Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths (1994)

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Tobacco use is a learned and socially mediated behavior. Experimenting with tobacco is attractive to children and youths because of associations they learn to make between tobacco use and the kind of social identity they wish to establish. Repeated and ubiquitous messages reinforcing the positive attributes of tobacco use give youths the impression that tobacco use is pervasive, normative in many social contexts, and socially acceptable among people they aspire to be like. Youths are led to believe that tobacco consumption is a social norm among attractive, vital, successful people who seek to express their individuality, who enjoy life, and who are socially secure. Several factors are involved in maintaining this impression among youths and in fostering tobacco use as a social norm at a time when public health messages are calling attention to the serious health risks associated with tobacco consumption. These factors will be highlighted in this chapter, and attention will also be called to a growing, largely local, movement calling for the exercise of greater social responsibility in the reduction of environmental cues that reinforce tobacco use in public spaces frequented by children and youths. At issue is an ecology of representations, ideas, images, cues, and the like, that foster tobacco use as normative behavior.

THE FUNCTION OF SOCIAL NORMS

The term "norms" has a broad range of meaning, with very specific connotations applied in the social sciences. In general, however, and for the purposes of discussion in this report, social norms are at once descriptive, that is, normative in a statistical sense denoting majority approval, and prescrip-

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tive, that is, guidelines for acceptable behavior associated with sociocultural  values. Norms are maintained both by social reinforcements and social sanctions. A social learning analysis of tobacco use takes into account the different types of social reinforcement that coincide with the development of tobacco use from experimentation to initiation to maintenance of regular use. Experimentation typically occurs under conditions of peer reinforcement; usually the initial inhalation of smoke is aversive but eventually the youth develops a tolerance to it. In other words, the adolescent "learns" in a peer context that tobacco use is an acceptable or desirable behavior, despite initial negative physiological reactions. Continued use produces pharmacologic reinforcement to sustain the behavior independent of social reinforcement. The behavior then occurs in different situations, where new learning takes place. The young smoker discriminates between situations in which smoking is socially acceptable or unacceptable. At the same time, various environmental or situational cues, such as an ashtray, or an empty cigarette pack, or a party, not only can suggest acceptability but can also stimulate physiological responses that reinforce the addiction to nicotine.1 Hence, whereas the addictive power of nicotine drives a person to use tobacco regularly and to maintain that regular use, it is the power of these perceived social norms that persuades children and youths to experiment with and initiate use of tobacco.

The development of these perceived norms among children and youths is influenced by pervasive images and messages of everyday life. These messages come from  numerous sources: friends, peers, family, school, the workplace, church, films, magazines, radio and television, billboards, electronic media, advertisements, sports events, arts performances, and so on. These messages typically have a prescriptive influence on social norms; in other words, in addition to characterizing what members of society do, they suggest to people what they should do. As standards set by a society or social group, norms define the boundaries of behavior; they dictate etiquette, protocol, and a sense of what is normal, natural, expected, and acceptable in given contexts. Because the norms of society are in large part prescribed through public sources, they are subject to the influence of interest groups that seek to legitimize an agenda and to engineer behavior.

Social groups are influenced by, but do not passively accept, prescribed norms. They mark their identity by selectively adopting and appropriating behaviors and images that take on meaning in opposition to behaviors and images adopted by other groups. Markers of group identity and conventions of group membership are not fixed, but rather change over time. Images associated with tobacco use are not stable, if not reinforced.

For adolescents, norms are particularly complex, for two reasons. First, adolescence is a transitional period "shaped by prior development in childhood and the future requirements of adulthood, as well as by current expectations and opportunities."2 Second, adolescence itself is a complex developmental period,

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marked by physiological, emotional, and psychological changes. Adolescentsare establishing their sense of self and redefining themselves socially in the contexts of family, peers, school, the workplace, and the local community.3 Parents and peers contribute in different ways to the development of adolescents' values. Adolescents tend to hold values similar to those of their parents regarding education, religion, and work, but are more similar to their peers in aspects of adolescent culture, such as music and appearance.4 Peers find security, identity, and a sense of wellness by constructing peer groups and group norms dictating valued behaviors.5 These behaviors have more potency if they are also perceived as normative for adults, yet not acceptable for children.6 If an adolescent perceives a specific behavior, such as drinking alcohol or using tobacco, to be normative in the peer group, he or she might adopt the behavior in order to belong to the group or to feel relaxed when with the group.

In developing peer norms, adolescents look to the greater social environment for concepts of adult identity, particularly in the behavior of leaders, heroes, and film stars, and in the media. Messages, especially repeated messages. that associate behaviors with maturity, peer approval, and independence tend to be the most influential. An overabundance of such messages in relation to a given behavior can result in a youth's misperception of how pervasive the behavior actually is. Misperception of the pervasiveness of tobacco use can be a powerful influence on behavior.

What are the current norms regarding tobacco use? How do social norms influence, or make children and youths susceptible to adopting, tobacco use? How can actions by parents, social groups, and communities set and reinforce social norms and thereby prevent the initiation of tobacco use by children and youths?

THE EMERGING TOBACCO-FREE NORM

The Decline of Tobacco Use

A useful scientific descriptor of the pervasiveness of behaviors is statistical trend data, which describe patterns of behavior with information obtained in an objective manner through surveys. A review of trend data on tobacco use reveals that currently the norm for three-quarters of the population in the United States is non-use of tobacco. The survey data describe the overall decrease in smoking prevalence in the general population from 40% in 1965 to 26% from 1990 to 1992.7 In the military, prevalence of any smoking decreased from 51% in 1980 to 35% in 1992; the prevalence of heavy smoking (one or more packs per day) decreased from 34% in 1980 to 18% in 1992.8 Among high school seniors, the prevalence of daily smoking was 29% in 1976, 21% in 1980, 17% in 1992, and 19% in 1993.9

Youths and adults alike want to quit using tobacco. A 1993 national Gallup

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poll reported that 76% of adult smokers have tried to quit smoking. Despite past failures, 73% believe that they will be nonsmokers within 5 years, and 30% were trying to quit at the time of the survey.10 Similarly, in a 1994 USA Today/CNN Gallup poll, 70% of smokers expressed interest in quitting; 48% had tried to do so but failed. About the same percentage (76%) of adolescent girls (smokers and ex-smokers) in the Teen Lifestyle Study had attempted to quit.11 Two large national surveys of teens also reveal that youths want to and try to quit. The 1989 TAPS (Teenage Attitudes and Practices Survey) data show that 74% of 12-through 18-year-old smokers had seriously thought about quitting; 64% had tried at some time to stop smoking and 49% had tried during the preceding 6 months (figure 3-1).12 The Monitoring the Future Project data show that nearly half of smokers who were seniors in high school between 1976 and 1989 wanted to quit, and about 40% had tried unsuccessfully to do so.13

As discussed above, social norms vary among groups, and the trend data describe a variety of tobacco use patterns in different groups identified by gender, ethnicity, and socioeconomic status. Knowing what the trends are for specific groups is important in determining what the social norms are perceived to be, and what factors may reinforce tobacco use, so that counter-strategies can be developed and implemented. For example, important racial/ethnic differences in cigarette smoking have become apparent among high school seniors during the

FIGURE 3-1  Sources: Nichter, Mark, Mimi Nichter, C. Ritenbaugh, and N. Buckovic.
The Teen Lifestyle Project: Preliminary Report. Tucson: University of Arizona. 1994 (unpublished);
and SmithKline Beecham. Gallup Report: A National Survey of Americans Who Smoke. New York, 1993.

