Health Education Research, Vol. 14, No. 6, 751-763,
December 1999
© 1999 Oxford University Press
Attitudes toward anti-tobacco policy among California youth: associations with smoking status, psychosocial variables and advocacy actions
Institute for Health Promotion and Disease Prevention Research, University of Southern California School of Medicine, 1540 Alcazar Street, CHP 207, Los Angeles,CA 90033, and
1 Stanford Center for Research in Disease Prevention, Stanford University School of Medicine,Palo Alto, CA 94304, USA
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionReferences |
|---|
To prevent smoking and exposure to environmental tobacco smoke, California has implemented anti-tobacco policies, including laws restricting youth access to tobacco, and smoking bans in workplaces, schools, restaurants and bars. Although studies have examined adults' attitudes toward anti-tobacco policies, little is known about adolescents' awareness of and support for these policies. This study examined attitudes toward anti-tobacco policies in a sample of 6887 10th grade California adolescents. Awareness of anti-tobacco policies was highest among current smokers and lowest among susceptible never-smokers. Support for anti-tobacco policies was highest among non-susceptible never-smokers and lowest among current smokers. Policy awareness and support were significantly associated with psychosocial tobacco-related variables (e.g. perceived consequences of smoking, friends' smoking, perceived access to cigarettes, prevalence estimates of smoking among peers, cigarette offers and cigarette refusal self-efficacy). Policy awareness and support were associated with the probability of performing advocacy actions against tobacco use. Although these results cannot prove a causal association, they suggest that adolescents' attitudes toward anti-tobacco policies may play a role in their decisions about smoking. Tobacco control and education programs should include information about existing anti-tobacco policies, and should educate youth about the importance and benefits of anti-tobacco policies.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Tobacco use is the leading preventable cause of premature morbidity and mortality in the US. In 1984, tobacco use was associated with 320 515 deaths, representing 15.7% of all deaths and 8.1% of all years of productive life lost during that year (Morbidity and Mortality Weekly Report, 1997). Although adult smoking rates have declined in recent years, smoking among adolescents has not (Centers for Disease Control and Prevention, 1994
; Gilpin et al., 1994). Among high school students in the US in 1995, 71% reported having experimented with cigarettes and 25% reported having smoked a whole cigarette before age 13 (Kann et al., 1996). The high prevalence of smoking among youth suggests a need for more effective interventions to prevent children and adolescents from experimenting with cigarettes.
To prevent adolescents from acquiring and using tobacco, many states and cities have implemented laws restricting tobacco sales to youth, tobacco advertising and marketing, and smoking in public areas (Centers for Disease Control and Prevention, 1995, 1996). These include minimum ages for tobacco purchase, laws banning minors from possessing or using tobacco products, restrictions or bans on cigarette vending machines, laws requiring merchants to post signs about the sale of cigarettes to minors, laws requiring merchants to be licensed to sell tobacco, and restrictions on smoking in worksites, public buildings and restaurants. The FDA recently began to regulate tobacco products, and has passed regulations prohibiting the sale of tobacco products to minors, the sale of single cigarettes or partial packs of cigarettes, and the placement of cigarette vending machines and self-service displays in areas where youth can access them (Department of Health and Human Services, 1996). The implementation of these regulations, however, has been delayed by legal challenges.
Research suggests that implementation of anti-tobacco policies may result in lower rates of smoking among adolescents. In a Minnesota study (Forster et al., 1998; Wolfson et al., 1998), communities were randomized either to a community organizing effort designed to establish anti-tobacco policies or to a control condition. All communities randomly assigned to the community organizing condition passed comprehensive ordinances to limit youth access to tobacco. These ordinances led to a 5% lower rate of adolescent daily smoking, a 6% lower rate of weekly smoking and a 7% lower rate of monthly smoking, relative to the control communities. In correlational studies, restrictions on smoking in public places are associated with lower rates of smoking among community-wide samples of 18- to 24-year-olds (Chaloupka and Wechsler, 1997) and anti-tobacco policies on college campuses are associated with lower rates of smoking among students (Apel et al., 1997). In a study of 23 California middle/junior high schools, Pentz et al. (Pentz et al., 1989) examined four components of school anti-tobacco policies: prohibition of smoking on school grounds, prohibition of smoking near school grounds, closed campus (a rule against students leaving campus) and formal education plans for smoking prevention programming. Schools with policies including all four components, as well as a high emphasis on prevention and low emphasis on cessation, showed the lowest rates of student smoking.
