parents’ smoking and mothers’ cessation (Emmons et al., 2001b). One randomized study offering counseling to parents who smoke, reported reduced exposure and cotinine levels, but did not report whether the reduced exposure was due to bans. Another randomized study found significantly lower nicotine levels in children of parents who received a motivational intervention compared to a self-help ban (Emmons et al., 2001b). One nurse-delivered clinical-based intervention for parents of asthmatic children increased home smoking bans (Wilson et al., 2001), but another controlled trial of an intervention to increase household and car smoking bans among parents of asthmatic children found no effect on either presence of bans or child cotinine levels (Wakefield et al., 2002a). A 2000 review concluded that interventions based on behavioral strategies were more effective than informational strategies (Arborelius et al., 2000). Another review, in 2003, concluded that more intensive and sustained interventions produce the greatest impact on SHS exposure in children (McQuaid et al., 2003).

In a cross-sectional survey exposure to a media campaign to increase awareness of health risks associated with SHS was associated with intentions to increase home smoking restrictions and improved attitudes toward protecting children from SHS (King et al., 2003).

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(ii) Are parental smoking location and practices associated with lower levels of exposure to second hand smoke (SHS) in children?

Several studies have examined whether where parents smoke in or near the home is associated with exposure to SHS in children, and in particular among asthmatic children, low-income children, multi-ethnic children and Native American children. In general, indoor smoking restrictions are associated with lower SHS exposure in children, but exposure is not as low as among children of non-smoking parents. Some studies showed a graded benefit, and others only an effect for complete bans.

Parents smoking outdoors with the door closed, was associated with lower SHS exposure (as measured by cotinine levels) than was smoking near the kitchen fan or outdoors with the door open. However SHS exposure was not as low as among children in non-smokers’ homes (Johansson et al., 2004). Children of parents who smoke outdoors had fewer (parent-reported) respiratory symptoms than children whose parents smoke indoors only (Johansson et al., 2003). In asthmatic children, tighter indoor household and car smoking restrictions were associated with lower air nicotine and child cotinine levels (Berman et al., 2003; Wakefield et al., 2000a).

Smoking outdoors was associated with lower air nicotine and infant cotinine levels than smoking indoors, but not as low as levels found in non-smoking homes (Matt et al., 2004). Strict indoor smoking bans were associated with lower cotinine levels in infants than no or some restrictions, but there was no difference between the latter two levels (Blackburn et al., 2003).

Home smoking bans were associated with lower frequency of children being in a room with someone who smokes (Kegler and Malcoe, 2002).

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(iii) What do guidelines say about the strength of the evidence for intervening on knowledge about and attitudes toward smoking bans in homes?

To date, based on a lack of evidence, no guidelines make recommendations to develop interventions to increase knowledge and to change attitudes about the health effects of exposure to SHS in the home (Hopkins et al., 2001).

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(iv) Is the presence of smoking restrictions in restaurants associated with youth exposure to second hand smoke (SHS)?

One survey reported an association between teens’ reported frequency of seeing smokers in restaurants and smoking regulations in local restaurants. Stronger regulation was related to lower levels of exposure to SHS. There were no biological measures of exposure (Siegel et al., 2004).

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(v) a) Is the decrease in population smoking rates associated with parallel decreases in prevalence of second hand smoke (SHS) exposure in children? b) Is the presence of children exposed to SHS in households associated with the presence and strength of restrictions? and c) Are there secular trends in the presence of smoking bans in the home?

These questions were addressed in several population-level studies. Between 1992 and 2000, SHS exposure decreased more markedly than population smoking levels (Soliman et al., 2004). Some studies found that households with children were more likely to have home smoking bans (Pizacani et al., 2003; Okah et al., 2002; Norman et al., 1999) and car smoking bans (Norman et al., 1999) than households without children. A comparison of household surveys conducted in Ontario in 1992, 1995 and 1996 found that both smokers’ and nonsmokers’ attitudes towards banning smoking in the home when children are present improved over time. However, in 1996 only 19.8% of smokers’ homes were reported to be completely smoke-free (Ashley et al., 1998). A study comparing smoking bans in households over time found an increase between 2000 and 2001, although bans were much less prevalent in the homes of smokers (McMillen et al., 2003).

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Outdoor smoking bans

(i) How are legislated smoking bans implemented in youth, and what are their perceived impacts?

None of the studies investigating outdoor bans assessed the impact of the bans on second hand smoke (SHS).

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Indirect effects

(i) Are home and workplace smoking restrictions associated with youth smoking?