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life of the Monitoring the Future Project. In the late 1970s three student ethnic groups—non-Hispanic whites, African Americans, and Hispanics—had fairly similar smoking rates; all three mirrored the general decline in adult smoking from  1977 to 1981.  Since 1981, however, a considerable divergence has emerged: smoking rates have declined very little for non-Hispanic white and Hispanic youths, but the rates for African-American youths have continued to decline steadily. As a result, in 1992, the smoking rates for African-American students were about one-fifth to one-third of those for white students; specifically, for African-American high school seniors, the prevalence of daily cigarette smoking reported is 4%, whereas for non-Hispanic whites it is 21%.14 Currently, there is no explanation for this difference. Data from the Monitoring the Future Project also reveal a striking difference between levels of education and amount of cigarettes smoked daily. For example, smoking half a pack or more a day is nearly three times as prevalent among the noncollege-bound youths (19% versus 7%) and these differences persist after high school.15

What little information is available on the smoking habits of American-Indian groups shows large regional and tribal variations. For instance, one study found tobacco use to be very high among girls, and daily cigarette smoking higher among girls than among boys, after the seventh grade. Daily cigarette smoking rose from 8.9% for girls and 8.1 % for boys in junior high to 17.8% and 15.0%, respectively, for high school students. Elsewhere rates of about 20% were reported for regular smoking among American-Indian youths, and the rates seem to be increasing.16

It is clear that the use of smokeless tobacco by young American Indians and Alaskan Natives, boys and girls, is higher than by any other ethnic group. In studies of communities, weekly use of smokeless tobacco by boys was 43% and by girls 34%.17 Furthermore, a study found rates of occasional use of smokeless tobacco by American Indians to be astonishingly high among the very young: 74% of girls and 90% of boys who reported weekly use of smokeless tobacco began using it before the age of 10.18 Other studies have documented that American-Indian children may initiate smokeless tobacco use before kindergarten.19

What are the reasons behind this diversity in tobacco use among the various age, gender, and ethnic groups? Why are some members of the population more susceptible to becoming addicted to this health risk? No clear answers have emerged. Several studies have shown that perceptions of vulnerability vary with ethnicity and that African-American and Hispanic adolescents feel more susceptible than their white peers to a variety of health outcomes, including cancer. AIDS, and pregnancy.20 One study found that differences in perceived vulnerability are a function of knowledge.21 Youths acquire knowledge through many cultural social systems, systems that also can convey erroneous impressions of the trends in tobacco use, as described in the section below.

The military services historically have reinforced a pro-tobacco norm, and

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had a smoking prevalence about 10% higher than that in the general population. Cigarettes have traditionally been cheaper in commissaries and post exchanges than in retail outlets, and cigarettes were distributed free to the troops during wartime. A high prevalence of tobacco use continued after World War II, and in 1980 was 51% for military men. (This finding was followed by a Department of Defense (DoD) memorandum requesting that an intensive antismoking campaign be carried out at all levels of DoD.)22 Studies by the Naval Health Research Center found that young men between the ages of 18 and 24 entering the Navy in 1986 smoked at the same rate (28%) as civilians of that age group, but that one year later the same group of naval recruits had a smoking rate of 41%.23 The reasons given for the smoking initiation were "curiosity" and "friends smoking." The researchers conclude that social factors may have a fairly strong influence on smoking behavior of new Navy personnel, especially given that the Navy encourages cohesiveness and uniformity. Fortunately, in the past few years, the prescribed norm for the military has been a tobacco-free environment, and research studies have shown that prevention interventions can be successful in reducing the percentage of recruits who take up smoking.

The Social Unacceptability of Tobacco Use

The social unacceptability of tobacco use throughout society in the United States is anchored in changing attitudes toward health and personal responsibility:

The contemporary place of the cigarette in American life is a distant shout from its accepted position in the 1950s. Despite the opposition of the tobacco industry, the public health campaigns of the past three decades have brought about a remarkable change in attitudes and meanings toward smoking. The health movement has produced a cultural shift in the meaning of health and patterns of living that would have seemed impossible 30 years ago.24

The emergent tobacco-free norm reflects two distinct links between personal responsibility and health. First and least controversial is the idea that it is socially, and perhaps morally, irresponsible to expose nonsmokers to the risks of disease associated with environmental tobacco smoke (ETS). In the wake of the 1993 report of the Environmental Protection Agency confirming the harmful effects of ETS, public support for laws and policies guaranteeing smoke-free environments is now nearly universal among nonsmokers, and even very high among smokers. In a recent Gallup poll of smokers, 42% of smokers said that nonsmokers' rights in public places should supersede smokers' rights.25 In a national poll of U.S. voters, 72% of voters believe that second-hand smoke can give nonsmokers cancer and other serious diseases, and 64% favored banning smoking in all public places, such as restaurants, stores, and government buildings.26 The apparently high level of compliance with public smoking restrictions

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reflects a widespread acceptance of both the norm favoring smoke-free environments and of its legitimacy. Indeed a norm of civility—obligating a smoker to request permission of nonsmokers to light up and enabling companions and social hosts to deny permission—has taken root throughout society.27

The second concept about health and personal responsibility underlying the emerging tobacco-free norms is that exposing one's own health to the risk of diseases, including tobacco-related diseases, is itself socially unacceptable. This attitude reflects a marked shift from the traditional libertarian intuition that tobacco use (or other personal risk-taking) is ''no one else's business." It now seems that tobacco use, just as other health-related behaviors, is seen as "everyone's business" because the costs of tobacco-related disease are borne by the whole society.28 In general, the public seems to have accepted the idea that unhealthy personal choices are of public concern. This attitude is associated with widespread acceptance of the legitimacy of public policies aimed at discouraging people from using tobacco, particularly through taxes that require tobacco users to absorb the social costs of their unhealthy choices.

Thus, the emerging tobacco-free norm has two underlying values. First, no one should be exposed to tobacco smoke, because it puts everyone exposed to it at risk; therefore the environment should be smoke-free. People who smoke should do so only in environments that protect others from exposure, for example, in areas with separate ventilation systems. Second, because the aggregate effects of tobacco-related health consequences affect everyone, society as a whole has an interest in discouraging tobacco use and in supporting the efforts of people who are trying to stop using tobacco. This means instilling and supporting the idea that to stop using tobacco is "the right thing to do."

TOBACCO USE AS PERCEIVED BY CHILDREN AND YOUTHS

Increasingly, through a variety of channels, the message is being conveyed that tobacco is not used by the majority of people and that it is not socially acceptable. The public health values underlying this tobacco-free norm are steadily growing stronger and are being articulated more emphatically. Nevertheless, youths do not perceive the norm to be tobacco-free; rather, they commonly overestimate the percentage of their peers and adults who use tobacco.

The Perception of Tobacco Use

In an interview study of 895 urban children and youths, the respondents greatly overestimated the prevalence of adult and peer smoking. The mean estimate for adult smoking was 66% at a time when 30% of adults were cigarette smokers. Estimates of peer smoking were about double the real figure by students in high school and higher by students in grade school.29  Other studies

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show similar results. Findings from  the 3-year (1990-1992) Teen Lifestyle Project reveal that, although only 5% of adolescent girls in a Tucson sample smoked regularly and another 20% smoked only occasionally or only at parties, 31% of their peers thought that 51-75% of girls at their school smoked and another 10% thought that 75-90% smoked. The estimates about percentages of boys who smoke were similar, as they were for adult men and women. For example, 28% thought that 51-75% of women were smokers and 15% thought that 75-90% were smokers.30 A study of over 200 adolescents in Michigan found that youths' perceptions of the prevalence of smoking were "highly inaccurate": 79% of the youths thought that over half of all adults smoke and 68% thought that over half of all teens smoke.31

Adolescents who smoke overestimate smoking prevalence by a greater margin than do nonsmokers. A study of 5,351 sixth to twelfth graders from a midwestern and a southwestern community found that adolescents who smoked estimated significantly higher numbers of smokers than did adolescents who did not smoke (table 3-1). For example, middle school students who smoke estimated that 48.9% of boys smoke, whereas nonsmokers estimated that 27.2% of boys smoke, a difference of 21.7%.  Smokers estimated that 66.8%  of men smoke, whereas nonsmokers estimated 56.5%.32 Similarly, a study of 5,610 students from the Los Angeles area found that students in the eighth and ninth grades greatly overestimate the number of adolescents and adults who smoke regularly. Adolescent smokers who were regular smokers made the greatest