Anti-tobacco policies may influence adolescent smoking in several ways. First, the restrictions on locations where smoking is allowed and restrictions on cigarette sales to minors may make it more difficult for adolescents to obtain and smoke cigarettes. If adolescents encounter increased barriers when they attempt to purchase cigarettes and if they are prevented from smoking in the areas where they wish to congregate, they may be deterred from smoking. In addition, the implementation of anti-tobacco policies may establish a social norm that smoking, tobacco sales to minors and tobacco marketing tactics targeted toward youth are unacceptable (Centers for Disease Control and Prevention, 1995; Pentz et al., 1997). This also may lead to lower rates of smoking among adolescents.
Unfortunately, anti-tobacco policies also may cause resentment and reactance. Adolescent smokers may believe that these policies limit their individual freedom and autonomy (Jeffery et al., 1990), and they may resent government intrusions into what they perceive to be their personal right to smoke. Reactance theory (Brehm and Brehm, 1981) predicts that a behavioral option will become more attractive if it is prohibited. Adolescents may perceive restrictive anti-tobacco policies as a threat to their freedom and they may smoke to reassert their personal autonomy. In addition, adolescents may perceive that if policies are necessary to prevent adolescents from smoking, smoking must be an enjoyable, rebellious, exciting and attractive behavior; this expectancy may increase their desire to smoke. If this is the case, anti-tobacco policies may have the unintended consequences of motivating smokers to smoke more and encouraging non-smokers to experiment with smoking. In support of this notion, a study of alcohol use among college students (Engs and Hanson, 1989) found that alcohol use was more prevalent among students under 21 years of age, for whom drinking was illegal, than among students 21 years of age or older. This indicates that the act of making a behavior illegal may make it more attractive.
To understand the effects of anti-tobacco policy on adolescent smoking, it is important to understand adolescents' attitudes toward anti-tobacco policies, as well as the associations between these attitudes and behavioral outcomes. To our knowledge, no studies have focused on adolescents' attitudes toward anti-tobacco policies. Several studies have assessed attitudes toward anti-tobacco policies among adults. A 1993 study of attitudes toward anti-tobacco policies in eight states (Centers for Disease Control and Prevention, 1994) found that the majority of adults supported bans or restrictions on smoking in fast-food restaurants, sit-down restaurants, indoor malls and indoor sporting events. In addition, most adults believed that strategies such as banning smoking in schools, removing cigarette vending machines, banning cigarette advertising, increasing the price of cigarettes and strongly enforcing anti-tobacco laws would be effective in reducing smoking among adolescents. In another study (Marcus et al., 1994), over 80% of the respondents believed that stronger laws should be enacted to prevent the sale of tobacco products to minors and that existing laws banning the sale of tobacco to minors should be better enforced. Over half of the respondents supported bans on cigarette vending machines, cigarette advertising in print media and billboards, distribution of free tobacco samples, and tobacco company sponsorship of sporting events.
Public opinion recently has become more favorable toward smoking restrictions. Two Ontario studies of changes in policy attitudes between 1983 and 1991 (Pederson et al., 1992; Bull et al., 1994) found that support for restrictions on smoking, restrictions on tobacco sales, restrictions on tobacco advertising, higher cigarette taxes, differential insurance rates for smokers and strict enforcement of anti-tobacco policies increased during this period.
Research also suggests that adult smokers and non-smokers differ in their attitudes toward anti-tobacco policies. In a study of adults in four states (Marcus et al., 1994), current smokers were less likely than former/never-smokers to support vending machine bans, smoking bans on airlines and extra tobacco taxes. A longitudinal study (Bull et al., 1994) found that increases in support for smoking restrictions from 1983 to 1991 were much greater in non-smokers than in smokers.
Surprisingly, adolescents' attitudes toward these policies are largely unknown. One may question the rationale for studying adolescents' attitudes toward anti-smoking policies. Adolescents do not vote for or against policies and they are not responsible for enforcing policies. Therefore, it might be argued that adolescents' opinions about anti-tobacco policies are irrelevant. However, adolescents are not merely passive targets of anti-tobacco legislation. Adolescents influence one another's smoking behavior through peer influence and social norms (Collins et al., 1987). If youth understand the rationale for these policies and support their implementation, they may be more likely to obey the policies, to encourage their peers to follow the policies and to report infractions of the policies. This may lead to lower smoking rates among adolescents. In addition, adolescents can engage in advocacy actions, such as writing letters to government officials to encourage policy development or enforcement, helping police to conduct `stings' against merchants who sell tobacco to minors, talking to store owners about selling tobacco to minors, reporting infractions of anti-smoking policies and asking others not to smoke. Alternatively, if adolescents perceive anti-tobacco policies as too repressive, they may rebel against these policies and use tobacco as a means of asserting their independence (Jeffery et al., 1990).