One study of the association between the presence of legislation and smoking restrictions in worksites and/or restaurants reported associations with youth smoking prevalence and stage of smoking uptake (Wakefield et al., 2000b). Using data from two large national surveys in the US, Farkas et al. (2000) showed that adolescents who lived in smoke-free homes or worked in smoke-free workplaces were significantly less likely to smoke. Another cross-sectional study showed that restrictive home smoking bans were associated with reduced likelihood of smoking experimentation among adolescents, but only among children of non-smoking parents (Proescholdbell et al., 2000).

Several studies found that clean indoor air laws are associated with less smoking among selected groups of youth (Chaloupka and Pacula, 1999; Ross and Chaloupka, 2003; Levy and Friend, 2003). The most consistent relationships were reported for school smoking restrictions, while clean air laws applied in other settings had inconsistent effects on youth smoking (Levy and Friend, 2003). A study of the Ontario school property bans showed that smoking rates as perceived by high school administrators, declined after the bans (Northrup et al., 1998).

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Questions not addressed in the literature

There are few Canadian data on the level of exposure to second hand smoke (SHS) among children at home or in cars, in public places, or near schools. There are no studies on the impact of outdoor bans on exposure to SHS in children. Finally there are no prospective studies investigating the impact of introducing non-home restrictions or bans on exposure to SHS in children.

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6.2 What are the best ways to help parents who smoke minimize their children’s exposure to second-hand smoke at home and in the car?

Questions addressed in the literature

(i) Will interventions aimed at smoking reduce children’s exposure to second hand smoke (SHS) in the home by either smoking restrictions, or cessation, or both?

Several studies in this area have focused on interventions aimed at reducing parental smoking, to determine if they will reduce exposure to SHS, both among children in general, and specifically among asthmatic children. Study endpoints include levels and rates of maternal smoking, and child cotinine levels.

While an earlier review (Hovell et al., 2000a) concluded that evidence for the effectiveness of interventions to reduce exposure to SHS among children was limited, a more recent review of 19 controlled studies concluded that several types of interventions are effective in protecting children from SHS (Wewers and Uno, 2002). In another review, ten interventions involved counseling in pediatricians’offices; and eight were home-based involving home counseling visits based on behaviour change theory, as well as provision of support materials. Home-based interventions were of greater intensity and duration; all but one produced effects on smoking attitudes or behaviour, although only two reduced cotinine levels. The interventions seemed to be as effective in asthmatic as in healthy children (Gehrman and Hovell, 2003).

One nurse-delivered clinic-based intervention produced reduced medical visits for acute asthma as well as reduced child cotinine (Wilson et al., 2001). Another study found contradictory results between self-reported smoking and parental cotinine levels (Fossum et al., 2004). One study that had nonsignificant cotinine and behavioural outcomes attributed the null findings to inadequate delivery of the behaviour change theory-based intervention by nonprofessionals (Conway et al., 2004). An intensive asthma education intervention with SHS-reduction coaching reduced children’s cotinine levels and reported smoking exposure more than an education only intervention (Hovell et al., 2002).

Overall the results suggest that parents can help protect asthmatic and non-asthmatic children by availing themselves of intensive, home-based interventions based on solid behaviour change theory.

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(ii) Are parental smoking location and practices associated with lower levels of children’s exposure to second hand smoke (SHS)?

Similar to Question 2 in Topic 6.1, the literature has examined whether parents can affect their children’s exposure to SHS by changing their smoking practices, especially through implementing smoking restrictions in the home. This question has only been addressed in cross-sectional studies; to date there have been no controlled trials.

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(iii) What are the effects of brief physician interventions on reducing children’s exposure to second hand smoke (SHS)?

Evidence for the impact of brief physician interventions on reducing exposure to SHS in children is limited (Gehrman and Hovell, 2003; Stein et al., 2000). In contrast to recommendations in survey studies (Schuster et al., 2002) and reviews (Stein et al., 2000), the results suggest that parents should not currently turn to physicians or pediatricians for support to help protect their children from SHS (Perez-Stable et al., 2001).

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Questions not addressed in the literature

While one meta-analysis suggests that some intervention approaches are more effective than others, no controlled studies have been undertaken using children’s biomarkers as endpoints. As well, no studies have examined the effects of childcare environments or court or adoption agency regulations on SHS exposure.

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7. Effects of Taxation and Pricing on Youth Smoking Behaviour

7.1 How does the price of cigarettes affect smoking by youth: a) how and where they obtain cigarettes; b) how much they smoke; c) how likely they are to start smoking; d) how likely they are to use other substances; and e) does the effect differ in different subgroups of youth?

Questions addressed in the literature

(i) How does the price of cigarettes affect how and where youth obtain cigarettes?

None of the studies reviewed addressed how price affects access to cigarettes, although one study investigated the effects of smuggling (Ross and Chaloupka, 2003).