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overestimates. Whereas in fact 9% and 12% of eighth and ninth graders, respectively, were regular smokers, students who were regular smokers estimated that 55% smoke regularly. Whereas 33% of adults were smokers at that time (1981 Los Angeles data), the students who were regular smokers estimated the figure to be 66-70% (figure 3-2). Interestingly, nonsmokers underestimated the percentage of adolescents who have ever tried smoking, whereas regular smokers

FIGURE 3-2  Fact: 12% of 9th graders are regular smokers. Perception: 9th graders who are regular smokers
estimate that 55% of their peers are also regular smokers. Source: Adapted from Sussman, S.,
C. W. Dent, J. Mestel-Rauch, et al. "Adolescent Nonsmokers, Triers, and Regular Smokers'
Estimates of Cigarette Smoking Prevalence: When Do Overestimations Occur and by Whom?"
Journal of Applied Psychology 18(7) (1988): 542-543.

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overestimated the percentage by 6-9%. In addition, the study found that inflated estimates, relative to the adolescent's stage of smoking development, were significantly associated with future onset of smoking. The researchers concluded that "the provision of accurate norms regarding regular smoking by adolescents and adults might be extremely beneficial to prevention efforts."33 In fact, overestimating smoking prevalence is one of the strongest predictors of smoking initiation.34

Spreading a False Impression: The Ubiquitous Pro-Tobacco Message

The misperception of youths that the large majority of peers and adults use tobacco may well derive from the near-constant exposure youths experience to pro-tobacco messages and images, which make tobacco use seem common. (See chapter 4 on advertising for a full discussion.) Pro-tobacco messages are ubiquitous in the American environment. Children walking home from schools see billboards in their neighborhoods promoting tobacco products (figure 3-3). Children themselves become walking billboards by wearing t-shirts, caps, and other clothing items that display tobacco logos. Children watch film and sports stars smoke and chew tobacco products. They read magazines with ads that either

FIGURE 3-3  The young children who will ride this bus to and from school will likely be exposed
to a number of tobacco advertisements along the way. Source: Courtesy of John Slade.

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directly or indirectly promote tobacco products. They eat in restaurants that permit tobacco use. They frequent and linger in shopping malls where tobacco use is permitted. Many even attend schools where smoking is permitted on the grounds and where teachers smoke even if the students are prohibited from smoking. Youths attend cultural events, such as music concerts, and sporting events, such as rodeos and car racing, either sponsored by the tobacco industry or where billboards, scoreboards, or contestants display tobacco logos. Furthermore, tobacco products are displayed in many stores frequented by youths and are easily purchased by youths. As a result, children learn early and erroneously that tobacco use is widespread and acceptable, especially as an adult behavior.

The primary concept conveyed by the multitude of pro-tobacco messages is that there are benefits to using tobacco. The repetition of these messages reinforces the perception of benefits, and that perception influences youths, making them susceptible to tobacco use. The importance of the perceived benefits of smoking as a predictor of susceptibility to smoking was examined in a study of teen smoking in California. That study defined "susceptibility" as "the absence of a determined decision not to smoke in the future."35 In surveys conducted in 1990 and 1992, adolescents were asked if they believed that smoking helps people when they are bored, helps them relax, helps people feel more comfortable at parties and in other social situations, and helps them keep their weight down. The findings were as follows:

1. In each year, over 40% of adolescents felt that smoking helped people socialize; over 30% felt that it helped people relax. The benefit least endorsed by teenagers related to weight control, with percentages at about 16%.

2. In each year, only one-third of adolescents did not perceive that smoking provided any of these benefits.

3. One-quarter of adolescents reported one benefit of smoking. 30% reported two or three benefits, and 12% reported four or five benefits.

4. Adolescents who were 12-13 years old were just as likely to perceive benefits of smoking as those who were 16-17 years old. This result suggests that the belief that smoking has utility is established before the adolescent years.36

The belief that there are benefits to smoking was a major predictor of both susceptibility and smoking in the last month in the 1990 and 1992 surveys. The univariate statistics from the 1992 survey indicate that, of those who did not perceive any of these benefits, 24% were susceptible to smoking; of those who perceived one benefit, 38% were susceptible to smoking; of those who perceived two benefits, 41% were susceptible; and of those who perceived three or more benefits, 57% were susceptible. In cross-sectional analyses of the 1992 survey data, the proportion of susceptible youth who experimented with cigarettes rose dramatically with age (14% of 12-year-olds versus 90% of 19-year-olds) compared to experimentation among those not susceptible (5% of 12-year-olds ver-

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sus about 25% of 19-year-olds). The investigators conclude that, "these data suggest that the susceptibility measure includes adolescents who may smoke in the future but have not yet tried a cigarette."37

The five most commonly presented "benefits" (discussed in more detail in chapter 4 on advertising) are presented as image messages in advertising:

1. Tobacco use is a rite of passage to adulthood.

2. Successful, attractive people use tobacco.

3. Tobacco use is normal.

4. Tobacco use is safe and healthful.

5. Tobacco use is relaxing in social situations.

In the Teen Lifestyle Study, about half of those adolescents who smoked said that they started smoking because they had stress in their lives and they thought that smoking would be relaxing. Over half of them smoke when they are with friends.38 In another study, to determine the power of image messages in reinforcing tobacco use, Pierce and colleagues related trends in smoking initiation to the sales of leading cigarette brands targeted to women in advertisements from 1944 through the mid-1980s. The analysis revealed gender-specific relationships with the tobacco advertising campaigns that targeted women and were launched in 1967.39 (See chapter 4 for details.)

A common practice of the tobacco industry, which has the effect of infusing society with pro-tobacco messages, is to sponsor or cosponsor cultural events. This sponsorship not only provides an opportunity for direct marketing to specific market segments but also creates a dependency on the industry for continuation of such events. For example, Philip Morris Inc. has sponsored performances of the Alvin Ailey Dance Theatre and a photographic exhibit of the late Dr. Martin Luther King, Jr. R.J. Reynolds Tobacco Co. and United States Tobacco sponsor Hispanic street fairs and festivals, such as Cinco de Mayo celebrations.  Brown and Williamson Tobacco Corp. presents "Kool Achiever" awards to persons who want to improve the "quality of life in inner-city communities" and has enlisted the National Urban League, the NAACP, and the National Newspaper Publishers Association in the nominating process. Contributions to African-American groups by Philip Morris and R.J. Reynolds in 1987 totalled $4.3 million.40

The ubiquity of the pro-tobacco message is an important influence on youths' desire to experiment with and to continue using tobacco products. The pro-tobacco environment leads youths to misperceive tobacco use as the public norm and to interfere with youths' perception of the serious, mortal consequences of tobacco use. The appropriate preventive public health approach, therefore, and the most effective approach given the large numbers of individuals involved and the variations in their group characteristics, is to change the environment or social context so that it fosters and reinforces the majority's value of a tobacco-free norm.  We must also correct misperceptions of the pervasiveness of

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tobacco use. As mentioned in chapter 4 on advertising, one important approach for competing against the pro-tobacco messages is an aggressive, ongoing counter-tobacco advertising campaign that promotes and reinforces the tobacco-free norm and presents its benefits.

OPPORTUNITIES FOR PROMOTING A TOBACCO-FREE NORM

Establishing a tobacco-free norm clearly and strongly in the lives of children and youths requires measures to counter all sources of pro-tobacco messages to which youths are exposed. The environmental conditions that reinforce tobacco use must be either eliminated or rendered ineffectual. Efforts to make the tobacco-free norm highly visible and ubiquitous must be persistent and continuous.

