5.20 Approaches to youth smoking prevention

Last updated October 2014 

Under the broader rubric of 'prevention' as described in Section 5.19, reviews of the literature consistently concur that effective youth smoking prevention requires a comprehensive multifaceted approach,1,2 involving a range of well-researched, coordinated and complementary strategies that reinforce each other,3,4,5,6,7,8,9,10 As in tobacco control generally, the impact of each strategy when used or considered in isolation is likely to lead to an underestimate of the impact of several strategies in combination, due no doubt to the importance of synergistic effects.11 One-off or single-focus interventions targeting young people are unlikely to produce lasting effects.3,12

A comprehensive review of the effectiveness of multi-component community (locally) based interventions in influencing smoking behaviour, including preventing the uptake of smoking in young people, incorporated 25 studies and was published in August 2010.13 The authors concluded that there is some evidence that coordinated, widespread, multi-component programs can be successful in influencing smoking behaviour and reducing the uptake of smoking in young people. Community members often play a role in design and implementation of such programs, which may include mass media, school and family-based components. The reviewers also note, however, that the evidence is not robust and contains a number of methodological flaws such as risk of various types of bias, incomplete or selective reporting of outcome data, and unclear comparability between baseline intervention and control characteristics.13

An earlier review of studies involving effective tobacco prevention strategies among young people14 similarly found strongest support for multi-component interventions. Specifically, researchers found that the strongest and most sustained impacts were achieved through multi-component, community-based interventions of at least three years duration, especially those involving school-based strategies with supportive parent, media, and community.14 Identified components of effective tobacco prevention programs included a focus on counteracting social factors that influence tobacco, through for example resistance and assertiveness skills training for young people, and being theory-based, with an emphasis on personal (attitudes and norms), social (e.g. group behaviour), and/or environmental (e.g. communications) level theories.14

Another review examined the long-term effectiveness of behavioural interventions in the prevention of cigarette use among young people, and compared school-based, community-based and multisectoral intervention strategies.15 Based on meta-analyses where possible, the review included 35 randomised controlled trials published in English or German between 2001 and 2006, targeting adolescents up to 18 years of age. Some positive long-term effects (12 months to 10 years) for behavioural smoking prevention programs were observed in the majority of studies, with modest reported decreases in smoking. Results suggested stronger evidence for the effectiveness of community-based (outside school) and multisector interventions (defined as comprising both school- and community-based components), while the evidence for school-based programs alone was inconclusive.15 The reviewers recommended that school-based prevention programs should be implemented in conjunction with community- and family-based interventions, at the same time as maintaining and strengthening population-wide and environmental smoking prevention strategies.15 While the inconclusive finding for school-based interventions stands in contrast to several other systematic reviews that have concluded that these can be effective in the long term 5, 16 it concurs with the findings of a 2006 Cochrane review that found no convincing evidence for the long-term effectiveness of school-based interventions.17

The timing of prevention approaches in terms of developmental ages and different levels of nicotine dependence is an important consideration in comprehensive interventions.15,16 For example, the implementation of preventive measures well before an age at which smoking experimentation begins to occur is recommended in order to influence young people's attitudes towards smoking early.15 In addition, an understanding of changes in the relative influence of factors in adolescent smoking (e.g. a decrease in the importance of peer behaviours, attitudes and norms over time and a rise in the role of psychopharmacological effects of nicotine) has been described as fundamental in improving the prevention of adolescent progression to more advanced stages of smoking.16

Walsh and Tzelepsis14 describe two areas offering potential improvements in adolescent smoking control efforts. One is expanding demonstrably effective educational programs such as evidence-based tobacco prevention curricula and national guidelines, in conjunction with relatively intensive engagement of influential community resources including parents and mass media.11 The other involves enhanced research to evaluate youth tobacco initiation and cessation interventions, particularly in non-school settings.14

Identifying best practice evidence-based youth smoking prevention strategies is hindered to some extent by the fact that only a small proportion of prevention interventions implemented in Australia and overseas have been rigorously evaluated, if they are evaluated at all.18 Guidance for effective prevention thus needs to be drawn both from understanding of the factors influencing uptake, as well as the efficacy of prevention efforts that have been evaluated or bear some evidence of positive effect. Comprehensive reviews recommend further research using methodologically high-quality studies to identify specific crucial components of effective prevention programs, examine their cost-effectiveness and evaluate key factors in the promotion, adoption and implementation of effective programs in schools and communities.13, 15, 19

