Recommendations for Practice

The following are recommendations, suggestions, observations, and interpretations made by the PEPS Expert Panel members regarding the prevention approaches evaluated in the preceding section of this guide. There are recommendations corresponding to each of the six prevention approaches.

The basis of the recommendations in this section includes the research and practice evidence listed in the "Research and Practice Evidence Analyzed" at the end of this guide and the Expert Panel members' research and practice experiences and opinions.

Recommendations for Prevention Approach 1: Economic Interventions

The Expert Panel recommendations regarding economic interventions focus on allocation of revenues, policy, and media efforts.

• When tax increases are implemented, an effort should be made to study the potential effect on youth consumption, including the establishment of baseline evaluations to accurately assess changes after implementation.

• Laws creating tobacco tax increases can include an allocation of resulting revenues for community health education, adult and adolescent tobacco use prevention and cessation programs, and tobacco-related prevention and disease research.

• Experience suggests that there will be strong lobbying from the tobacco industry to decrease the amount of proposed tobacco taxes. Prevention groups, therefore, have often worked to help set high initial taxation thresholds. Some have lobbied and others may lobby for the highest tax possible.

• Experience suggests that there will be aggressive, targeted advertising by the tobacco industry against tobacco tax increases. As a result, an aggressive mass-media campaign is an integral component of prevention efforts. Such campaigns include sustained and intense media interaction, and providing the media with information, the names of community partners, and activities that are media-worthy. Results from adolescent purchase attempts locally and regionally can be provided for media coverage.

Recommendations for Prevention Approach 2: Counteradvertising

The Expert Panel recommendations regarding counteradvertising focus on youth participation, media messages, and sustained efforts.

• Adolescents can provide to adults a distinctive understanding of the beliefs, attitudes, perspectives, and opinions of young people. They can be motivated to participate in efforts to prevent adolescent tobacco use. Therefore, youth can have a valuable role in the planning and development of counteradvertising prevention programs.

• Providing too much information at one time can weaken a mass media campaign. Media campaigns should have simple and focused messages that can be understood by the target audience.

• Adolescents can play an important role in the formative evaluation of potential prevention approaches. Media approaches, especially counteradvertising, should be evaluated by adolescents prior to implementation, such as through focus groups and surveys. Indeed, one study noted that the goals and aims of one media-based prevention effort was not understood by the youths to whom it was directed.

• When possible, mass media campaigns should be multimedia and should include television, radio, billboards, and print media. Radio, however, may be the most cost-effective approach.

• A statewide multimedia antismoking campaign has a role in decreasing cigarette use, as demonstrated by the studies by Glantz (1993) and Popham et al. (1994), which demonstrate the effect of the 1990-1991 Tobacco Education Media Campaign conducted by the California Department of Health Services. Proposition 99 included a 25-cent cigarette tax increase and a media campaign involving: paid advertising to promote media messages; a full range of communication approaches, including public and community relations; and mass-media spots targeting the general public and specific cultural groups, such as African Americans, Hispanics, Vietnamese, Koreans, Japanese, and Chinese. The enactment of Proposition 99 resulted in a tripling of the rate at which cigarette consumption had been falling. Results showed an increase in the awareness of the media campaign among students, a decrease in the percentage of students who were smokers, an increase in the proportion of smokers with an intention to quit, and an increase in health-enhancing attitudes. Campaign-exposed students demonstrated stronger health-enhancing attitudes than their campaign-unexposed counterparts. Although this media campaign was eventually suspended, such studies demonstrate the need to promote ongoing support for similar campaigns.

• Because tobacco use norms are changing rapidly and new generations of adolescents will view tobacco use differently, media approaches should constantly be modified and tailored to encourage antitobacco attitudes among new generations of youth.

Recommendations for Prevention Approach 3: Retailer-Directed Interventions

The Expert Panel recommendations regarding retailer-directed interventions focus on community readiness for change and improving the effectiveness of prevention efforts.

• It is important to document the magnitude of the problem of youth access to tobacco in one's community. Providing quantitative profiles and descriptions of the local community increases awareness of adolescent tobacco use problems. Also, such documentation can stimulate community interest in taking action.

• Communities differ with regard to readiness for prevention efforts, especially those that involve community organizing. Some communities seem primed for establishing comprehensive prevention efforts, whereas others do not recognize adolescent tobacco use as a major concern. Thus, analysis of community readiness must precede attempts to engage reluctant communities in prevention efforts.

• Community readiness planners should also assess the readiness of specific agencies that apply as lead agencies for prevention projects. In some communities, lead agencies, which may include hospitals, schools, or substance abuse agencies, may be reluctant to engage in controversial activities, even when Requests for Proposal spell out activities such as compliance checks. Community readiness can be increased by obtaining the support of community leaders for such prevention and educational efforts.

• Adolescent access to tobacco is not limited to direct purchase at stores, but includes purchase, receipt, or theft from adults and peers, theft from stores, and receipt of free samples in cigarette giveaway events. Therefore, researchers and practitioners should consider venues of access other than stores.

• Research and experience suggest that prevention issues and messages should be localized and individualized for each community. As a result, local and small media should be important components of all prevention efforts. These can include local print, radio, and television media, when available, as well as newsletters for agencies and organizations.

• Research and experience demonstrate that adolescents have almost unrestricted access to tobacco vending machines. In addition, laws prohibiting tobacco sales to minors have almost no effect on adolescent access to tobacco vending machines. Similarly, research and experience demonstrate that locking devices on tobacco vending machines are ineffective in practice because compliance with the operating procedure is low except when supported by ordinances enacted by communities.