Messages countering pro-tobacco messages and images must be as pervasive and frequent and as imaginative as the pro-tobacco messages themselves. Counter-tobacco advertising through media-based approaches has included antismoking messages in newspapers and on television and radio broadcasts. Typically these take the form of brief announcements but also occasionally are developed as special programs and curricula. Mass-media messages were included in early smoking prevention efforts of the federal government and voluntary health organizations. The effectiveness of counter-smoking advertising was demonstrated from 1967 to 1970, soon after the release of the landmark surgeon general's report on smoking but during a time when the tobacco industry still aired pro-smoking advertisements. Antismoking messages were widely aired on television and radio as a result of the FTC's Fairness Doctrine. A study of nearly 7,000 adolescents found that the teenage smoking rate was 3 percentage points smaller during the period of the Fairness Doctrine than during the preceding 16-month period. The Fairness Doctrine had its greatest impact during its first year, in something of a "shock" effect.41 These study findings "suggest that a nationwide, well-funded antismoking campaign could effectively counter the effects of cigarette advertising in its currently permitted media forms."42

Counter-tobacco messages should especially address the "benefits" commonly presented in pro-tobacco advertisements, and reverse the perception that tobacco use is normal, attractive, safe, and healthful. The most effective use of mass-media interventions has been in conjunction with other materials and programming, such as school-based programs.43 Messages in the media should be coordinated to enhance and support other efforts to promote a tobacco-free norm at home and in schools, workplaces, public buildings, shopping malls, restaurants, sports arenas, and entertainment facilities. Youths should be involved in the development of the design and evaluation of health messages and programs. (See chapters 4, 5, and 7 for potential applications of the concept of including youths in developing research questions and message concepts.)

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Families

The degree of parental influence on tobacco use by youths is not clear; in fact, research studies have reported contradictory effects and different effects for different ethnic groups. For example, in southern California, a longitudinal study of 11- through 14-year-olds found parental smoking to be predictive of a child's smoking for non-Hispanic whites but not for Hispanics, African Americans, or Asians.44 Similarly, a longitudinal study of 8- through 17-year-olds in the southern United States found parental behavior to be predictive of children's smoking initiation for whites but not for African Americans.45 The 1994 surgeon general's report presents the results of 27 prospective studies on the onset of smoking. In 15 of the studies investigating parental smoking as a factor in initiation, 7 studies showed that parental smoking was predictive; 2 studies suggested that it was predictive only for girls. Six of the studies did not show parental smoking as a predictive factor in onset.46

Parental attitudes and reactions to tobacco use may be a stronger influence on adolescent smoking than the actual smoking status of parents. Parental disapproval toward smoking was shown to indirectly predict low levels of use in a study that investigated parental actions toward smoking among 10- to 12-year-olds.47 Comparison of parental strictness toward smoking among different age groups indicates that 14- to 16-year-olds are less likely to begin smoking if they perceive that parents disapprove.48 In a survey of teens in Fond du Lac, Wisconsin, parental disapproval was an important reason that teens did not smoke—for 45% of eighth graders, 33% of tenth graders, and 27% of twelfth graders. For teens in Manitowoc, Wisconsin, the percentages were even higher—62%  of eighth graders, 60% of tenth graders, and 48% of twelfth graders. In both places, parental influence was greatest for the younger adolescents.49

A study in Norway demonstrated that when parents set clear standards disapproving of tobacco use, adolescents responded to those standards by subsequently being less likely to take up smoking, regardless of parental smoking status.50 Similarly, a study of 10,000 adolescents in the United Kingdom found that parental opposition to smoking was a more important direct predictor of the adolescents' intention to smoke than was parental smoking behavior.51  Thus, one opportunity for establishing a tobacco-free norm is for parents to establish and consistently reinforce a standard of no tobacco use for their children. Even parents who smoke can be effective in doing this if the standard is accompanied by an explanation of the regrettable addictiveness of nicotine, which is controlling their own tobacco use. It is the lack of a parent's general concern for his or her child that seems to increase the risk of tobacco use,52 whereas general parental support appears to decrease risk. Parents, like children, are influenced by their environment. In a Gallup poll for adult smokers, 50% reported that "pressure from family and friends" was a major reason for wanting to quit and 70% were concerned (53% saw this as a major concern) that their children might start smoking because they see them doing it.53

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Peer Context

Although the influence of peers is a common factor in determining the circumstances of tobacco experimentation—that is, when and how the tobacco will be tried—it is important to remember that children and youths who choose to use tobacco have already been influenced by the norms of the larger society and, in particular, by continuous exposure to pro-tobacco messages. Experimentation is preceded by a preparatory stage during which a child or adolescent forms attitudes and beliefs about the benefits of smoking. The child or adolescent who chooses to smoke probably sees smoking as functional: as a way to appear mature, as a way to display either independence or bonding, as a way to cope with stress, and as a way to be relaxed in a social situation by having something to do.54 Thus, whereas the ritual of experimentation commonly is peer-influenced, the predisposition to use tobacco is generated and reinforced by multiple environmental factors. The peer environment often serves as a convenient context in which to mimic a seemingly adult behavior.

Even within this broader frame of reference, the role of peer influence may be less robust than is commonly assumed. In the Teen Lifestyle Study, although the adolescents' perception of peer and adult smoking prevalence was highly exaggerated, the perception was not based on their best friends' behavior or their parents' behavior: 62% said that their best girlfriend never smokes and only 10.7% said that their best friend smokes regularly; 56% reported that their parents are nonsmokers. Thus, the girls' erroneous perception that the majority of people smoke must be deriving from sources other than immediate friends and families.55 Data from the Monitoring the Future Study show that peer disapproval of cigarette smoking is rather high: in 1993 71% of high school seniors and 80% of eighth graders said that they disapprove of people who smoke a pack of cigarettes a day; 74% of tenth graders and 77% of eighth graders disapprove of using smokeless tobacco regularly.56

Studies of adolescent decision-making do not provide clear-cut evidence of the role of peer influence on risk-taking. In a review of the empirical evidence on risk-taking and decision-making in adolescence, Furby and Beyth-Marom reported mixed results about peer influence on risky behaviors:

In sum, adolescents may care very much what their peers think of them, but that apparently does not necessarily mean that their decisions about engaging in risky behaviors are heavily influenced by peers. In most studies, perception of influence has been measured, but actual influence on behavior has not been assessed. Furthermore, the emphasis has usually been on whose advice adolescents follow. However, they might not necessarily seek that advice.57

Interestingly, adolescents report that they are more influenced by prosocial or neutral pressures from peers than by pressures toward misconduct.58 The positive influence of peers may be reflected in surveys of teens in Fond du Lac and Manitowoc, Wisconsin. The percentages of nonsmokers who gave as a reason

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for not smoking the fact that their friends do not smoke averaged 29%  in Manitowoc and in Fond du Lac, 23% for eighth and tenth graders, and 13% for  twelfth graders.59 Thus, the peer context can become an opportunity for prevention and reinforcement of a tobacco-free norm if youths are taught refusal skills (as discussed in chapter 5 on prevention), especially when peer leaders play an active role in the teaching. Youths with such skills who are either indecisive or who feel pressured to respond to the experimental context would not only be able to resist in an acceptable manner but would also be communicating thereby that tobacco use is not the norm. In the study of Michigan youths mentioned above, 54% of current smokers suggested having "a friend to quit with" as a potentially successful approach to smoking cessation.60