The duration, funding and sustainability of interventions are also important. The imperative for sustained effort and funding has been highlighted in some states in the US, where the initial successes of large-scale and comprehensive campaigns and intense tobacco-control activity of the 1990s has diminished, reflected in the halted decline of teenage smoking.17 The efficacy and acceptability of programs targeting young people is also enhanced by their involvement in intervention planning and development,14 an approach supported by the United Nations' Convention on the Rights of the Child.20 In the tobacco-control literature, youth participation in intervention design is not often explicitly discussed, and as noted by Williams and colleagues, there is a lack of controlled studies measuring the impact of youth involvement.2

Table 5.20.1 maps some of the key uptake factors identified earlier in this chapter that are amenable to intervention, as identified from the literature.

Table 5.20.1
Core components of comprehensive youth smoking prevention

Influences to smoke

Intervention approaches that can address this

Family environment
(see Section 5.7)

Adult campaigns (see Chapter 14) and cessation interventions (see Chapter 7)

Parent/home components of school-based interventions (see Section 5.29)

Information and resources directed at parents regarding youth smoking (see Section 5.27)

Smoking behaviour of peers, and peer attitudes and norms
(see Section 5.8)

Mass media campaigns targeted at young people (see Section 5.25) (and flow-on effects of adult campaigns)

Peer influence strategies incorporated into school interventions, youth resources etc (see Section 5.29)

Peer education approaches (see Section 5.28)

Intentions, attitudes and beliefs
(see Section 5.6)

Youth-directed mass media campaigns (see Section 5.25)

School-based programs (see Section 5.29)

Targeted resources, internet and technology strategies (see Section 5.24)

Strategies that denormalise smoking (including smokefree public places) (see Section 5.24 and Chapter 15)

Educational environment
(see Section 5.9)

School curriculum and programs (see Section 5.29)

School smokefree policy (see Section 5.14.1).

Complementary initiatives that are protective against smoking (e.g. physical activity, school connectedness)

Accessibility to and availability of tobacco products
(see Section 5.11)

Sales to minors interventions (see Section 5.21)

Regulation of display of stock at point of sale (see Chapter 11, Section 11.4)

Removing display at point of sale in retail outlets (see Chapter 11, Section 11.9)

Licensing of retailers (see Section 5.21.5) , licensing of smokers? (Section 11.9.2)

(see Section 5.12)

Pricing and taxation (see Section 5.22 and Chapter 13)

Tobacco advertising and promotion targeted at young people, including portrayal of smoking in the popular media
(see Section 5.15 and 5.16)

Advertising and promotion bans

Health warnings on packaging (see Chapter 12, Attachment 12A)

Plain packaging of tobacco products/packets (see Chapter 11, Section 11.10)

Monitoring and advocacy to expose new tobacco industry tactics to target young people

Helping young people to decode deceptive tobacco industry marketing approaches (including smoking in movies) (see Section 5.26)

Tobacco products created to appeal to new users
(see Section 5.13)

Regulation of packaging and of flavourings that appeal to young people (see Chapter 12, Section 12.7)

Relevant news and research

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1. Grimshaw G and Stanton A. Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews 2006;4:CD003289. Available from: http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003289/pdf_fs.html

2. US Department of Health and Human Services, Preventing tobacco use among young people: A report of the Surgeon General, 2012, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2012/

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11. US Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. Available from: http://www.cdc.gov/tobacco/sgr/sgr_2000/index.htm

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14. Walsh R and Tzelepis F. Adolescents and tobacco use: systematic review of qualitative research methodologies and partial synthesis of findings. Substance Use & Misuse 2007;42(8):1269–321. Available from: http://www.informaworld.com/smpp/content~db=all?content=10.1080/10826080701204904

15. Muller-Riemenschneider F, Bockelbrink A, Reinhold T, Rasch A, Greiner W and Willich SN. Long-term effectiveness of behavioural interventions to prevent smoking among children and youth. Tobacco Control 2008;17(5):301-2. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/17/5/301

16. Skara S and Sussman S. A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine 2003;37(5):451-74. Available from: http://www.sciencedirect.com/science/article/pii/S009174350300166X

17. Thomas R and Perera R. School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews 2006(3):CD001293. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001293/frame.html

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20. Office of the United Nations High Commissioner of Human Rights. Convention on the rights of the child. Geneva: United Nations, 1989. Available from: http://www.unhchr.ch/html/menu3/b/k2crc.htm