• Prevention efforts should be part of a sustained process, not random and isolated events. In addition, it is important to show that the prevention process is effective. Therefore, interventions, including adolescent purchase attempts, should be regularly scheduled and their results heavily publicized. Interventions should be continually assessed and improved. The community partnership should be continually strengthened with new members, and community education should be ongoing.

• One aspect of an effective approach for enforcing laws prohibiting tobacco sales to minors involves the enactment and enforcement of licensure of retail tobacco outlets. In this way, only stores with tobacco licenses can sell tobacco. Furthermore, violation of the tobacco access laws can result in suspension or revocation of the tobacco license. This creates an incentive for the merchant to comply with the law. Some States use their alcohol licensing laws as the model for their tobacco licensing laws. However, the wording of alcohol licensing laws should be carefully examined. The laws may contain language that hamper enforcement (e.g., "knowingly sell") or ban the use of minors for compliance checks.

• Even when there is a comprehensive prevention program, violators of the tobacco access laws are often not disciplined, fined, or sentenced. Judges report that they are reluctant to impose the legal consequences because they view the crimes as minor and do not want the merchants to have criminal records. This is especially true in small cities. Therefore, because the judicial system is an important link in a comprehensive prevention program, judges should be approached and included as members of community partnerships. This can be particularly important when law enforcement partners are active. The police may become reluctant to pursue further efforts if they see that judges are throwing the cases out of court.

• Since many judges are reluctant to impose consequences on merchants for tobacco sales to minors when the law defines the violation as a criminal offense, some States have changed tobacco access laws from criminal to civil laws. When a violation of tobacco access laws becomes a civil rather than a criminal offense, judges may be more amenable to impose penalties.

• Prevention programs should include positive reinforcement of clerks and merchants for not selling tobacco to adolescents, for asking proof of age, and for obeying other aspects of the law. Such incentives may include local media publicity and rewards, such as free dinners or products donated by local restaurants and merchants.

Recommendations for Prevention Approach 4: Multicomponent School-Linked Community Approaches

The Expert Panel recommendations regarding multicomponent school-linked community approaches focus on improving the impact of mass media interventions.

• The impact of mass-media interventions on adolescents is more likely when the interventions:
  • Are linked with other program channels, such as schools, parent groups, and newsletters

  • Share common objectives with school programs

  • Are provided in sufficient duration

  • Use multiple channels

  • Are presented at times and places when adolescents report their highest use of media

  • Use a variety of message styles

  • Appeal to age- and gender-specific motives that have been determined through formative research

  • Use messages portraying perceived social support with age- and gender-relevant models providing appropriate behavioral skills, alternatives, and reinforcement

  • Include media-based antitobacco information that can reach adolescent students within schools and communities. Programs that use media approaches should be prepared to measure the extent to which the target audience is exposed to the message.

• Visual rather than written intervention materials may be more appropriate and effective for groups with low literacy rates and for such communities as adult Asian and Pacific Islander immigrants, refugees, and certain high-risk youths.

• Antitobacco activism may have an important role in promoting antitobacco attitudes and behaviors among youth, even in the face of protobacco messages in the environment. Furthermore, antitobacco activism may help to support other elements of a multicomponent prevention program.

• Many prevention practitioners support peer activism as an integral component of a comprehensive prevention strategy. Several States have a Teen Institute for substance abuse prevention, and there are numerous community activities that engage youth as antitobacco activists.

• The ability of parents to influence the substance use choices of their children is strongly suggested by prevention participation and, to a lesser degree, by research. However, there are barriers to the successful implementation of these influences. These barriers are varied and include current or past parental substance use and addiction, tobacco industry messages, and the selection of user-friendly mediums for the intended messages.

Recommendations for Prevention Approach 5: Tobacco-Free Environment Policies

The Expert Panel recommendations regarding tobacco-free environmental policies focus on the target of policies and community support.

• Policies restricting smoking that are limited to one but not all groups may be ineffective and may send mixed messages. For instance, a school-based policy that enforces the legal ban on tobacco use among students but allows the legal use by teachers and staff may send the message that tobacco use among adults is acceptable. Therefore, smoking policies should be designed to be consistent across the board. For instance, in the case of schools, the same policy should be enforced for students, teachers, staff, and visitors and should be enforced at all school-related functions, not merely on school grounds.

• When nonsmoking policies are established and mandated without local support, problems may arise with regard to compliance and enforcement. Therefore, efforts to establish nonsmoking policies should utilize a grassroots approach involving the community and youth in the planning, development, and implementation of policies. Nearly all States are funded through either the National Cancer Institute's ASSIST (American Stop Smoking Intervention Study) program or the Centers for Disease Control and Prevention's IMPACT (Initiatives to Mobilize for the Prevention and Control of Tobacco use) program to establish and implement such grassroots approaches.

Recommendations for Prevention Approach 6: Restriction of Advertising and Promotion

The Expert Panel recommendations regarding advertising and promotion restriction interventions focus on community partnerships and integrating messages.

• It is recommended that practitioners and even community groups not attempt to conduct these types of interventions in isolation. Rather, they should work in close partnership with community leaders, grassroots organizations, and members of the community. An aggressive attempt should be made to seek and receive acceptance of the interventions from community members and from policymakers. Perhaps the most serious mistake is entering a community and appearing to dictate how things are done in that community. Cooperation on all levels is necessary.

• An important lesson learned from multicomponent prevention programs is that the individual components of such a program should be complementary elements that share the same overall goals and philosophy. When tobacco-free or antitobacco messages are incorporated into event activities, they should be integrated with existing activities, messages, and promotions. They should not be merely add-on messages but should support other activities.

• The generalizability of these promising interventions to other social settings depend on a number of variables, such as the readiness of the community for such activities, the geographic area, and the social and cultural support for prevention of adolescent tobacco use.