For these reasons, it is important to understand how adolescents perceive the anti-tobacco policies that are increasingly being imposed on them. Several key questions remain unanswered. First, to what extent are adolescents aware of anti-tobacco policies and to what extent do they support them? Second, do awareness of and support for anti-tobacco policies vary by adolescents' smoking status? Third, are awareness of and support for anti-tobacco policies associated with psychosocial variables, such as perceived consequences of smoking, perceived prevalence and acceptability of smoking, perceived access to cigarettes or cigarette refusal self-efficacy? Fourth, are awareness of and support for anti-tobacco policies associated with the probability of performing advocacy actions against tobacco use, such as asking others not to smoke or contacting government officials about tobacco-related issues?
This study examined awareness of anti-tobacco policies and support for anti-tobacco policies among 10th grade youth in California, using data collected for an independent evaluation of the California Tobacco Control Prevention and Education Program. We hypothesized that (1) awareness of and support for anti-tobacco policies among adolescents would vary according to their smoking status, (2) policy awareness and support would be significantly associated with tobacco-related psychosocial variables, and (3) awareness of and support for anti-tobacco policies would be associated with the probability that adolescents would perform advocacy actions aimed at reducing tobacco use.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
This study used data from a representative sample of 10th grade California youth (N = 6887). The data were collected in 65 schools in 18 California counties and the sample has been weighted to represent the population of California youth enrolled in public schools. The data were collected during the 1996–1997 school year as part of an Independent Evaluation of the California Tobacco Control Prevention and Education Program (Independent Evaluation Consortium, 1998
). As part of the Independent Evaluation, school districts were selected randomly within each of 18 California counties, schools were selected randomly within districts and classrooms of students were selected randomly within schools. Because the surveys were anonymous, the Institutional Review Board approved an implied consent procedure (students were assumed to have parental consent if their parents did not return a signed form declining their children permission to participate). Even if their parents did not decline participation, students were free to decline participation. Of the students in the selected classrooms, 96% provided parental and student consent in this manner; these 6887 students comprise the sample. Students were surveyed in their classrooms by trained data collectors who explained the purpose of the study, the anonymity of the questionnaire and the students' right to decline participation.
Measures
Smoking status
Students were classified either as never-smokers, susceptible non-smokers, experimenters, current smokers or quitters. Never-smokers were students who met the following three criteria: (1) had never tried smoking, (2) would `definitely not' smoke a cigarette if it were offered by a best friend and (3) would `definitely not' smoke a cigarette in the next year. Susceptible non-smokers are those adolescents who have not yet smoked but who do not express a firm commitment not to smoke in the future. Susceptibility represents a cognitive shift in favor of smoking that precedes actual experimentation and it has been shown to be an important first step in the initiation of smoking behavior among adolescents (Pierce et al., 1996; Unger et al., 1997). Students were classified as susceptible if they had never tried a cigarette but indicated a possibility of either accepting a cigarette from a best friend or smoking in the next year. Experimenters were students who had tried smoking but had not smoked at least 100 cigarettes. Current smokers were students who had smoked at least 100 cigarettes and had smoked in the past month. Quitters were students who had smoked at least 100 cigarettes but had not smoked in the past 30 days.
Attitudes toward anti-tobacco policy
Awareness of anti-tobacco policy was assessed with 12 items assessing adolescents' awareness of the following policies: school no-smoking policies, school bans on clothing/products with tobacco names/logos, police stings to catch merchants who sell cigarettes to youth, fines for minors who attempt to purchase cigarettes, removal of cigarette vending machines, limitations on tobacco advertising on billboards, buses, bus shelters and stores, restaurant smoking bans, and fines for restaurant owners who permit smoking. Some of these policies have been implemented statewide in California and others have been implemented in selected counties or cities. Although some of the respondents lived in areas where not all of these policies had been implemented, the respondents may have been exposed to information about these policies through the media (which crosses city and county boundaries) and by traveling to other cities or counties within California. Therefore, all of these policies were included in the policy awareness scale and county of residence was included as a covariate to control for between-county differences in anti-tobacco policies. The Cronbach's 
of this scale was 0.66.
Support for anti-tobacco policy was assessed with six items assessing adolescents' support for the following policies: expulsion of youth caught smoking cigarettes at school, strong enforcement of laws preventing cigarette sales to minors, fines imposed on youth caught buying cigarettes, school bans on clothing/products with tobacco company names/logos, bans on tobacco advertising in places where youth will see it, fines imposed on restaurant owners who permit smoking and the age that tobacco purchase should be legal. Similar to the policy awareness scale, policies were included in the policy support scale even if they were not currently in effect in all counties, because adolescents could form opinions about these policies regardless of whether the policies currently were in effect. The Cronbach's of this scale was 0.79.
