Tobacco Documents Online

C TESTIMONY PRESENTED BEFORE THE SENATE SUBCOL~L*IITTEE ON HEALTH' AND SCIENTIFIC P.ESEAEtCH' ON r1AY 25119178, CONCERNING THE NATIONAL DISEASE PREVENTION ~'.ldD, HEf:LTH P'R0M0TIC1N ACT OF 19'78. My name is James W1. Sw~inehart. I am a social psychologist,, and' during the past 15 years zay work has involved teaching, research, and practice in the field of health communications. I favor all the provisions of the bil!1 under consideration, but wouldd like to comment particularly on that part of_Tit3e IV which concerns deterrencg of' snoking, anong children and adoleseents. This section o.` the bill proposes research onithe determinants of smoking, and' support for community and' school-based' programs. Ideal'ly, of course, one should know a great deal about the determinants of a problem before undertaking efforts to control ilt; in the case of smoking, our present knowledge provides an adequate basis for program planning,but needs to be expanded if control programs are tolbe made more effective., For example, we know that modeling and peer influence are closely related to smoking behavior. The boy or girl most likely to begin smoking has two parents who smoke, an older brother or sister who sniokes, and a close friend whoismokes; the presence of a nonsmoking parent or sibling or friend is associated with markedly lower rates of smoking in cniSdren.i This suggests that a deterrence effort should address parents, teachers, and other adult role models rather than focusing exclusively on children =d adolescents. As part of a project carried our by young people in San Diego, teenagers were asked why the}, smoked. The eight reasons given most often are not in O EJ the jargon of biomedical or behavioral research, but they cover a lot of M ground and provide obvious clues for the design of control programs: "I'm young now--why not smoke? I can quit later." "I don't inhale, so smoking ean"t hurt re.'"' "'rfY folks smoke--why shouldn't I?"

"If I don't spend the money on cigarettes, I'd spend it on something .~, c1se "Smoking makes mc look grown up and' mature.,'° '•Smol;ing can' t hurt rne--I smulce I'iltcr ciuarettcs.•'1 "'Smoking is better than putting,on a lot of weight." "All my friendls smoke--why shouldn't 1?" These comments confirm the view that teens'' und'erstanding,of smoking risks is often superficial, and that they are concerned about personal attractive- ness, being accepted, being "'normal," and' becoming independent. Given some knowledge of reasons why children begin smoking, what should be done in cor.m:unity programs developed under the proposed bill? How wouldl they, differ from programs now operating?' Opinions on these questions will vary, but I believe most health professionals would regardithe foll'owing, answers as reasonable. Many control programs are now being implemented in school systems tr•-oughout the country. Some of these, particularly the ones which cover smoking as a part of a general orientation to health, have shown promising, results., New prograsms should be encouraged' to utili2e a wide variety of approaches, including the development of coping,skills which could enable ~ children to resist pressures to engage in various other behaviors harmful to health. ~ A number of current programs offer only a single brief exposure to information about smoking, presumably on the assumption that this will somehow ""innoculate'' children against subsequent pressures to smo?:e. S}nce the dacision not to smoke must be made periodically rather than only once, efforts to support this decision should'be provided on alcontinuing or periodic basis from thejprimary grades through high school. Programs which provide information about physiology ancl the specific effects of smoking are appropriate as part of a general edUcation, but they are clearly inadequate as means of deterring, smokino in adoliescents. There is a need' to .~:

print media, such as news stories, feature articles, editorials, cartoons, and letters to the editor. Commercial advertisers typically place their materials where they will be seen or heard by persons in the market for their products. It makes sense for smoking control programs to do the same. Some examples of media which reach children and adolescents, in addition to those listed above, are comic books,, posters for schools (,and' for kid'sp rooms at home),, shorts or "trailers" for use in movie theaters, placemats in fast-food restaurants, bumper stickers, buttons, milk cartons, and'T-shirt imprints. All of these could be used in a comprehensive conmunity program--not to provide detailed information but to serve as reminders and'perhaps to help~establish nonsmoking as a norm. A special note shouldi be added' here regarding the scale of advertising and related elements of smoking control programs. In an environment where aa totacco company can spend $40 million to develop and' promote a single new brand of cig,arette, and where well over $250 rr.illionia year is spent to ad- vertise the top 20 brands, the odds are slight that a small counter-effort can have much impact on the "'climate" regarding smoking. By the age of 12 a cnild has experienced a long period of exposure to cigarette adveertising, d and the example of adult smoking; thus it seems unrealistic to expect sig- nificant results from fragnentedprograms of small size or duration. Whatever the nature of the interventions empl'oyed,, all programs funded under the proposed bill should be required'to (,1) characterize in detail the methods and approaches used; (2) ' use evaluation designs which meet specified criteria for appropriateness and scientific rigor; and (3) use outcome measures which include behavioral assessments as well as self-reports fror children. The purpose of these requirements would be to make program results cunri7:ative,, that is, to make possible an accurate determination of the relative value off various approaches so that those foundito be most effective canibe implementedd on a widcr scalie.,

In summary, the following should characterize newco ity prograrnsii • Plans based on accurate and' current knowledge of children's beliefs and attitudes regarding smoking (derived from surveys,, focus groups, etc.) • Use of specific objectives, so that efforts can be kept on track and results evaluated' clearly Extensive cooperation among school systems,, voluntary and public health agenciess and other interested groups 41 Involvement of health professionals, particularly practicing physicianss and' dentists • Use of a, variety of media • Emphasis on immediate personal andi social reinforcement of nonsmoking bchavi,or, and' avoid!ance of exhortation or sermonizing • Involvement of children and adolescents in program planning, and design of' materials • Pretesting of materials with revisions made as needed! • Use of athletes and other va.lued figures as nonsmoking exemplars U's~e~ of multiple appeals, including social and: pe~~rsonal : th~emes~ un- related related to physical health, I • Controlled placement of advertisements in print and broadcast media. • Reinforcement of basic messages over a period of years • Use of rigorous evaluation techniques which permit comparative assessment of different approaches and programs _ It has been estimated that one-fifth of the cost of medical care~ today arises because of tobacco and alcohol abuse. Even if smoking-related problems accounted for only one-hundredth of the $16p'billion spent on health care in this country last year, that would be $1.6 billion. Clearly the potential cost savings that could' result from effective smoking control programs, apart from the values in terms of personal health and productivity, are enormous. .

-:3!- supplement this information with non-trealth appeals, since most teenagers who start smoking do so because this provides other values which seem to outweigh the perceived health risks. Nine out of ten teenagers believe that smoking, is harmful to healthy but they are in a conflict situation because they also see smoking as a source of peer approval and' alsymboli of adulthood. The design of control programs in this area is made especially difficult by the fact that the positive consequences of smoking (such as peer acceptance) are 'unmediate, while the negative health consequences may not appear until years later. It may be necessary to devise forms of immediate reinforcement of nonsmokir.g beha:sior if controS programs are to become genuinel.y effective. New conMm.Lnity-based programs should involve greater cooperation on the part of school systems, health departments, affiliates of voluntary health organizations (such as the American Cancer Society, American Heart Association, ' and American Lung Association), and other appropriate co.mmtmity groups. Whenever possible,, children or adolescents should participate in the CJ' development of new program materials directed to them, and such materials should be tested for appeal and effectiveness before being produced in quantity. The number of anti-smoking spots broadcast on radio and television has dropped'sharply over the past few years. Rather than relyingsolely on public service time contributed by radio and TV stations, which is extremely limited (especially during time periods when a large audience is available), community programs should be permitted to purchase time andi thus co:rtrol t2ae frequency and times of placement. Persons responsible for these programs shouldseek to supplement paid commercials through appropriate use of talk shows, ed'itorials, segments on, news shows, documentary features, and special children's proe,ram.ming. In the same way, local control programs should be able to purchase space for display aducrtisinp, in newspapcrs and in metropolitan magazines. Compre- hensive proorams shouldl also include attempts to utilize other vehicles in the