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(ii) How does an increase in the price of cigarettes affect smoking prevalence and intensity in youth?

The literature has focused on the effects of cigarette price increases on smoking prevalence and intensity in youth, using price elasticities as the outcome, i.e. the percentage change in the smoking outcome variable with every 1% change in the standardized, inflation-adjusted price of cigarettes.

Using large population surveys from many jurisdictions, studies have consistently shown that price increases are either followed by or associated with decreases in smoking prevalence and quantity of cigarettes smoked among youth (Ross and Chaloupka, 2003; Chaloupka 2003; Liang and Chaloupka, 2002; Harris and Chan, 1999). Several investigators have argued that price is the most consistently effective policy intervention in deterring youth smoking (Lian et al., 2003).

Price elasticity (price effect) appears to be greatest among those who smoke the most (Liang and Chaloupka, 2002), although Harris and Chan (1999) find that elasticities were greater for those who smoke occasionally. Price elasticity is also greatest among older youth smokers (Harris and Chan, 1999; Emery et al., 2001; Gruber and Zinman, 2000). Both heavy smokers and older youth smokers are most likely to buy their own cigarettes.

Price has an effect even when psychosocial and demographic factors, including household income, are controlled (Emery et al., 2001), although household income may have an independent effect on price elasticity (Liang et al, 2003). The price effect is present for several types of price measures, and is best assessed using teens’ perceived price of cigarettes, which reflects what they have actually paid; this strategy overcomes limitations in using retail prices or tax levels (Ross and Chaloupka, 2003).

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(iii) What are the direct impacts of a specific price increase or decrease?

The impact of specific price increases/decreases has been examined in the form of natural experiments, and the findings support the results from cross-sectional studies. One of stronger studies was conducted in Ontario (Waller et al., 2003). It examined data from repeat cross-sectional surveys of high school students for several years before and after a 1993 tax decrease. Results showed a sharp increase in smoking prevalence and mean number of cigarette smoked per day by daily smokers after the decrease. After a small cigarette tax was imposed in Massachusetts, teen smokers were less likely than adults to consider quitting, with the greatest effect of the price increase observed among youth from lower-income households (Biener et al., 1998).

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(iv) Will the decreases in youth smoking obtained through price increases translate into decreased long-term adult smoking rates and associated morbidity?

Several studies have recently shown that the effects of tax increases on youth smoking attenuate over time, so that much of the potential population health effect disappears after several years. Using data from six cohorts born between 1944 and 1967, Glied (2002) showed that by age 40, differences in taxes faced by youth at age 14 had no effect on population smoking rates. Some investigators argue that current public health emphasis on preventing youth smoking is misplaced (Gruber and Zinman, 2000; Glied 2003; Glied 2002). They state that efforts should be concentrated in sustaining delayed initiation into adulthood and helping adult smokers quit, because prevention effects are investments in health capital, not immediate health, and smoking-related diseases occur later in life.

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(v) What are the impacts of pricing on smoking initiation or experimentation?

The literature has examined the impact of pricing on smoking initiation and experimentation, often contrasting effects among youth who are already current or established smokers. The findings suggest that the effect of price increases is greatest among, and possibly limited to, older youth who are already heavy smokers.

Using survey data on teens collected in 1993, prices were found to have no relationship to experimentation with smoking but were associated with a decrease in the amount smoked among current and established smokers (Emery et al, 2001). An economic modeling study of Israelis aged 18 to 40 retrospectively examined the age at which people started smoking in relation to pricing and found that, after controlling for other variables, higher prices were associated with older age at initiation (Beenstock and Rahav, 2002).

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(vi) What are the effects of cigarette prices on the use of illicit drugs?

The literature examining the effect of cigarette prices on the use of illicit drugs has focused mainly on cannabis use. There is some evidence that higher cigarette prices are associated with reduced use of cannabis among teens. Using data from 7 years of the National Household Survey on Drug Abuse for respondents aged 12 to 20, Farrelly et al. (2001) found that higher cigarette excise taxes decrease the intensity of marijuana use, with a lesser effect on the probability of use. These effects were only significant among males.

An economic modeling study of Israelis aged 18 to 40 also found that people who grew up when cigarette prices were lower were more likely to smoke, to start smoking at younger ages, to subsequently use cannabis, and to use cannabis at younger ages (Beenstock and Rahav, 2002). This study did not take the effect of the social environment on behaviour into account.

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(vii) What is the effect of price increases according to gender, race and ethnicity?

Chaloupka and Pacula (1999) found that high school boys were much more sensitive to the price of cigarettes than high school girls. Higher prices were shown to affect smoking initiation among boys but not girls; girls’ smoking initiation was more strongly influenced by weight concerns than by prices (Cawley et al., 2004).