Covariates
The demographic variables included as covariates were age, gender, ethnicity, acculturation, grades in school and county. Age was coded in years. Gender was a dichotomous variable. Ethnicity was measured with an item that listed 13 ethnic categories and allowed respondents to check all that applied. Some respondents reported membership in more than one ethnic group. Dichotomous variables were created to indicate membership in the following groups, with white as the reference group: African-American, Latino/Hispanic and Asian-American. Respondents received a code of `1' for each ethnic group they checked on the questionnaire and a code of `0' for each ethnic group they did not check. Acculturation was measured with a single item that asked what language the respondent spoke at home. Responses were rated on a five-point scale ranging from `only English' to `only another language'. Grades in school were assessed with an item that asked, `What grades did you get in school last year?'. Responses were rated on a nine-point scale ranging from `mostly As' to `mostly Fs'. Because policy implementation, enforcement and publicity differed across counties, county of residence was included as a covariate.
Psychosocial smoking-related variables
Perceived access to cigarettes was assessed with an item that asked, `Do you think it would be easy or hard for you to get cigarettes if you wanted some?'. This item was rated on a four-point scale ranging from `very easy' to `very hard'. Perceived positive consequences of smoking were assessed with five questions that asked whether smoking makes young people more grown-up, more relaxed, have more friends, look cool and keep their weight down. These items were rated on a four-point scale ranging from `yes, definitely' to `no'. The Cronbach's of this scale was 0.70. Perceived negative consequences of smoking were assessed with five items that asked whether smoking makes teeth yellow, causes one to lose friends who do not smoke, makes people smell bad, shortens life and reduces energy, and an item asking whether breathing second-hand smoke is bad for health. These items were rated on a four-point scale ranging from `yes, definitely' to `no'. The Cronbach's of this scale was 0.77. Prevalence estimates of smoking among peers were assessed with an item that asked, `Out of every 100 students your age, how many do you think smoke cigarettes once a month or more?'. Responses were rated on a 11-point scale ranging from `none of them' to `about 100'. Best friends' smoking was assessed with an item that asked, `How many of your best friends smoke cigarettes?'. Responses were rated on a four-point scale ranging from `none' to `a lot'. Cigarette offers were assessed with an item that asked, `During the last month (30 days), how many times have you been offered a cigarette?'. Responses were rated on a five-point scale ranging from `none' to `5 or more times'. Cigarette refusal self-efficacy was measured with an item that asked, `If your best friend offered you a cigarette and you did not want it, how easy or hard would it be to say `no'?'. Responses were rated on a four-point scale ranging from `very easy' to `very hard'.
Advocacy actions
The following advocacy actions were included: asking someone not to smoke, signing a petition about reducing tobacco use, attending a press conference about reducing tobacco use, talking to a store employee about not advertising cigarettes or selling tobacco to minors, contacting government officials or news reporters about reducing tobacco use, attending youth summits or conferences about reducing tobacco use and helping police to see if stores were selling cigarettes to youth. Respondents were asked which of these they had done in the past year.
Analysis
Analysis of variance (ANOVA) models were used to test for significant differences in policy attitudes among the five smoking status groups. All analyses were controlled for the covariates and psychosocial variables listed above, and least-squares means were computed.
To create summary measures of awareness of policy and support for policy, the individual items measuring these constructs were standardized and averaged together. ANOVA models were then used to test for significant differences in these summary measures among the five smoking status groups, controlling for the covariates and psychosocial variables. Next, multiple regression models were used to determine whether the psychosocial variables were significantly associated with policy awareness and support, controlling for the covariates. Finally, logistic regression models were used to determine whether the summary measures of policy awareness and support were significantly associated with the probability of performing anti-smoking advocacy actions. The logistic models were controlled for the covariates and psychosocial variables.
The data used in this analysis were collected using a multilevel sampling process (students nested within classrooms nested within schools nested within districts nested within counties). This sampling design may result in intraclass correlations that can decrease the standard errors of parameter estimates and therefore overestimate the statistical significance of these parameter estimates. Therefore, the MIXED procedure in SAS was used to include these grouping variables as random effects, as described by Singer (1998).
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Table I
shows the demographic characteristics of the sample by smoking status. Most of the respondents were 15 (70%) or 16 (25%) years of age and approximately half (49%) were female. Nearly half (48%) of the respondents identified themselves as Caucasian, 27% as Latino, 21% as Asian-American, 7% as African-American, 5% as Native-American and 5% as another ethnicity. (The sum of these percentages is greater than 100% because some respondents identified with more than one ethnic group.)
|
Figures 1 and 2
show the students' scores on the summary measures of policy awareness and support, according to their smoking status. These scores are controlled for the covariates listed above. Smokers showed the highest levels of awareness of anti-tobacco policies and susceptible students showed the lowest levels of awareness (Figure 1). Never-smokers showed the highest levels of support of anti-tobacco policies and smokers showed the lowest levels of support (Figure 2).
