Smoking Prevention

There are more than one billion smokers worldwide. If current trends continue, 8.4 million smokers are estimated to die annually of smoking-related deaths by the year 2020. Tobacco use remains the single major preventable behavioral cause of death and disease in the United States. Despite the adverse health outcomes and enormous costs associated with smoking, nearly one-fourth of adult Americans—an estimated 50 million people—continue to smoke cigarettes. In addition, it has been estimated that more than 3,000 children and adolescents begin smoking each day. At least 70% of these young smokers want to quit smoking, but only approximately 5% succeed.

Since the 1964 report to the surgeon general on the health consequences of smoking, the public health community has played a key role in focusing efforts to reduce the continuing toll of tobacco use by discouraging smoking initiation and promoting smoking cessation. Universal interventions, that is, prevention programming delivered to an entire population regardless of risk status, have been utilized most often. Targeted interventions, which are designed to tailor programming to those groups at higher psychosocial-based risk (selective) or individuals who have demonstrated to be at greatest risk of continued smoking behavior (indicated), have also been implemented, but relatively few such programs exist.

Preventive interventions that have provided evidence of effectiveness include school-based educational programs, family-based informational programs, mass media campaigns, regulatory efforts, tobacco excise taxes, and comprehensive community-based activities. Although much more research is necessary, a comprehensive approach that combines these educational, social, regulatory, and economic aspects through multiple intervention modalities may be most effective in controlling and preventing tobacco uptake.

School-Based Educational Programs

The most widespread prevention approaches are those implemented through the school system and designed to counteract the psychosocial influences that promote tobacco use initiation. The two major psychosocial approaches that have been adopted by schools are the social influences approach and the more comprehensive personal and social skills enhancement approach. Social influences programs are designed to increase the awareness of social influences promoting drug use, alter norms regarding the prevalence and acceptability of drug use, and build drug resistance skills. Skills enhancement programs incorporate aspects of the social influence approach and also include general self-management and social competence skills. Literature reviews and meta-analyses of modern tobacco use prevention programs have indicated short-term (less than 24 months) reductions in the rate of initiation of tobacco use generally ranging from 30% to 50% or more in students exposed to social influences programs compared to control students. A few targeted programs implemented with older teens have found 27% prevalence reductions in tobacco use lasting up to 2 years post-program. These programs utilize a skill enhancement approach and also incorporate motivation enhancement material to effect changes in personal attitudes that may impede skill development and behavior change. In both universal and targeted programs, effective educational strategies are those that are implemented interactively rather than with a didactic lecture style. Although much less evidence exists for the long-term follow-up success of these tobacco use interventions, current empirical data indicate reductions ranging from approximately 10% to 15%, lasting for up to 15 years after programming.

Empirically validated programs are available for dissemination. These programs have been promoted for use through federal and state policies that require schools that receive funds from Safe and Drug-Free Schools and Communities and Tobacco Use Prevention Education (TUPE) programs to implement research-based programming. However, it appears that these “proven” programs still have not been widely adopted by the nation’s schools. Instead, a large majority of schools are implementing tobacco prevention programs that are aggressively marketed and relatively easy to implement, but have not shown evidence of effectiveness or have not been properly evaluated.

Family-Based Informational Programs

Family involvement is a relevant means of providing prevention material outside of school. Various public health organizations have launched informational campaigns aimed at getting parents and teens to talk about tobacco use prevention. These family-based programs typically offer parent-based booklets and websites. Program contents typically stress the importance of teaching open communication and parents serving as good role models by not smoking, and discuss peer pressure, the role of the parent in prevention, responsible decision making, health consequences of smoking, and costs of smoking. One shortcoming of parent-based programming is that some efforts are directed at parents, not children. Thus, it is not clear whether their children will receive any relevant information. Furthermore, youth at highest risk for tobacco use are relatively unlikely to have parents who will take on the responsibility of teaching prevention material to their children or serve as support persons for other programming. One promising family-directed program utilized mailed booklets and telephone contacts by health educators. This program provided some evidence that universal, family-based programming may prevent adolescent tobacco use.