Chaloupka and Pacula (1999) also found that young black men were more responsive to price changes than young white men. Data from the National Health Interview Survey from 1976 to 1993 showed that price elasticities had a greater impact among younger smokers, although these data only included respondents 18 years and older. The price increase impact was greater among minority group young adults (CDC 1998).

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Questions not addressed in the literature

The impact of price changes on sources of cigarettes has not received much attention. More Canadian data are needed on all of these issues, with a link to minority group status as is experienced in Canada. More research is needed to explain gender differences in price elasticities for cigarettes, comparing smoking to other discretionary spending among boys and girls.

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7.2 What do tobacco companies do to offset the impact of tax increases on tobacco?

Questions addressed in the literature

(i) How have cigarette companies used information about the relationship between prices and smoking among youth in their marketing efforts?

Tobacco companies use both epidemiological information and their own data in their business strategies. The evidence on this topic is documentary, from reviews of internal tobacco company documents.

Tobacco companies’ calculations of price elasticities usually replicate those in the published research literature very closely. They conduct sophisticated analyses of the impact of price on sales with very detailed segmentation (Chaloupka et al., 1999; Ling and Glantz, 2002b). For example, documents obtained from Phillip Morris market studies showed that males aged 18-24 had been segmented into Macho Hedonists, 50s Throwbacks, Enlightened GoGetters and New Age Men, while women 18-24 had been segmented as 90s Traditionalists, Uptown Girls, Mavericks and Wallflowers.

Tobacco companies monitor the impact of price increases not only on sales, but also on smoking levels, cessation rates, brand utilization and a host of other variables. They have responded to price increases by using pricing-related strategies such as price reductions (or more generally, strategic price management), development of generic or discount brands, multi-pack discounts, discount coupons, buy-one-get-one-free promotions, cash rebates, and bulk/no frills packaging (Chaloupka et al., 1999).

Since the Master Agreement in the US, tobacco companies have expanded point-of-sale strategies such as product placement and gifts-with-purchases (Wakefield et al., 2002b). They have also used smuggling as a marketing strategy (Leverett et al., 2002). These strategies are aimed at offsetting the larger declines in smoking expected among youth than adult smokers.

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Questions not addressed in the literature

The Chaloupka paper raises questions about cigarette affordability for young people in relation to other areas of spending, notably gasoline, but also food (especially meat) prices. His argument suggests that recent gasoline price increases will reduce youth smoking. We found no research papers on price-related marketing strategies among Canadian tobacco marketers.

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8. Social Marketing, Denormalization, Mass Media Interventions, Community Mobilization Campaigns

8.1 What evidence is there that anti-tobacco marketing campaigns are effective at a) preventing youth smoking and b) reducing youth smoking? What strategies should be used in conjunction with marketing campaigns to maximize their effectiveness?

Questions addressed in the literature

(i) What are the effects of publicly-funded mass-media campaigns directed to youth?

Much of the literature focuses on the effects of publicly funded mass-media campaigns directed at youth. Most studies assess both prevention and reduction effects in youth exposed to the campaign, often as a component of comprehensive tobacco control programs.

Recent reviews have concluded that state and local mass-media campaigns are sometimes, but not always, effective in both preventing youth from smoking and reducing youth smoking levels (Farrelly et al., 2003; Friend and Levy, 2002; Wakefield et al., 2003a; Sowden and Arblaster, 2000; Siegel 1998). Among the most recent and well-researched examples are the “Truth” denormalization campaigns in California, Florida (Sly et al., 2001a; Sly et al., 2001b; Niederdeppe et al., 2004) and Massachusetts (Siegel and Biener, 2000), and the campaign by the national American Legacy Foundation (Farrelly et al., 2002a), which produced large net declines relative to other states in youth smoking. Smoking was measured by 30 day prevalence and having ever tried smoking. Some campaigns have not produced strong effects (Farrelly et al., 2003; Friend and Levy, 2002; Seghers and Foland, 1998). Siegel and Biener (2000) found an effect only in younger youth (aged 12-13). Wakefield et al. (2003b) concluded that media campaigns are most effective among pre-adolescents and younger adolescents, by preventing smoking uptake.

It is often unclear what proportion of observed reductions can be attributed to media campaigns rather than to concomitant price reductions, policy measures, or youth empowerment movements. At least one review concluded that well-funded, -planned and -targeted campaigns can produce independent effects (Farrelly et al., 2003).

Media campaigns directed at youth are most effective under certain conditions: high levels of funding, high penetration (e.g. lots of ads in prime-time hours), long campaign duration, and implementation at the state level in conjunction with comprehensive tobacco control programs (Farrelly et al., 2003; Friend and Levy, 2002; Sowden and Arblaster, 2000). Radio and billboard components of campaigns have not been shown to be effective (Siegel and Biener, 2000).