|
|
Table II
shows the adolescents' awareness of and support for anti-tobacco policies, stratified by their smoking status and adjusted for the covariates. For the majority of the policy awareness questions (seven out of 12), current smokers were more aware of anti-tobacco policies compared to adolescents in other groups. For the majority of the policy support questions (four out of five), never-smokers showed higher levels of policy support than did adolescents in other groups.
|
Table III
shows the associations between policy awareness and support, and demographic, smoking and psychosocial variables. As shown in Table III, in addition to smoking status and demographic variables, tobacco-related psychosocial variables were associated with policy awareness and support. Perceived negative consequences of smoking, prevalence estimate of smoking among peers, cigarette offers and cigarette refusal self-efficacy were associated positively with policy awareness, while perceived access to cigarettes and perceived positive consequences of smoking were associated inversely with policy awareness. Perceived negative consequences of smoking and cigarette refusal self-efficacy were associated positively with policy support, while perceived access to cigarettes, perceived positive consequences of smoking, prevalence estimate of smoking among peers, friends' smoking and cigarette offers were associated inversely with policy support.
|
Nearly one-half of the respondents (48.3%) reported performing at least one advocacy action. The proportion of respondents who performed each specific advocacy action is shown in Table IV
. Because some respondents performed more than one advocacy action, the proportion of respondents who reported performing any advocacy action (48.3%) is lower than the sum of the proportions shown in Table IV. Of the respondents who had performed one or more advocacy actions, 72.9% reported that their only advocacy action had been asking someone else not to smoke. The remaining 27.1% of the respondents who had performed advocacy actions (13.1% of the entire sample) had performed one or more of the other six advocacy actions. These respondents reported performing a mean of 1.65 advocacy actions other than asking someone not to smoke (SD = 1.19).
|
Respondents who performed any of the advocacy actions (other than asking someone else not to smoke) differed from the non-advocates on several characteristics. The advocates were older than the non-advocates (
2 = 40.43, P < 0.001), they were more likely to be male (2 = 25.09, P < 0.001) and they were more likely to be African-American (2 = 11.85, P < 0.001) or Latino (2 = 6.13, P < 0.05). Rates of advocacy actions did not differ by smoking status (2 = 7.91, P = 0.095), although a non-significant trend showed that advocacy was highest among quitters and lowest among susceptible never-smokers.
Table IV
shows the relative risk of performing anti-smoking advocacy actions, according to respondents' levels of policy awareness and policy support. As shown in Table IV, policy awareness was associated with a higher probability of asking someone not to smoke, signing a petition about reducing tobacco use, attending a press conference about reducing tobacco use, talking to store employees about not advertising cigarettes or selling tobacco to minors, contacting government officials or news reporters about reducing tobacco use, attending youth summits or conferences about reducing tobacco use and helping police to see if stores were selling cigarettes to youth. Policy support was associated with a higher probability of performing all of these actions except for attending a press conference. Policy support was associated with a lower probability of attending press conferences about reducing tobacco use.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
The results of this study provide important new information about adolescents' attitudes toward anti-smoking policies. Whereas previous studies have examined policy attitudes primarily among adults, this study found that awareness of anti-tobacco policies and support for anti-tobacco policies vary widely among adolescents. Furthermore, adolescents' policy-related attitudes show strong associations with their smoking status, smoking-related psychosocial variables and anti-smoking advocacy actions. This suggests that attitudes toward anti-tobacco policies may be an important determinant (or consequence) of smoking behavior among adolescents.
In this sample, current smokers were most aware of anti-smoking policies. This suggests that adolescent smokers may become aware of anti-smoking policies through direct experience with the policies or they may attend more carefully to information about policies because the policies are relevant to them. Reactance theory (Brehm and Brehm, 1981) offers another interpretation of this finding. According to reactance theory, adolescents who are most aware that anti-tobacco policies are restricting their freedom to smoke may be more likely to smoke as a way of reasserting their autonomy. Because these data are cross-sectional, the results are consistent with either of these two interpretations; the direction of causality cannot be determined.
Interestingly, the lowest awareness of anti-tobacco policies was found among the susceptible non-smokers—those youth who have not yet smoked but who acknowledge the possibility of smoking in the future. Previous studies (Unger et al., 1995, 1997) have found that susceptible non-smokers differ from non-susceptible adolescents on other tobacco-related risk factors: they are especially attracted to pro-tobacco advertisements, they report having received more cigarette offers, they have more friends who smoke and they believe more strongly in the positive consequences of smoking. The results of this study, combined with previous research about susceptible adolescents, suggest that susceptible adolescents may overestimate the benefits of smoking and underestimate the negative consequences of smoking, including punishment associated with violating anti-tobacco policies. Perhaps educating susceptible youth about the existing anti-tobacco policies would decrease their susceptibility to smoking and would thereby prevent or delay their smoking onset. Alternatively, however, it is possible that increased salience of the restrictions constraining susceptible adolescents' behavior might cause these adolescents to rebel by experimenting with smoking. Experimental studies are necessary to determine the effects of increases in policy awareness on the smoking behavior of susceptible non-smokers.
