Smoking Prevention

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Smoking Prevention

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

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Composite Theoretical Model
Positive Attitudes, Expectations
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Outline

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

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Increasing the Unit Price for Tobacco Products?
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Increasing the Unit Price for Tobacco Products?

• Yes!
• (Strong Evidence)

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Composite Theoretical Model
Positive Attitudes, Expectations
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Composite Theoretical Model
Positive Attitudes, Expectations
Price Increases
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Price

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

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Price Studies

• More effect among African Americans than
  Caucasians
• More effect among males than females
• More effect among younger than older

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Kinds of Excise Tax

• Federal
• State
• Local

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State Excise Tax

• Mean 80 cents
• Highest rates
• NJ (2.57)
• RI (2.46)
• WA (2.02)
• AZ (2)
• ME (2)
• MI (2)
• AK, HI (2) later this year

• Lowest excise taxes
• NC (35)
• FL (34)
• KY (30)
• VA (30)
• TN (20)
• MS (18)
• MO (17)
• SC (7)
• PA 1.35 (15)

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Other Excise Taxes

• Local
• AL, 1 to 6
• IL, 10 to 15
• MO, 4 to 7
• NYC 1.50
• TN, 1
• VA, 2 to 15

• Federal
• Increased to 39 in 2002
• ALA and others seek 2 increase

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Anatomy of Cigarette Price

• Illinois
• Factory Price 2.28
• Federal Excise Tax 39
• Retailer markup 1.12
• State Excise Tax 98
• Sales Tax 29
• TOTAL 5.23

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Mass Media Education Campaigns?
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Mass Media Education Campaigns?

• Yes!
• (Strong Evidence)

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Composite Theoretical Model
Positive Attitudes, Expectations
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Composite Theoretical Model
Positive Attitudes, Expectations
Education Campaigns
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Mass Media Education Campaigns

• PSAs Print, TV, Radio
• 12 studies, all aimed at adolescents
• Compare smoking rate changes in different
  communities
• Florida, Massachusetts, Minnesota
• Hard to control for other factors

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Shards O Glass Light
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Mass Media Education Campaigns

• Decrease by about 2.4 (absolute)
• Most effective gt2 years
• Those that combined education campaigns with
  other interventions worked better
• Contests
• Community education
• School-based programs
• Effects decrease over time

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Youth Access?
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Youth Access?

• Maybe ...

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Composite Theoretical Model
Positive Attitudes, Expectations
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Composite Theoretical Model
Positive Attitudes, Expectations
Youth Access
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Minimum AgePhotographic ID Required
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Composite Theoretical Model
Positive Attitudes, Expectations
Youth Access
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Clerk Intervention
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FreeDistribution/Samples
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Vending Machines
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Other Access Issues

• Packaging
• Graduated Penalties
• Random Inspections
• Statewide Enforcement

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Recommended

• Community Mobilization When Accompanied by
  Additional Interventions
• Absolute reductions as much as 5.8

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Insufficient Evidence

• Sales laws directed at retailers alone
• Laws directed at minor purchase alone
• Active enforcement of sales laws alone
• Retailer education alone

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Reduce Smoking Promotions?
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Reduce Smoking Promotions?

• Yes! (and no ...)

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Composite Theoretical Model
Positive Attitudes, Expectations
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Composite Theoretical Model
Positive Attitudes, Expectations
Reduce Promotion
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Smoking Promotions Definitely Increase Smoking

• Tobacco Promotion and the Initiation of Tobacco
  Use Assessing the Evidence for Causality
• DiFranza, Wellman, Sargent et al
• Pediatrics 2006 117 e1237-e1248

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Films
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Advertisements
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Flexibility of the Industry

• TV
• Movies
• Billboards
• Concerts, other promotions
• Kool Mixx tour
• Stir the Senses tour
• Free products

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Camel Seven Pleasures of the Exotic
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School-Based Programs?
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School-Based Programs?

• Unknown ...

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Composite Theoretical Model
Positive Attitudes, Expectations
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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Composite Theoretical Model
Positive Attitudes, Expectations
School-Based Programs
Personal Factors Rebelliousness Sensation
Seeking Grades Environmental Factors Parental/Sib
ling Peer Media Demographics Gender/Age Race/Ethn
icity SES
Intention
Smoking
Sense of Norms
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HSPP (JNCI, 2000)

• Curriculum for youth, 3rd-10th grades
• 47.25 hours total
• Social Influences approach
• How to say no, effects on body, resisting peer
  influence, self esteem, etc.
• 20 school districts got the program, 20 did not
• 94 follow up, high implementation fidelity

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Results of HSPP

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

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Depends on the Kind of Program

• Life Skills Training/Social Influences
• Self esteem
• Refusal
• Media Literacy
• Analysis of tobacco advertisements/promotions
• Understanding of marketing and industry

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Summary

• Price Increases
• Comprehensive Mass Media Education Campaigns
• Youth Access
• Reduction of Advertising
• School Community Based Programs

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bprimack_at_pitt.edu
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Price References

• CDC 1998
• Chaloupka 1996, 1997, 1999
• Gruber 2004
• Lewit 1981, 1997
• Ohsfeldt 1994, 1997
• Wasserman 1991

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Media Campaign References

• Bauman, 1991
• CDC, 1999
• Flay, 1987, 1995
• Flynn, 1997
• Hafstad, 1997
• Johnson, 1990
• Kaufman, 1994
• Murray, 1994

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Economic Analysis

• 4 year study from MT, NY, VT
• 5-10th grade students followed for 2 years
• Mass media campaign and school-based program
• Smoking 20.4 vs. 25.9
• Cost per smoker averted 6069
• Program cost/QALY 333