Some research suggests that the effects of the campaign may wear off after about three years (Friend and Levy, 2002; Sly et al., 2001b) or once campaign intensity is reduced (Wakefield et al., 2003b). A study of susceptibility to smoking after a statewide campaign was ended showed that susceptibility increased compared to during-campaign measures (CDC 2004; Sly et al., 2002).

A computer simulation study estimated that media interventions of sufficient scope and duration would be more effective in reducing premature deaths if they targeted the whole population, not just youth (Levy and Friend, 2001). Also several studies have reported that media campaigns have greater effects on progression to established smoking than on smoking initiation (Sly et al., 2001a; Sly et al., 2001b).

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(ii) Is there a dose-effect for publicly funded campaign exposure?

Some studies have addressed the possibility of a dose-effect for campaign exposure. A study by Sly et al., (2002) found that the number of different TV advertisements seen over a 22-month period by youth aged 12-17 increased their likelihood of remaining non-smokers.

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A comparison of cross-sectional surveys conducted before and after a publicly funded and an industry anti-smoking campaign showed that while the publicly funded campaign had the desired effect on anti-smoking attitudes, the industry-sponsored campaign engendered more favorable feelings toward the tobacco industry (Farrelly et al., 2002a).

Analyses of a cross-sectional survey of eighth-grade students showed that exposure to both pro-tobacco and anti-smoking campaigns was associated with higher receptivity to the messages (Unger et al., 2001). In a similar study of junior and middle-school youth (but with a low response rate), smokers and nonsmokers were equally likely to have been exposed to cigarette advertising, but smokers were more likely to believe cigarette ad messages (such as “People who smoke are healthy”) than were non-smokers (Hawkins and Hane, 2000).

Analysis of internal documents on worldwide industry-sponsored anti-smoking campaigns showed that these aimed to 1) further industry goals in deflecting the impact of more restrictive regulations, 2) improve company credibility through the use of third parties (e.g. National Association of State Boards of Education) and 3) legitimize industry-sponsored research on adolescents. These campaigns did not use strategies shown to be effective (such as denormalization). In addition they did not measure outcomes such as smoking rates; they simply measured exposures (Landman et al., 2002).

A study of product- and message-stripped images in cigarette and anti-cigarette advertising showed that youth reacted with more positive emotions to images stripped from the former than the latter (Shadel et al., 2002). Among never smokers, both anti-smoking messages and pro-tobacco advertising have been shown to affect intentions to smoke (Straub et al., 2003).

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In some studies, girls were more influenced by marketing campaigns (Biener 2002; Wakefield et al., 2003a). In particular “Truth” marketing campaigns influenced girls more than boys (Sly et al., 2001a). Racial differences did not seem to be so consistent.

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Reviews have concluded that current findings are equivocal as to which types of messages are most effective (Friend and Levy, 2002; Wakefield et al., 2003b; Levy and Friend, 2000).

In some qualitative studies, “Truth” messages (which attack the tobacco industry) and second hand smoke messages were found to be more effective than other types of messages (Goldman and Glantz, 1998). However one review concluded that these messages require an older and more sophisticated audience to be effective (Wakefield et al., 2003b). In one study, the two central messages of the “Truth” campaign were the only significant attitudinal predictors of current smoking (Niederdeppe et al., 2004). Other findings contradict these results, reportinng that ads portraying the serious consequences of smoking were judged by youth to be more effective (Biener, 2002). Some studies have found negative, fear-arousing emotional content to be more effective than humor (Wakefield et al., 2003a,b; Siegel and Biener, 2000) in three different countries (Wakefield et al., 2003a,b). Single, previously-tested, and clear messages are more cost-effective (Friend and Levy, 2002). The effectiveness of anti-smoking brandings (as in “Truth”) has not been assessed.

Campaigns emphasizing healthy choices tend to be ineffective among youth (Wakefield et al., 2003b).

An analysis of the factor structure underlying beliefs about the tobacco industry supported counter-industry campaigns. Compared to all other US states, states with aggressive counter-industry campaigns had less progression on a continuum of smoking among teens and young adults, while controlling for cigarette prices and other tobacco control policies. These effects were mediated by the production of negative beliefs about and attitudes toward the tobacco industry (Hersey et al., 2003).

Campaigns that target adults can also have effects on adolescents, resulting in reported attempts to cut down and to quit (White et al., 2003).

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(vi) What is the relative cost-effectiveness of campaigns?

Campaigns in Vermont, California, Massachusetts, Florida and Canada were compared. The Vermont campaign was most cost-effective and the Canadian campaign was least cost-effective. Predictors of cost-effectiveness were: that the campaign messages were based primarily in a single message known to be effective; the messages were clear; and the campaign used youthful spokespersons (Pechmann and Reibling, 2000).