Consistent with studies of adults (Bull et al., 1994; Marcus et al., 1994), adolescents who were current smokers expressed less support for anti-tobacco policies than did never-smokers, susceptibles, experimenters or ex-smokers. The results shown in Figure 1 suggest that support for anti-tobacco policies may decline steadily as an adolescent progresses through the stages from a never-smoker to a smoker. Interestingly, quitters showed about the same low levels of support for anti-tobacco policies as did current smokers. These adolescents' smoking cessation, therefore, may have been due to changing attitudes about the physiological or social consequences of smoking, rather than changes in opinions that adolescent smoking should be legal or the perceived consequences of violating policies. Future research should determine whether interventions designed to increase support for anti-tobacco policies would encourage current smokers to quit or would discourage non-smokers from starting to smoke.
Some tobacco education interventions, such as the California Tobacco Control Prevention and Education Program (Independent Evaluation Consortium, 1998), include information designed to increase awareness of and support for anti-tobacco policies. For example, a recent California television advertisement encourages the public to support a ban on smoking in bars and billboards encourage people to report merchants who sell cigarettes to minors. Theoretically, increased public support for anti-tobacco policies will lead to enactment of more anti-tobacco laws (or more restrictive laws), which, if successfully enforced, will lead to decreased smoking prevalence. Recent research (Flynn et al., 1998) suggests that legislators may be more likely to vote for anti-tobacco legislation if they perceive a strong anti-tobacco social norm among their constituents (Flynn et al., 1998).
However, it is not known whether increasing the public's awareness of and support for anti-tobacco policies leads to declines in smoking prevalence. The implementation of anti-tobacco policies may increase the salience of the health risks of smoking, which may create an anti-tobacco social norm that discourages people from smoking (Pederson et al., 1991). Longitudinal studies are needed to determine whether changes in attitudes toward anti-tobacco policies can lead to changes in smoking behavior. In addition, the extent to which the public's attitudes toward anti-tobacco policy can be influenced by tobacco control interventions is not yet clear.
The results of this study suggest that attitudes toward anti-tobacco policies are associated with many variables that have previously been shown to be important predictors of adolescent smoking. Policy awareness and support were especially low in respondents who had high perceived access to cigarettes, many perceived positive consequences of smoking, few perceived negative consequences of smoking and low self-efficacy to refuse cigarette offers. This suggests that attitudes toward anti-tobacco policy represent one of a constellation of attitudes associated with high risk for adolescent smoking.
The associations between acculturation and policy attitudes are interesting, although they should be interpreted with caution because of the limitations of the one-item acculturation measure. Acculturation was associated with greater policy awareness and lower policy support. Although more acculturated adolescents may have access to more information about anti-tobacco policies, their lower support for these policies may lead them to violate these policies more often than do their less acculturated peers.
Policy awareness and support were strongly associated with the likelihood that adolescents would report performing anti-tobacco advocacy actions. For example, a 1 SD increase in policy awareness was associated with more than a 2-fold increase in the probability of signing petitions, attending press conferences, contacting government officials, attending youth conferences and assisting with police stings to catch merchants who sell tobacco to minors. Higher levels of policy support were associated with higher probabilities of performing all advocacy actions except attending press conferences. However, the associations between policy support and advocacy actions were not as strong as the associations between policy awareness and advocacy actions. It is not immediately obvious why policy support and attendance of press conferences were inversely associated. Perhaps adolescents who oppose anti-tobacco policies attend press conferences, demonstrations or rallies to protest the passage of anti-tobacco policies that they find unreasonable. Another explanation of this finding is that `high-risk' youth may have been chosen by tobacco control advocates to participate in these activities, in the hope that their participation would deter them from smoking in the future (Komro et al., 1996). Further studies are necessary to gain a more complete understanding of the characteristics of youth who participate in anti-tobacco advocacy activities.
Limitations
The design of this study creates several limitations. These results are based on cross-sectional data, so causal relationships cannot be determined. This study found significant associations among policy attitudes, smoking status and tobacco-related psychosocial variables. However, the direction of causality is not clear. It is possible that tobacco-related psychosocial variables influence attitudes toward anti-tobacco policies, which in turn influence smoking behavior. Alternatively, it is also possible that smoking leads to changes in attitudes about anti-tobacco policies. Longitudinal studies are necessary to clarify the direction of causality. However, the current results indicate that adolescents' attitudes toward anti-tobacco policy vary according to their smoking status and other tobacco-related psychosocial variables.