Furby and Beyth-Marom suggest that altering various aspects of the social-structural environment in which adolescents find themselves may be equally, or even more, effective in improving the quality of their choices than attempts to influence individual decison-making processes.61 An example of the power of peer rejection of smoking as a norm and of the capability of teens to influence their social-structural environment occurred in 1990 in Bozeman, Montana. A stringent tobacco-free policy was adopted in Bozeman via a referendum voted on by students and staff, at the request of student representatives to the Board of Trustees. The district's 1,900 students in grades 7-12 and 300 staff members and the trustees agreed in advance to abide by the results of the referendum. The tobacco-free schools policy was ratified by a vote of 79% of students and 77% of staff. The staff and students implemented the policy themselves. A second referendum, this time regarding sales of tobacco products to youths under age 18, was authorized by the 1991 Montana legislature. Approximately 60% of 50,000 students voting in grades 7-12 voted "Yes—I do favor requesting that stores refuse to sell cigarettes and tobacco to persons under 18 years of age."62

The School Environment

Outside of the home, the principal consistent environment of children and adolescents is the school. The school environment, as a social organization, prescribes social norms, whether stated directly in school policies, implied in the expectations and behavior of teachers, or promoted by peer groups. The school therefore offers an important opportunity for promoting the tobacco-free norm, for countering pro-tobacco messages, and for creating a health-promoting environment in general. As discussed in chapter 5, schools are the natural setting for educating children and youths about the consequences of tobacco use and for teaching them refusal and other social skills. In addition, schools should establish no-smoking policies that apply to students and all school personnel alike. Tobacco-free policies have been endorsed by educational organizations such as the National School Boards Association and the American Association for Health, Physical Education, and Recreation. Among the Healthy People 2000

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Objectives for the Nation, Objective 3.10 specifically addresses tobacco-free environments in the school: ''Establish tobacco-free environments and include tobacco use prevention in the curricula of all elementary, middle, and secondary schools, preferably as part of quality school health education."63 School policies can and do have an impact on tobacco use behavior. In California, the written smoking policies of 23 schools (over 4,000 adolescents) were evaluated on whether they banned smoking on school grounds, banned smoking near school, and included an education program on smoking prevention. The schools that had significantly lower smoking rates had policies in all of these areas and emphasized prevention and cessation.64 In 1992, 28 states had state-level mandates to offer tobacco-use education in the schools, and 31 had statewide restrictions on tobacco use in schools.65

The state of Colorado provides an example of how a serious commitment by interested organizations can take action to establish a tobacco-free school environment. A 1988 survey by the Colorado Department of Health revealed that only eight Colorado school districts (5% of the total) had comprehensive tobacco-free policies. The Colorado School Health Council, a state constituent of the American School Health Association, in response to their concern, developed the Colorado Tobacco-Free Schools and Communities Project. With the support of over 25 collaborating agencies statewide, Colorado has moved from 8 to 81 tobacco-free school districts in a little over 4 years. The Colorado program defines "tobacco-free" as "no use of any tobacco products in school buildings, on school grounds or at school-sponsored activities by students, staff, and visitors."66 In Minnesota, the tobacco-free school environment is already statewide.

Activity to require tobacco-free school policies is also occurring at the federal level. On March 23, 1994, the House and Senate included a provision in an education bill that would ban smoking in all public schools that receive federal money, including Head Start Centers, day care centers, and most community health centers. The Lautenberg amendment is part of the Goals 2000: Educate America Act, which sets national education goals. Although federal and state requirements are effective means of instituting tobacco-free policies in schools, another important means should also be considered: involving students in establishing the policies, as was done in the Bozeman referendum described above.

The Community Environment

The daily life of adolescents extends broadly into the local community, as they progressively take on greater autonomy and require less adult supervision. Yet, certain restrictions continue to apply to them (for example, restrictions on smoking and drinking), and these restricted behaviors become symbols for adult status.67 Therefore, as adolescents venture more and more into the community, their perceptions that certain norms seem to apply only to them and not to adults may promote health-compromising behaviors. On the other hand, public restric-

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tions that apply to all persons in an environment can enhance the adolescent's perception of himself or herself as emerging toward an adult role in society.

Restrictions on tobacco use in public places are statements of the preferences of the larger community. Restrictions on smoking in public places state and reinforce the norm that tobacco use is not acceptable, and create a social climate where not using tobacco is considered normal.68 Social policy thereby communicates the message that tobacco use causes health problems for everyone exposed to it, even to environmental tobacco smoke. The restrictions also reduce the number of opportunities to use tobacco; thus, tobacco use is not only a behavior disapproved by society but also an inconvenient behavior. These messages counter the pro-tobacco message and diminish the perception that psychosocial benefits are associated with tobacco use.

Currently there is broad public support for restricting tobacco use in public places. In the American Cancer Society's Survey of American Voters, 64% of all voters polled said that they favor banning smoking in all public places, such as restaurants, stores, and government buildings.69 Results from a 1994 USA Today/CNN Gallup poll of adults nationwide reveal that support for a ban on smoking in public places has doubled in the last 7 years, with a majority favoring restrictions in restaurants, offices, and hotels.70 A large percentage of smokers (42%) polled in a 1973 Gallup survey felt that nonsmokers' rights in public places should supersede smokers' rights.71 The more these public attitudes are expressed in actual tobacco control ordinances—and enforced—the more children and youths will encounter a tobacco-free environment and will perceive that tobacco use is not normative. In the Fond du Lac and Manitowoc surveys mentioned earlier, about 20% of the teens in the former and 29% in latter said that they do not smoke because it bothers others.72

The community environments in which youths spend much of their time, and which are therefore the environments that provide their context for tobacco use, are workplaces, shopping malls, fast-food restaurants, sports facilities, and community and youth organization meeting places.

The Workplace

The workplace is an important social context for adolescents for two reasons. First, more than half of high school students hold part-time jobs; they work in a wide variety of places, such as restaurants, offices, and stores. Second, as part of their developmental task of social redefinition, adolescents are preparing for responsible roles in society as adults, and even more specifically, in school they are learning skills that prepare them for work. Thus, while still in high school, adolescents are exposed to the norms of the work environment and they experience what will be expected of them in the future in the workplace.

Increasingly, workplaces have adopted no-smoking policies, particularly since the publication of the Environmental Protection Agency's report on envi-

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ronmental tobacco smoke. Usually, these policies are initiated by management, but recently, in March 1994, employees took the initiative to make their workplace smoke free. The last United Auto Workers local to settle with General Motors voted, as part of its contract, to prohibit smoking at its plant.73 In adopting tobacco-free policies, employees and employers are not only literally protecting employees from the elements in smoke that are harmful to one's health, but they are also clearly stating and promoting the public health norm that an individual should not impose health risks on other individuals. The worksite objective in the Healthy People 2000 proposal is "to increase to at least 75% the proportion of worksites with a formal smoking policy that prohibits or severely restricts smoking at the workplace."74 The objective is not unrealistic if current momentum can be maintained.

On March 25, 1994, the Department of Labor proposed a virtual ban on smoking in the workplace as part of a comprehensive plan to increase the air quality in workplaces. The proposed ban would be instituted through the Occupational Safety and Health Administration (OSHA) and would cover approximately 6 million workplaces. The OSHA regulation would apply to private-sector employers everywhere and to public-sector employers in the 25 states and territories that have their own OSHA programs.75 Meanwhile, Washington will likely be the first state to have a statewide ban on smoking in workplaces. On March 16, 1994, Washington State Labor Director Mark Brown signed into law a directive to ban smoking in the workplace, effective September 1, 1994.76

The Department of Defense (DoD) is the largest employer in the United States, with nearly 3 million employees. DoD implemented a far-reaching smoke-free workplace policy in April 1994, banning smoking of tobacco products in all DoD work facilities worldwide. The policy is intended to meet three objectives: (1) to provide a safe and healthy workplace for all DoD employees, (2) to contribute to the readiness of the armed forces by maintaining healthier personnel, and (3) to be a leader in creating a smoke-free workplace.77 The leadership role of this policy will carry over to the general population to the families and friends of the military personnel, as well as to prospective recruits in the general population.