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(vii) What interventions can be used in conjunction with marketing campaigns to maximize their effectiveness?

Reviews have concluded that media campaigns targeting youth were more effective when implemented in conjunction with school-based programs (Sowden and Arblaster, 2000; Silver 2001). Program that combined strategies were also more effective than school-based programs alone. Media campaigns implemented in conjunction with community involvement programs and tobacco control policies may also be more effective (Farrelly et al., 2003; Friend and Levy, 2002) but the synergies are not clear.

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Questions not addressed in the literature

Friend and Levy (2002) and Farrelly et al. (2003) both argue that more controlled research is needed on message content, including better understanding of the interaction between specific types of messages and socio-demographic characteristics of the target audience. Media campaign research has focused exclusively on television advertising. Questions have not been asked about the effectiveness of televised campaigns delivered through programs (i.e. not ads) and campaigns in other youth-oriented media, such as the internet, and their interaction. Specifically, Farrelly et al. identify two key questions: 1) Can youth-focused media campaigns produce long term behavioural changes or simply delay the onset of cigarette smoking to early adulthood? 2) What synergies exist between media campaigns and other tobacco control interventions (e.g., school-based prevention, excise taxes, clean indoor air laws, community-based programs)?

Wakefield identified research needs for: 1) more studies of a potential “developmental window” (i.e. age range) for optimum influence of media campaigns; 2) longitudinal studies and multi-level studies; 3) studies of the interaction between smoking and anti-smoking advertising; 4) studies of tobacco industry prevention programs; 5) studies of the optimum configuration of anti-smoking efforts; and 6) studies of coverage of smoking in the news and portrayal in movies and other media. They argue that there has been a disconnect between campaign designs and theories of persuasive communication.

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8.2: What marketing strategies do tobacco companies use to reach youth?

Questions addressed in the literature

(i) How are youth exposed to tobacco advertising? How effective are those channels?

Tobacco companies are highly successful in reaching youth through marketing, and in conveying specific messages to specific groups. A study in England found that 95% of youth surveyed were aware of tobacco advertising and 100% were aware of point-of-sale marketing. Smokers were more likely to have been exposed to various forms of tobacco promotions (MacFadyen et al., 2001). A cross-sectional study established that two advertising campaigns that had been highly successful in terms of sales among youth were more appealing to adolescents, linking this to the establishment of brand popularity (Arnett and Terhanian, 1998).

Using longitudinal data for never-smokers at baseline, Pierce et al. (1999) calculated the number of new smokers that can be attributed to marketing campaigns of specific brands, and then imputed future smoking attributable mortalities per brand (e.g. 520,000 deaths from Camels, 300,000 from Marlboros, 220,000 from other brands).

Prospective studies clearly show that tobacco advertising, in particular promotional items with company logos, has an influence on smoking uptake. Youth who were more receptive to tobacco marketing products such as promotional items were more likely to progress to established smoking three years later (Choi et al., 2002). Similar results were reported by Biener and Siegel (2000) and Pierce et al. (1998). In a 21-month study, smoking uptake was higher among students who acquired a promotional item or who became open to it after baseline, and lower among those who had been receptive to such items but lost them or became unreceptive (Sargent et al., 2000). Cross-sectional studies confirm the relationship between receptivity to promotional items and smoking susceptibility (Feighery et al., 1998), although differences appear to exist among ethnic groups (Chen et al., 2002).

One study showed that increases in smoking rates above predictions from a diffusion model were associated with increased expenditures over and above advertising on sales promotion marketing (e.g. coupons, free samples, premiums, in-store displays) by tobacco companies, with year-to-year changes in promotional expenditures accounting for about 54% of the variance in the deviation from expected smoking (Redmond 1999).

Use of visible cigarette brands was shown to be present in 35% of films rated as suitable to adolescents and 20% of films rated as suitable for children. Actor endorsements of cigarettes in films increased after a ban on direct payments for exposure in films (Sargent et al., 2001).

A four-year, longitudinal observational study of billboard advertising in ethnic neighborhoods of Los Angeles found evidence of ethnic targeting combined with youth targeting: ads in minority neighbourhoods used higher proportions of youthful and/or cartoon characters (Stoddard et al., 1998).