These results are based on adolescents' self-reports of their smoking status, policy attitudes and other psychosocial variables. Respondents may have biased their responses in an attempt to avoid punishment or to present a favorable impression to the experimenters. However, because all surveys were confidential, it is unlikely that the respondents would have been motivated to alter their responses significantly.
Despite these limitations, the results of this study provide important new information about attitudes toward anti-tobacco policies among adolescents. They suggest that tobacco control and education programs should include information about existing anti-tobacco policies, and should educate youth about the importance and benefits of anti-tobacco policies. In addition to creating and enforcing anti-tobacco policies, enlisting adolescents' support for these policies may increase their voluntary compliance. If awareness of anti-tobacco policies and support for these policies among youth can be increased, perhaps more adolescents may decide not to experiment with cigarettes.
|
Acknowledgments |
|---|
Collection of the data described in this article was supported by a contract from the California Department of Health Services, Tobacco Control Section (contract 95-222998). The analyses, interpretations and conclusions are those of the authors, not the California Department of Health Services.
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Brehm, S. and Brehm, J. W. (1981) Psychological Reactance: A Theory of Freedom and Control. Academic Books, New York.
Bull, S. B., Pederson, L. L. and Ashley, M. J. (1994) Restrictions on smoking: growth in population support between 1983 and 1991 in Ontario. Canada. Journal of Public Health Policy, 15, 310–328.
Centers for Disease Control and Prevention (1994) Attitudes toward smoking policies in eight states: United States, 1993. Morbidity and Mortality Weekly Report, 43, 786–788.
Centers for Disease Control and Prevention. (1995) CDC Surveillance Summaries. November 3, 1995. Morbidity and Mortality Weekly Report, 44, SS-6.
Centers for Disease Control and Prevention. (1996) State Tobacco Control Highlights—1996. CDC publ. no. 099-4895. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Promotion, Office on Smoking and Health, Atlanta, GA.
Chaloupka, F. J. and Wechsler, H. (1997) Price, tobacco control policies and smoking among young adults. Journal of Health Economics, 16, 359–373.[Web of Science][Medline]
Collins, L. M., Sussman, S., Rauch, J. M., Dent, C. W., Johnson, C. A., Hansen, W. B. and Flay, B. R. (1987) Psychosocial predictors of young adolescent cigarette smoking: a sixteen-month, three-wave longitudinal study. Journal of Applied Social Psychology, 17, 554–573.[Web of Science]
Department of Health and Human Services (1996) Regulations Restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents; final rule. Federal Register, 61, 44395–44445.
Engs, R. and Hanson, D. J. (1989) Reactance theory: a test with collegiate drinking. Psychological Reports, 64, 1083–1086.
Flynn, B. S., Goldstein, A. O., Solomon, L. J., Bauman, K. E., Gottlieb, N. H., Cohen, J. E., Munger, M. C. and Dana, G. S. (1998) Predictors of state legislators' intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157–165.[Web of Science][Medline]
Forster, J. L., Murray, D. M., Wolfson, M., Blaine, T. M., Wagenaar, A. C. and Hennrikus, D. J. (1998) The effects of community policies to reduce youth access to tobacco. American Journal of Public Health, 88, 1193–1198.
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program: Wave 1 Data, 1996–1997. The Gallup Organization, Rockville, MD.
Jeffery, R. W., Forster, J. L., Schmid, T. L., McBride, C., Rooney, B. L. and Pirie, P. L. (1990) Community attitudes toward public policies to control alcohol, tobacco, and high-fat food consumption. American Journal of Preventive Medicine, 6, 12–19.[Web of Science][Medline]
Komro, K. A., Perry, C. L., Murray, D. M., Veblen-Mortenson, S., Williams, C. L. and Anstine, P. S. (1996) Peer-planned social activities for preventing alcohol use among young adolescents. Journal of School Health, 66, 328–334.
Marcus, S. E., Emont, S. L., Corcoran, R. D., Giovino, G. A., Pierce, J. P., Waller, M. N. and Davis, R. M. (1994) Public attitudes about cigarette smoking: results from the 1990 Smoking Activity Volunteer Executed Survey. Public Health Reports, 109, 125–134.[Web of Science][Medline]
Pederson, L. L., Wanklin, J. M., Bull, S. B. and Ashley, M. J. (1991) A conceptual framework for the roles of legislation and education in reducing exposure to environmental tobacco smoke. American Journal of Health Promotion, 6, 105–111.[Medline]
Pederson, L. L., Bull, S. B., Ashley, M. J. and Kozma, D. (1992) Restrictions on smoking: changes in knowledge, attitudes and predicted behaviour in metropolitan Toronto from 1983 to 1988. Canadian Journal of Public Health, 83, 408–412.[Medline]
Pentz, M. A., Brannon, B. R., Charlin, V. L., Barrett, E. J., MacKinnon, D. P. and Flay, B. R. (1989) The power of policy: the relationship of smoking policy to adolescent smoking. American Journal of Public Health, 79, 857–862.