Prohibiting tobacco use in the workplace has proven to be an effective way of reinforcing society's tobacco-free norm and decreasing tobacco consumption. A study in California of the relationship between workplace smoking policies and smoking prevalence and cigarette consumption found that employees in smoke-free workplaces have a lower smoking prevalence and, among continuing smokers, lower cigarette consumption than individuals working where smoking is permitted. The researchers estimate that cigarette consumption among employees indoors is 21% below that which would occur if there were no smoking restrictions in California workplaces.78 In a recent Gallup poll, 23% of smokers reported bans on smoking in the workplace as a major reason for wanting to quit

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smoking and 21 % reported lack of locations in which to smoke as a major reason (multiple reasons were allowed in the survey question).79

As youths encounter a tobacco-free workplace norm, they will become increasingly aware that tobacco use is not an adult norm and is becoming less socially approved. They will also be cognizant of the fact that they will have to forego tobacco use in the workplace themselves. This recognition provides an important opportunity for schools and parents to help adolescents. For example, a technical institution in Minnesota implemented a smoking prevention project because women attending technical institutes often enroll in training programs for occupations with traditionally high smoking rates, at a time when no-smoking policies are increasingly being adapted in the workplace. Entitled "Smoking Doesn't Work," the program used employability as the central theme in school-wide events and classroom activities. The intervention resulted in significant increases in knowledge and awareness of smoking and employability issues; the young women had not been highly aware of the relationship between smoking status and employability.80 In a 1994 national poll, 20% of respondents said that they would be less likely to hire an applicant who is a smoker.81

Fast-Food Restaurants

Fast-food franchise restaurants estimate that as many as 25% of their customers are under the age of 18, with 10% under the age of 10. These children not only eat at the restaurants but also spend extended time there in special play areas for children, complete with jungle gyms and slides. Additionally, 40% of employees in fast-food restaurants are under age 18. In 1993, after reviewing these and other data supplied by the industry, the attorneys general of 16 states made the following observations in a preliminary report, "Fast Food, Growing Children, and Passive Smoke: A Dangerous Menu":

· The overwhelming majority of fast-food restaurants permit smoking on the premises.

· No major fast-food chain prohibits smoking altogether.

· Only 25% of customers smoke.

· Most fast-food companies would ultimately like to go smoke free.

· Most companies would prefer to wait until legislative smoking bans are in place before mandating a smoke-free policy for their customers.

· The companies would not oppose legislation to ban smoking in restaurants.

· The companies are concerned that they would lose business if they implemented a smoke-free policy before their competitors.82

In the report, the attorneys general requested fast-food establishments to enact smoke-free policies, recommending specific steps of a staged implementation plan.

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A number of fast-food chains responded quickly to the appeal. In March 1994, Taco Bell banned smoking in all of its 3,300 company-owned restaurants, and expects its 1,000 franchise stores will also go smoke free. The company said its decision was based, in part, on a year-long customer survey which found that 70% of smokers and 84% of nonsmokers found smoking in fast-food restaurants to be offensive.83 As of March 1994, one-third of the members of the National Council of Chain Restaurants had banned smoking, and the council endorsed a proposed federal bill that would ban smoking in restaurants.

Though fast-food companies are inclined to go smoke free, apparently a concern holding them back is that of diminished sales, a concern that is unwarranted. Although smoking customers had reported that they would not frequent the restaurants, several studies have shown that restaurants do not suffer loss of sales when they go smoke free. For example, a recent study found that the first 13 U.S. cities (10 in California, 3 in Colorado) to ban smoking in restaurants are not losing customers or sending money to neighboring communities that allow diners to smoke, countering the claim of the tobacco industry and other opponents of smoke-free ordinances that such bans have caused up to a 30% dip in restaurant business.84

Shopping Malls

Popular places for adolescents to congregate are shopping malls; adolescents congregate in the open areas, arcades, food court areas, and movie theaters. Malls are areas in which youths can socialize, entertain themselves, and pass time in an unsupervised setting. The circumstances are conducive to tobacco use both by the youths and adults in the malls. One of the first counties to prohibit smoking in enclosed private malls was Howard County, Maryland in 1992. Since then many malls across the country have enacted smoke-free policies. Maine, New York, and Washington include shopping centers in their legislation for clean indoor air. One of the largest malls in Virginia (home to Philip Morris) went smoke free on April 4, 1994. The manager of Potomac Mills Mall stated the following reason:

We value all of our customers and employees, including those who choose to smoke. However, Potomac Mills must do everything possible to maintain the healthiest environment possible for our visitors and employees.85

Tobacco-use restrictions in malls are important not only because they reinforce the smoke- free norm in an adult environment but also because they considerably diminish the opportunity for tobacco use.

Sports Facilities

Sports, both participatory and spectator sports, are a favorite pastime of

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youths. Sports stars are heroes and role models for youths. The arena of sports offers three distinct opportunities to promote a tobacco-free norm. First, one's physiologic performance while participating sports is diminished by tobacco use. By recognizing that participation in sports can be a receptive learning moment for an adolescent, peers, parents, and coaches could have an important influence on a youth who is active in sports. Second, many youths imitate the behavior of sports stars, including the use of spitting tobacco and cigarettes. In 1993, professional baseball minor-league teams adopted a total ban on smoking or chewing by all players, coaches, and umpires anywhere in the ballparks. Third, two-thirds of major-league stadiums have voluntarily eliminated smoking from their seating areas; 18 stadiums have eliminated tobacco advertising. At least half of the 50 states restrict smoking in gymnasiums and arenas as part of their clean indoor air legislation.86 A Current Population Survey survey of youths asked if they thought that smoking should be allowed in indoor sporting events; 65% replied "not at all," and 28.6% replied "to allow in some areas."87

Community and Youth Organizations

One of the highest rates of tobacco use is among youths who have dropped out of high school; they are of course the least likely group to be reached through school programs. It might be possible to reach some of these youths through their communities, that is, through organizations or events sponsored by community groups. Youths who remain in school may be likely to participate in organizations for youths. Thus, community groups and youth organizations provide an important means of promoting the tobacco-free norm to youths at all risk levels and of providing alternative behaviors to tobacco use through organizational activities that allow youths to have a sense of belonging and to be relaxed among their peers. Organizations can also provide opportunities for youths to become active in promoting the tobacco-free norm to their peers.

Organizations have begun to recognize their potential for preventing tobacco use by children and youths and a number of them have begun to affiliate in order to enhance their resources and effect. For example, a national alliance of organizations that serve youths or have youth memberships, the Coalition for America's Children, was founded in 1991 "to promote health, education, safety, and security for all American children" by increasing public awareness of children's issues through member organizations and by providing materials and technical assistance to member organizations. In 1993-1994, the Coalition adopted prevention of tobacco use by children as a major issue. The Institute of Medicine collaborated with the Coalition to conduct a survey of the Coalition's member organizations to determine their level of involvement in tobacco control issues and the level of interest in becoming more involved. The results indicate that while there is some interest and activity in tobacco issues, organizations that serve children are not fully aware of the seriousness of the issues. For example,

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66% of the responding organizations have a formal policy on tobacco use that is enforced; an effort is made to prevent the use of tobacco by staff in 47% of the organizations and by the general public in 28%; however, only a few provide assistance for tobacco cessation. Sixty-three percent of the respondents felt that tobacco use by children was less important than other issues in which their organizations were involved; another 34% felt the issue was of about the same importance. (Note that staff size, minimal funds, and specificity of mission may be factors influencing their thinking and activities.) Nevertheless, 81% indicated that they would be very likely or somewhat likely to distribute information on tobacco issues to members, and 77% indicated that they would be very likely or somewhat likely to incorporate tobacco into their health materials. According to 68% of the respondents, public awareness in their community of the issues surrounding children's use of tobacco is less than that for other children's issues; 45% feel that there is little or no media coverage devoted to this topic.