A longitudinal survey of 12-15 year olds showed that exposure to specific brands in magazines was significantly associated with young peoples’ choice of brands among those who started smoking four years later (Pucci and Siegel, 1999). Cigarette companies are more likely to advertise brands popular with youth smokers in magazines with high rates of readership by youth (King and Siegel, 2001; King et al., 1998; Sanchez et al., 2000). Analysis of internal tobacco industry documents suggests that the disproportionate popularity of menthol cigarettes among youth may be attributed to marketing messages aimed specifically at youth (Sutton and Robinson, 2004). Black youth were shown to be more exposed to magazine advertising for cigarette brands popular with black youth, as number of advertising pages for those brands was more than three times higher in magazines with high levels of black leadership (King et al., 2000). Magazine exposure of adolescent girls to images involving cigars increased between 1992 and 1998 (Feit 2001). Most of the evidence to date however comes from American studies. Because Canada has different politics and legislature, it is not clear if these data are relecvant in the Canadian setting.

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(ii) What are the impacts of changes in strategies adopted by tobacco companies following the Master Agreement and broader anti-smoking sentiment?

The studies which have investigated this topic conclude that the overall impact of the Master Agreement on youth exposure to cigarette advertising had been less than anticipated. A study of the effects of the Agreement on cigarette advertising in magazines found that it had had little impact, in that the vast majority of youth were still exposed to youth-oriented advertising (King and Siegel, 2001).

Analysis of displays in a random sample of 586 stores in California found that 94% of stores had some advertising, 85% of which was 1.3 metres from the cash. Pharmacies had the greatest amount of advertising. About half the stores had displays at child height. It was concluded that tobacco companies were using in-store point-of-purchase marketing more aggressively and that the spirit of the Agreement had not been actualized (Feighery et al., 2001). Studies of retailers confirmed that tobacco company tactics included retailer incentive programs to ensure effective product placement (Feighery et al., 2003; Bloom 2001). An observational study of point-of-purchase advertising and promotion showed that stores surveyed after the billboard advertising ban had more interior and exterior advertising than stores surveyed before (Wakefield et al., 2002b). Point-of-purchase advertising and promotions for two specific brands (as determined by systematic observation) in stores within a one-mile radius of schools were strongly predictive of those schools’ student smokers’ favorite brand, for one brand but not the other (Wakefield et al., 2002b).

Document analysis showed that pack design has become a more important marketing component for youth since the Master Agreement, with companies constantly testing packaging that will appeal to young and never-smokers (Wakefield et al., 2002c).

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(iii) How does the impact of cigarette advertising differ according to youth and family characteristics?

The differential impact of cigarette advertising has been examined by several studies. In a cross-sectional survey, youth with symptoms of depression and who were more receptive to tobacco advertising were more likely to smoke (Tercyak et al., 2002). Receptivity to tobacco advertising accounted for more uptake among adolescents whose parents have a more authoritative parenting style than it did among those with a less authoritative parenting style, which was interpreted to mean that advertising undermines the positive effects of authoritative parental style (Pierce et al., 2002).

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(iv) What is the status of Internet marketing?

Internet marketing has received some research attention. A review of internet tobacco vendors in the US found that most did not prohibit, in either policy or practice, sales of cigarettes to minors. Attempts to regulate internet sales in the US have not been successful. When four youth aged 13 to 15 attempted to buy from internet vendors, they were successful in 92% of purchase attempts. However, other data suggest that internet sales are not yet accounting for a large part of cigarette sales, as retail outlets still offer fewer barriers to youth buying cigarette (e.g. offer smaller quantities, cash purchase). A study of internet sites selling cigars found that 75% did not prohibit sales to minors and many used tactics to increase youth appeal and accessibility (Malone and Bero, 2000).

Pro-smoking information is delivered through internet sites not directly supported by tobacco companies, and there are sites that specifically promote youth smoking (Ribisl 2003). Content analysis in 1999 of 30 websites promoting a smoking culture and lifestyle showed that none required age verification, and that there were strong associations with sexual content. For example, of 1,689 photographs coded, 94% contained images of women, and 15% contained some level of nudity or partial undress (Ribisl et al., 2003).

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(v) What are tobacco companies’ marketing strategies? What are their specific targeting strategies?

Tobacco companies’ marketing strategies have been identified through investigation of their internal documents, released through litigation; it is clear that specific targeting strategies have been researched and described. Many examinations of internal documents have shown that tobacco companies use highly sophisticated techniques to segment markets, with a particular interest in young people, including non-smokers (or pre-smokers) and underage smokers (Ling and Glantz, 2002a; Perry 1999; Cummings et al., 2002). These techniques have been based on stage models of progression to addiction that are very similar to public health models (Ling and Glantz, 2002a). Analysis of Canadian documents confirms that these strategies have been used here as well (Pollay 2000).

Specific subpopulations have received special attention from tobacco marketing when they have higher than average smoking rates: strategies were revealed targeting gay youth and street/counterculture youth (Washington et al., 2002). In Australia, a document-analysis study described tobacco companies’ strategies to gain the youth market when brands that had been successful with youth in North American failed (Carter 2003).