Mass Media Campaigns

Mass media (television, radio, film, and print) play an important role in smoking control activities, particularly among youth, who are heavily exposed and susceptible to media influences. Media-based campaigns have been used to communicate factual information about tobacco use, influence public perceptions of appropriate behavior, and directly counteract pro-tobacco advertising. Results from empirical studies that examine the impact of media campaigns have varied. Advertisements that graphically, dramatically, and emotionally portray the serious negative consequences of smoking are consistently ranked as the best among youth in terms of getting them to stop and think about not smoking. Furthermore, research on long-term preventive effects has indicated that an intervention combining mass media and school-based programming was more effective than the school-only program in preventing adolescent cigarette use across a follow-up period of 6 years.

Regulatory Efforts

Since 1964, various legislation, policies, and litigation initiated by federal, state, and local governments have regulated tobacco product distribution, and may lead to prevention or cessation outcomes. Regulatory attempts include various restrictions on tobacco industry advertising and promotion, restrictions on access to tobacco by minors, and implementation of clean indoor-air policies. However, due to the powerful lobbying forces representing the tobacco industry, attempts to regulate tobacco industry activity in the United States have had only modest success compared to some other countries, including Canada and New Zealand. U.S. regulations include requirements for health-warning labels on all cigarette packages. In addition, these regulations include prohibition of broadcast media (television and radio) advertisements, prohibition of the purchase of tobacco products by individuals under the age of 18 years (in all but two states and Puerto Rico), and creation of a smoke-free environment in various settings. Smoke-free settings include government offices, eating and drinking establishments, and workplaces, and are quickly expanding in type and number across the United States. Unfortunately, tobacco control regulations are not always aggressively enforced due to lack of both funding and infrastructural support. Moreover, it is unclear whether regulatory efforts have induced changes in social norms regarding smoking, or, conversely, whether the passage of legislation and policies are a reflection of a social environment that discourages smoking. Regulatory approaches that restrict smoking across a range of environments (e.g., home, school, and public places) do show some real promise in reducing levels of smoking among adolescents.

Tobacco Excise Taxes

Federal, state, and many local governments have imposed excise (per unit) taxes on tobacco products as a means of preventing or reducing tobacco consumption. Increased tobacco prices due to taxation may lead cost-conscious youth to refrain from starting smoking, reduce the amount that they smoke, or quit smoking. Research studies examining the effects of the price of tobacco products on youth smoking have shown mixed results, requiring further evaluation. However, the general consensus is that higher cigarette taxes would lead to significantly reduced smoking rates among youth. As another benefit, in addition to its potential to discourage smoking by youth, this strategy generates revenue (from tobacco users) that has helped to fund smoking control activities.

Community-Based Activities

Many community-based programs take advantage of multiple channels of program delivery, and are the most comprehensive prevention services available. Community-wide efforts, including coalitions, campaigns, programs, and policies, have been increasingly used to prevent tobacco use within local communities. These projects typically involve multiple public and private organizations and agencies, such as law enforcement, social services, education, private businesses, and community-and faith-based organizations, which collaborate in support of strengthening, expanding, and coordinating existing smoking prevention initiatives. As a result, community interventions have the capability of coordinating and utilizing multiple systems, channels, and strategies to influence individual behavior, community-wide norms, and local policies related to youth tobacco use. Although community-based programs achieve some of the strongest preventive effects, they tend to be weaker in methodological design. In addition, community institutionalization of effective programming may be particularly difficult.

The Need For Multiple Modalities Of Delivery—Nationally And Internationally

Studies of comprehensive community prevention initiatives suggest that smoking prevention programs that utilize multiple delivery modalities, whereby youth receive a consistent message across various contexts and over time, are most likely to yield and maintain positive program effects. Future system-wide approaches that include demand reduction efforts such as school-based, family-based, and mass media strategies, along with strong supply reduction approaches (e.g., restrictions on tobacco industry advertising and promotion, prohibition of minors’ access to tobacco, environmental bans on smoking, and higher cigarette prices), may combine synergistically to maximize smoking prevention efforts across the nation.

Tobacco control efforts should be coordinated internationally. International tobacco control efforts should include the promotion of legislation on smoke-free venues and policies that follow international standards and are organized by national governments. These efforts should involve a sharing of research and technical expertise, funding of international tobacco control activities, and cooperation of organizations such as the World Health Organization and the World Bank, and discouragement of favorable tobacco trade export policies that undermine tobacco control efforts. By working together, the international tobacco control community will have the ability to help eradicate the culture of smoking created by the tobacco industry, moving another step forward in halting the worldwide epidemic of tobacco-related death and disease.