The Join Together Project, funded by the Robert Wood Johnson Foundation, is a national resource for information and technical assistance to coalitions of community organizations that combat tobacco, alcohol, and other drug abuse. In 1993 Join Together surveyed 12,000 collaborative agencies nationwide, soliciting information on how their coalitions are organized and what they do.88 Of the 5,475 responding agencies, 2,196 are lead agencies or sponsoring agencies of coalitions or organizations. Of this subset, 23% (779) reported having extensive programs on tobacco prevention, and some were considering expanding their activities. Most of those agencies are attempting to reach high-risk populations, such as pregnant teens, juvenile offenders, and dropouts, as well as the general youth populations. They focus on the community environment as opposed to needs of individuals, and on system-wide change rather than on specific areas. Among the policy barriers most frequently identified by the agencies was the need to break down barriers that exist between organizations and governments.

The community coalitions are broad-based collections of public and private agencies and many volunteers, and most have either equal participation by professionals, government officials, and lay people or are led mostly by lay people. Local police and schools are represented in a high percentage of the coalitions; however, participation should be broadened in two respects. Local recreation departments, where youths may spend time after school and on weekends, are active in less than one-third of all substance abuse coalitions. The mass media were reported to be active in less than one-half (41%) of the community coalitions, even though they can be influential in helping set the tone for a community's approach to substance abuse.

ADVOCACY FOR A TOBACCO-FREE NORM

Many organizations and coalitions have taken on advocacy roles, promoting a tobacco-free norm. For example, some religions have begun to

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unite in their efforts to prevent tobacco use by youths. The Interreligious Coalition on Smoking OR Health represents 15 religious organizations. In supporting tobacco control initiatives, the coalition holds that there is "an obligation to preserve the quality of human life" and "a moral obligation to protect the vulnerable, such as the young."89 Similarly, the Union of American Hebrew Congregations adopted a resolution in 1987 to promote tobacco control. The resolution includes implementing tobacco education for youths and enacting smoke-free policies in public places.90 Churches and church-affiliated activities and organizations are important norm-setting sources of influence on children and youths.

Coalitions have also been established through government-supported tobacco control initiatives. State and local coalitions support policy change on a large-scale basis by involving communities. Staffed by state and local government health officials, these coalitions are composed of a spectrum of organizations and individuals concerned with tobacco control. Examples are regional coalitions such as the Rocky Mountain Tobacco-Free Challenge, the Tobacco-Free Heartland Coalition, and the National Cancer Institute's American Stop Smoking Intervention Project (ASSIST). ASSIST, which is conducted in partnership with the American Cancer Society, provides funding to 17 states to support community-based tobacco control interventions. The $150 million project, to be implemented from  1993 to 1998, aims to reduce tobacco use through policy interventions and media advocacy mobilized by statewide and local coalitions. Youths are a priority prevention group in the ASSIST effort. The 17 states are Colorado, Indiana, Maine, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, North Carolina, Rhode Island, South Carolina, Virginia, Washington, West Virginia, and Wisconsin.

A state-initiated and state-supported program resulted from California's Proposition 99. In 1988, California voters approved Proposition 99, an excise tax on tobacco products that earmarked 20% of the revenue to support tobacco control efforts. Enabling legislation provided funding of approximately $14 million in 1990-1991 and $79 million in 1991-1992. As a major component of the tobacco control program, the state health department funds 61 local coalitions supported by local health departments, 10 regional coalitions staffed by administrative agencies, and 4 ethnic networks.91

Other combined local and national efforts are being implemented by voluntary health organizations and by health and health professionals' organizations. For example, tobacco control is an important issue for the American Heart Association, the American Cancer Association, and the American Lung Association. These organizations, which traditionally have focused on public education and research, are increasingly pursuing public policy initiatives to tobacco control.

Health and health professionals' organizations, at national, state, and local levels are drawing on their memberships to support policy efforts. These include organizations such as the American Medical Association, American Public Health Association, American Medical Women's Association, American Acad-

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emy of Family Physicians, American Dental Association, American Association of Occupational Health Nurses, and Doctors Ought to Care (DOC). The American Medical Association (AMA) took a major step into the realm of tobacco control advocacy when it sponsored the Tobacco Use in America Conference in 1989, which brought together tobacco control advocates and members of Congress. The 100 invited conference participants formed workgroups around major tobacco control policy issue areas and developed recommendations.92 In 1993, the AMA sponsored a second conference, again promoting collaboration among legislators and advocates and producing a series of recommendations. Special tobacco editions of the Journal of the American Medical Association are important sources of research and draw media attention to tobacco issues. The AMA serves as the administrative agency for the $10 million Robert Wood Johnson Foundation SmokeLess States program. This program will support statewide coalitions to reduce tobacco uptake and use and increase public awareness of the role of tobacco control policy in health care reform.

Supporting organizations are not frontline advocacy groups themselves, but support the efforts and coordinate advocacy groups. At the national level, the Advocacy Institute's Smoking Control Advocacy Resource Center (SCARC) plays a unique role by bringing together disparate parts of the tobacco control movement. Its electronic communications network, SCARCNet, provides advocates with timely, concise strategic resources and offers them the opportunity to confer about strategic questions and share advocacy successes and failures. Over 400 U.S.-based advocates representing all areas of tobacco control have joined the network, and hundreds more receive periodic mailings updating them on tobacco control strategies. Other organizations have taken frontline positions as advocates of tobacco control, for example ANR, ASH, and GASP.

Foundations and others have also increased funding for advocacy activities. The Robert Wood Johnson Foundation (RWJ) now plays the leading foundation role in supporting these efforts. RWJ funded the Tobacco Policy Research Project in 1991, which brought together committees of researchers and experts in tobacco control policy to assess research needs; the committee reports were published as a supplement to the journal Tobacco Control. Following this project, RWJ launched a 4-year, $5 million program to support policy-related research. Most recently, RWJ launched its SmokeLess States initiative, a 4-year, $10 million program to support up to 18 statewide coalitions. Grantees will implement comprehensive tobacco control programs including education, treatment, and policy initiatives.

All tobacco control policies, either directly or indirectly, affect youths. To that extent, the range of groups described above all address issues concerning youths. For many, however, their youth-focused activities are not primary. A few groups do focus on youths in particular, including the following. Stop Teenage Addiction to Tobacco (STAT) focuses primarily on the issue of tobacco and youth. STAT advocates directly for policy changes at the federal, state, and

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local levels  In 1989 STAT began hosting an annual conference focused on advocacy activities around youth tobacco use; at the 1993 conference, attendees included approximately 100 youths who participated in a separate youth track. Through a 3-year, $1 million grant from the Robert Wood Johnson Foundation, STAT also funds four youth-involved local initiatives to reduce youth tobacco use prevalence. Smokefree Educational Services (SES), a relatively small-scale organization with an all-volunteer staff, has scored many policy victories in New York City. SES works with hundreds of youths on youth-focused advocacy efforts and disseminates information on its efforts and other important issues to over 13,000 advocates nationally through its newsletter. The North Bay Health Resources Center's STAMP (Stop Tobacco Access for Minors Project), funded through Proposition 99, distributes signs to stores regarding youth access in a 6-county (approximately 40-city) region of Northern California.