A thorough study of the redesign process of Camel cigarettes between 1983 and 1993 showed that young men were deliberately targeted to aid initiation through both image and product changes, which coincided with an increased market share for Camel, as well as increased smoking rates in this segment (Wayne and Connolly, 2002).

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Questions not addressed in the literature

Public health research could benefit from a better grounding in business and marketing tactics, as many investigators express outrage at what are simply routine business practices in the tobacco industry. On the other hand, it could be argued that this line of research is doing the industires’ research for them. Prospective work attempting to stay ahead of the tobacco industry survival struggle might be more beneficial. Several interesting speculations on the influence of larger trends in marketing for other product categories on tobacco companies, have not been the focus of any research to date. This might be useful to help predict likely future strategies that will be used by thetobacco industry.

Ribisl proposed a research agenda for tobacco-related content on the internet that addresses four questions: 1) what content is available? 2) which youth groups are exposed to it? 3) what impact does it have?, and 4) what is the impact of tobacco control efforts?

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9. Cost-effectiveness of Youth Tobacco Intervention

9.1 What are the most cost-effective cessation and prevention interventions?

Questions addressed in the literature

(i) What is the cost-effectiveness of school-based prevention programs?

The literature on the cost-effectiveness of prevention and cessation programs has focused mostly on school-based prevention programs. One US study concluded that school-based prevention generates costs of $20,000 per Quality Adjusted Life Year (QUALY). This is not a savings, as taxpayers will have to contribute $20,000 per every QUALY gained. Cost-effectiveness contributed more to lowering the cost per person than mortality avoided (Tengs et al., 2001). In contrast Wang et al. (2001) found a savings of $8,482 per QUALY saved (Wang et al., 2001).

A Canadian study showed that, at a cost of $67 per student, lifetime health care savings would be $3,400 per person and $14,000 per person for productivity (Stephens et al., 2000).

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(ii) What is the cost-effectiveness of enforcing tobacco prohibition to minors?

DiFranza et al., 2001 found that if enforcement of tobacco prohibition to minors could reduce smoking by at least 1% (which in fact some controlled studies have already established) it could be a cost-effective strategy compared to implementing smoking cessation guidelines

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(iii) What is the cost-effectiveness of price controls?

A tax increase which raised cigarette prices by 10% was shown to be cost-effective, resulting in costs of $12,313 per Disability Adjusted Life Years (DALY) saved globally; price controls were more cost-effective than nicotine replacement therapy (NRT).

(iv) What is the cost-effectiveness of anti-smoking campaigns?

In a comparison of the cost-effectiveness of anti-smoking campaigns in Vermont, California, Massachusetts, Florida and Canada, the Vermont campaign was found to be the most cost-effective, and the Canadian campaign was the least cost-effective. Predictors of cost-effectiveness were: use of a single campaign message known to be effective, and use of youthful spokespersons (Pechmann and Reibling, 2000). This was not a traditional cost-effectiveness study; it relied on published reports for the effectiveness data. The study provided weak evidence about cost-effectiveness, but corroborates findings about effective message content.

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(v) What are the impacts of increased public investment on actual delivery of smoking prevention?

Increased public expenditure in California was not reflected by increased levels of prevention program delivery at the school level (Distefan et al., 2000).

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Questions not addressed in the literature

There are very few studies on cost-effectiveness, and those that exist have not been conducted in ways that will help practitioners decide on intervention strategies. Other than Ranson et al. (2002) who compared price controls to NRT, there are few examples of comparative cost-effectiveness studies in the literature (i.e., pitting different forms of intervention together in the same population). Similiarly the cost effectivenenss of combinations of interventions in the context of comprehensive community programs has not yet been investigated.

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III. SUMMARY OF SCAN

This scan has systematically identified recent studies reported in the literature on a variety of current issues related to youth smoking. This literature has been summarized succinctly above to highlight key findings in the literature and to identify important gaps that will require more research. The reader who requires more detailed information on any of these issues is referred to the Appendices which provide abstracts for all publications reviewed in each priority area. Table 2 below succinctly summarizes the findings of the scan. Overall, the results suggest a relatively underdeveloped literature in many areas, many methodological difficulties which limit the interpretation of the findings, and a variety of important gaps in knowledge in most priority areas. It is clear that it would be a challenge for practitioners and policy-makers to use this literature systematically to better understand youth smoking and to identify intervention strategies that are clearly going to be effective. More well-designed studies with adequate samples sizes and long-term follow-up are clearly needed in many, if not most priority areas. In general, this kind of scan will be helpful to begin to set and prioritize a systematice research agenda that will lead to the development of effective intervention strategies to reduce the burden of youth smoking.

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INDEX