Pentz, M. A., Sussman, S. and Newman, T. (1997) The conflict between least harm and no-use tobacco policy for youth: ethical and policy implications. Addiction, 92, 1165–1173.[Web of Science][Medline]
Pierce, J. P., Choi, W. S., Gilpin, E. A., Farkas, A. J. and Merritt, R. K. (1996) Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology, 15, 355–361.[Web of Science][Medline]
Singer, J. D. (1998) Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth models. Journal of Educational and Behavioral Statistics, 23, 323–355.
Unger, J. B. (1996) Stages of change of smoking cessation: relationships with other health behaviors. American Journal of Preventive Medicine, 12, 134–138.[Web of Science][Medline]
Unger, J. B., Johnson, C. A. and Rohrbach, L. A. (1995) Recognition and liking of tobacco and alcohol advertisements among adolescents: relationships with susceptibility to substance use. Preventive Medicine, 24, 461–466.[Web of Science][Medline]
Unger, J. B., Johnson, C. A., Stoddard, J. L., Nezami, E. and Chou, C. (1997) Identification of adolescents at risk for smoking initiation: validation of a measure of susceptibility. Addictive Behaviors, 22, 81–91.[Web of Science][Medline]
Wolfson, M., Forster, J., Murray, D., Blaine, T., Hennrikus, D. and Wagenaar, A. (1998) Results of a community trial to reduce youth access to tobacco: the TPOP study. Presented at the 6th Annual Meeting of the Society for Prevention Research, Park City, UT, June 4–7, 1998.
Received on August 17, 1998; accepted on December 29, 1998
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  W. C. Livingood, L. D. Woodhouse, and P. Wludyka Implementation of Possession Laws and the Social Ecology of Tobacco Control Health Educ Behav, April 1, 2009; 36(2): 214 - 229. [Abstract] [PDF]
|
|
|
|
 |
|
 S Thomas, D Fayter, K Misso, D Ogilvie, M Petticrew, A Sowden, M Whitehead, and G Worthy Population tobacco control interventions and their effects on social inequalities in smoking: systematic review Tob. Control, August 1, 2008; 17(4): 230 - 237. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S T Leatherdale, P Smith, and R Ahmed Youth exposure to smoking in the home and in cars: how often does it happen and what do youth think about it? Tob. Control, April 1, 2008; 17(2): 86 - 92. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. M Carter and S. Chapman Smokers and non-smokers talk about regulatory options in tobacco control. Tob. Control, October 1, 2006; 15(5): 398 - 404. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. G. Ramirez, L. F. Velez, P. Chalela, J. Grussendorf, and A. L. McAlister Tobacco Control Policy Advocacy Attitudes and Self-Efficacy Among Ethnically Diverse High School Students Health Educ Behav, August 1, 2006; 33(4): 502 - 514. [Abstract] [PDF]
|
|
|
|
 |
|
 B. A. Primack, M. A. Gold, G. E. Switzer, R. Hobbs, S. R. Land, and M. J. Fine Development and Validation of a Smoking Media Literacy Scale for Adolescents Arch Pediatr Adolesc Med, April 1, 2006; 160(4): 369 - 374. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L Henriksen, A L Dauphinee, Y Wang, and S P Fortmann Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect Tob. Control, February 1, 2006; 15(1): 13 - 18. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. M. Ribisl, A. Steckler, L. Linnan, C. C. Patterson, E. S. Pevzner, E. Markatos, A. O. Goldstein, T. McGloin, and A. B. Peterson The North Carolina Youth Empowerment Study (NCYES): A Participatory Research Study Examining the Impact of Youth Empowerment for Tobacco Use Prevention Health Educ Behav, October 1, 2004; 31(5): 597 - 614. [Abstract] [PDF]
|
|
|
|
 |
|
 K. M. Turner and J. Gordon A fresh perspective on a rank issue: pupils' accounts of staff enforcement of smoking restrictions Health Educ. Res., April 1, 2004; 19(2): 148 - 158. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. M. Turner and J. Gordon Butt in, butt out: pupils' views on the extent to which staff could and should enforce smoking restrictions Health Educ. Res., February 1, 2004; 19(1): 40 - 50. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. Carver, B. Reinert, L. M. Range, and C. Campbell Adolescents' attitudes and self-perceptions about anti-tobacco advocacy Health Educ. Res., August 1, 2003; 18(4): 453 - 460. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. C. Livingood, C. D. Woodhouse, J. J. Sayre, and P. Wludyka Impact Study of Tobacco Possession Law Enforcement in Florida Health Educ Behav, December 1, 2001; 28(6): 733 - 748. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||