Across the nation, youths themselves are becoming involved and carrying the issue forward. Involving youths in working on tobacco control efforts has been a way to empower them and to increase youth awareness of tobacco issues. For example, the Gold Country, a 13-county region in California, has active youth coalitions in each county and holds an annual youth summit that provides advocacy training. Additionally, many statewide and local coalitions such as those established for ASSIST and California have youth representatives. Youths are involved in all phases of advocacy, including documenting the problem in the community, developing strategies for addressing the problem, and presenting their ideas to the community, media, and policymakers. Youths who have been willing to speak out for their own concerns have inspired respect for their cause. For example, testimony before the city council by teens from San Jose STAT proved important in convincing the San Jose City Council to implement a vending machine ban.93

While youths have been central in these efforts, until recently they have only been part of organizations run and funded by adults, and their numbers are small compared to SADD and other anti-drug efforts. At the 1993 annual STAT conference, a group of 20-30 youths from across the country decided that it was time to establish an organization created and run by youths. They formed their own organization—Students Coalition Against Tobacco (SCAT)—which aims to establish nationwide chapters that will focus on peer education as well as advocacy efforts. SCAT's young chairperson has expressed the need for youth involvement as follows:

The next step must be to create school based clubs, following the model of SADD, that will advocate for social change on the level where the problem is originating. We must empower young people to work within their domain—the school system. These teens can conduct peer educational programs and work to enhance comprehensive health educational programs. The mere presence and advertisement of such a group will bring an awareness to students of the issues. Young people know where the problems lie and upon mobilization can enact

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change more rapidly than any organization acting on behalf of young people. It will be the job of these young people to target their peers for a smoke-free lifestyle before the industry ... can get to them.94

In summary, there has been an initiation of community activity supporting tobacco control policies. The efforts of community organizations, coalitions, and advocacy groups have been successful in establishing hundreds of ordinances that seek to improve the public health through a tobacco-free norm. In the process, the public has become somewhat more aware of the problems of tobacco and more supportive of tobacco control efforts. Those activities are an important beginning because they demonstrate that the public will support tobacco control measures and that youths are responsive to helping set the tobacco control agenda. However, the efforts to date are not sufficient in themselves to counter the pro-tobacco messages in our culture and to correct the misperception of the level of tobacco use. Community organizations and coalitions are potentially the most effective means of accomplishing those objectives, but they need support to broaden their bases.

REINFORCING THE TOBACCO-FREE NORM: CONCLUSIONS AND RECOMMENDATIONS

We must not become complacent about the downward trend of smoking prevalence during the past two decades. To the contrary, the public should be concerned about the fact that prevalence has leveled off and that there was a slight increase in youth smoking in 1993. Renewed efforts are required to once again start the downward trend and to prevent youths from ever initiating tobacco use.

The forces influencing tobacco use originate well beyond a youth's immediate personal environment of family and peers; youths encounter pro-tobacco messages everywhere and repeatedly in the social environment. Therefore, countermeasures should be actively undertaken to promote a tobacco-free norm. The Committee recommends that:

1. Public education programs and messages should be increased and implemented on a continuous basis to (a) inform the public about the hazards of tobacco use and of environmental tobacco smoke and (b) promote a tobacco-free environment. In particular, mass media campaigns, including paid counter-tobacco advertisements, should be intensified to reverse the image appeal of pro-tobacco messages, especially those that appeal to children and youths.

2. Tobacco-free policies should be adopted and enforced in all public locations, especially in those that cater to or are frequented by children and youths, including all educational institutions, sports arenas, cultural facilities, shopping malls, fast-food restaurants, and transit systems.

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3. All levels of government should adopt tobacco-free policies in public buildings. The Department of Defense should continue its aggressive efforts to adopt tobacco-free policies in all military services.

4. All workplaces should adopt tobacco-free policies.

5. All organizations involved with youths should adopt tobacco-free policies that apply to all persons attending or participating in all events sponsored by the organizations, and should actively promote a tobacco-free norm.

6. Parents should clearly and unequivocally express disapproval of tobacco use to their children, and, if smokers themselves, should quit smoking.

To advance understanding of how best to promote a tobacco-free social norm, the Committee recommends that the following research approaches be undertaken:

7. Research should be conducted to determine the factors influencing the substantial decline in tobacco use by African-American youths, with particular attention to the role of social norms.

8. Youths should be involved in the development of research questions and approaches and in designing and evaluating health messages and programs.

REFERENCES

1. U.S. Department of Health, Education, and Welfare. Smoking and Health. A Report of the Surgeon General, 1979. DHEW  Pub. No. (PHS) 79-50066. Rockville, MD: Office on Smoking and Health. 16-5, 6.

2. Crocket, Lisa J., and Anne C. Petersen. ''Adolescent Development: Health Risks and Opportunities for Health Promotion." In Millstein, Susan, Anne C. Petersen, and Elena O. Nightingale, eds. Promoting the Health of Adolescents: New Directions for the Twenty-first Century. New York: Oxford University Press, 1993. 13.

3. Hurrelmann, Klaus. "Adolescents as Productive Processors of Reality: Methodological Perspectives." In Hurrelmann, K., and U. Engel, eds. The Social World of Adolescents: International Perspectives. Berlin: Walter de Gruyter, 1989.

4. Kandel, D. B. "Processes of Peer Influences in Adolescence." In Silbereisen, R. K., K. Eyferth, and G. Rudinger, eds. Development as Action in Context.. Berlin: Springer-Verlag, 1986. 203-227; Lerner, R., M. Karson, M. Meisels, and J. R. Knapp. "Actual and Perceived Attitudes of Late Adolescents: The Phenomenon of the Generation Gap." Journal of Genetic Psychology 126 (1975): 197-207.

5. Leventhal, Howard, and Patricia Keeshan. "Promoting Healthy Alternatives to Substance Abuse." In Millstein, Susan, Anne C. Petersen, and Elena O. Nightingale, eds. Promoting the Health of Adolescents: New Directions for the Twenty-first Century. New York: Oxford University Press, 1993. 260-284.

6. Jessor, Richard, and S. L. Jessor. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York: Academic Press, 1977.

7. Centers for Disease Control. "Cigarette Smoking Among Adults-United States, 1992." Morbidity and Mortality Weekly Report 43:19 (20 May 1994): 342-346.

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8. Bray, Robert M., L. A. Kroutil, J. W. Luckey, S. C. Wheeless, V. G. Iannacchione. D. W. Anderson, M. E. Marsden, and G. H. Dunteman. Highlights: 1992 Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel. RTI/5154/06-17FR. Research Triangle Institute, December 1992. 45.

9. Johnston, Lloyd, P. O'Malley, and J. Bachman. "Monitoring the Future Study." Press release. The University of Michigan, Ann Arbor. January 27, 1994.

10. SmithKline Beecham. Gallup Report: A National Survey of Americans Who Smoke. New York, 1993.

11. Manning, Anita. "Poll Shows More Back Smoking Ban." USA Today (16 Mar. 1994): Dl; and Nichter, Mark, Mimi Nichter, C. Ritenbaugh, and N. Vuckovic. "The Teen Lifestyle Project: Preliminary Report, 1994." University of Arizona, Dept. of Anthropology. Unpublished data.

12. Allen, Karen, A. Moss, G. A. Giovino, D. R. Shopland, and J. P. Pierce. "Teenage Tobacco Use: Data Estimates From the Teenage Attitudes and Practices Survey, United States, 1989." Advance Data 224 (I Feb. 1993): 9.

13. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People. A Report of the Surgeon General, 1994. S/N 017-001-004901-0. Washington, DC: U.S. Department of Health and Human Services, 1994. 78.

14. Johnston, Lloyd D., P. M. O'Malley, and J. G. Bachman. National Survey Results on Drug Use from Monitoring the Future Study, 1975-1992; Vol. II. NIH Pub. No. 93-3598.  Washington, DC: National Institute on Drug Abuse, 1993. 15-17.

15. Ibid., 15.

16. Schinke, Steven P., Robert F. Shilling, Lewayne D. Gilchrist, Marianne R. Ashby, and E. Kitajima. "Native Youth and Smokeless Tobacco: Prevalence Rates, Gender Differences, and Descriptive Characteristics." NCI Monograph 8: Smokeless Tobacco Use in the United States. NIH Pub. No. 89-3055. (1989): 39-42.

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18. Schinke et al., 1989.

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37. Ibid., 48.

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