Last updated: 30-Nov-2012

Interventions to Reduce Initiation Rates

The focus of this subsection will be on reducing the initiation of tobacco use among adolescents, as this is the age and stage when by far the majority of individuals take up smoking as a long-term habit.

If smoking does not occur in adolescence, it is unlikely to ever occur.[1] As well, adolescents who begin at a younger age are more likely to become regular and heavier smokers, and are less likely to quit.[2],[3] Individuals who begin smoking during childhood or early adolescence are also at a higher risk of developing airway diseases and lung cancers than are individuals who start later, likely due to the irreparable damage to the lungs and airway tissues at a point when these organs are still in a developmental stage.[4],[5] Most alarming of all, nicotine dependence often begins with the first few cigarettes smoked during adolescence.[6] A study published in November, 2004, notes that children who smoke as few as one cigarette by 5th grade were twice as likely to be current smokers at age 17.[7]

Community-based Interventions

Smoking behaviour, like other health-related behaviour, is influenced by the environment in which adolescents live. This recognition has led to the development of community-wide programs targeted at teens. Community interventions are defined as “co-ordinated, widespread programs in a particular geographical area (e.g. school districts) or region or in groupings of people who share common interests or needs, which support non-smoking behaviour.” [8] Such initiatives have the following advantages:

  • multi-dimensionality, with different components working together
  • maximizing the chance of reaching all members of a population
  • ongoing and broad support for the maintenance of non-smoking behaviour.

As suggested, community programs geared towards any age group usually have multiple components (which also makes it somewhat difficult to compare them in studies). Typical components of programs related to smoking include:

  • mass media communications such as counter-advertising
  • special (non-curricular) initiatives in schools, e.g., no smoking policies
  • age restrictions on the purchase of tobacco products
  • increased unit price for tobacco products (i.e., taxation)
  • tobacco-free public places

Sometimes the community initiatives are launched by non-profit groups, whereas others are more government-mandated. It is clear that there can be a substantial overlap of content between community programs for adolescents and adults (see below), and possibly good arguments for coordinated initiatives across all ages.

Program Effectiveness
A 2003 Cochrane review[9] of community-wide programs geared to youth found 17 studies of sufficient rigor to include for evaluation. About a third of them offered limited support for the effectiveness of community interventions in preventing the uptake of smoking in young people, especially related to programs that had multiple components (e.g., media, school and homework interventions combined) versus, for instance, a media campaign alone. Of the 13 studies which compared community interventions to no intervention controls, only two reported a lower smoking prevalence. Of three studies comparing community interventions to school-based programs only, one found differences in reported smoking prevalence. One study found a lower rate of increase in a community receiving a multi-component intervention compared to a community exposed to a mass media campaign alone while another reported a significant difference in smoking prevalence between a group receiving a media, school and homework intervention compared to a media component alone. The review concludes that “there is some limited support for the effectiveness of community interventions in helping prevent the uptake of smoking in young people”.

These results mirror the equivocal results in the review of school-based programs combined with community programs as described below.[10] One possible explanation is that the particular design of the counter-advertising campaigns in the successful community programs may be the main the driving force for effectiveness.[11] This appears to be an area where further research is warranted, though comparability of conditions remains a problem. For instance, the studies which reported no effects on smoking prevalence comprised a wide variety of community programs; understanding the contribution of individual programs and their interaction is a complex task, not to mention assessing the impact of confounding social factors.

 

School-based Interventions

Over the past three decades, high schools have been a key focus of efforts to affect adolescent smoking behaviour, though few of the tobacco education curricula have been rigorously evaluated. It is vital to assess the evidence that is available, as there continues to be uncertainty about the effectiveness of school-based educational programs and wide variation in how they are implemented in different countries.

Several different categories of curricular interventions have been reviewed:[12]

  • providing basic information, including health risks of tobacco use
  • affective education, enhancing social competence and self-management skills, based on the theory that susceptibility to smoking initiation is increased by weak social skills and poor self-concept
  • the most widely used (and most studied) type is a social influence training approach (e.g. anti-tobacco resistance skills training, such as teaching students to recognize high risk situations); sometimes these programs involve applying social competence and self-management skills to specific anti-tobacco goals
  • combining curricular approaches with community-wide programs (see the subsection below)

The Cochrane review (2004) of school-based interventions looked at 76 RCTs.[13] Only 16 of the studies were rated as category one, i.e., meeting all quality criteria and therefore most valid. Category two studies (37 in total) had one or more methodological deficiencies, whereas the remaining category three papers were so flawed their results had to be largely discounted.

Basic Information-Giving, Affective Education & Combined Approaches

The conclusion of the Cochrane review was that there is insufficient evidence for basic information-giving (8 studies, none of them category one), affective education / social competence interventions—including where these were combined with social influence approaches (15 studies, only 2 being category one), or school programs combined with multi-modal community interventions (3 category one studies). Most of the studies in this inventory showed one or more methodological deficiencies. One combined approach, the widely-researched Life Skills Training, has shown good results. In one case, the intervention was delivered to middle-schoolers, including cognitive-behavioural skills for building self-esteem, communicating effectively and developing personal relationships, countering advertising and developing strategies to resist social influences to smoke. This trial stands out, even though rated as a category two study, because of long-term follow-up; after 5 years there was less weekly smoking (21-23% vs. 27%) and less monthly smoking (26-27% vs. 33%).[14]

Social Influence Training

There was significant research support for only one type of intervention, i.e., social influence approaches, though even here the evidence was equivocal. The positive results, seen in 8 of the 15 highest quality studies, were mostly small.[15] For example, the well-known Project TNT (Toward No Tobacco Use) studied, among other interventions, social influence techniques. With the best combination of curricular content and a refresher course in grade 8, the increase in the prevalence rate of weekly smokers from grade 7 to grade 9 was reduced from 9% to 4%; otherwise the effects of the curriculum were insignificant.[16]

The largest and most rigorously tested social influence program, the Hutchinson Project, found no sustained effect on smoking prevalence at all.[17] The most widely-used school-based program, Drug Abuse Resistance Education (D.A.R.E.), is found in three quarters of US schools, as well as in B.C. and the rest of Canada. The program is reportedly popular with police officers and parents.[18],[19] There have been many D.A.R.E. reviews and evaluations, but few rigorous scientific evaluations. In trial reports from 1996 and 1999, the program was shown to have no effect on smoking prevalence at 5 and 10 year follow-up.[20],[21]

Smoke-free Schools

A large cross-sectional survey by Wakefield and colleagues revealed that school smoking bans, as well as limiting environmental tobacco smoke exposure, could produce less intense uptake of smoking and a lower smoking prevalence rate among youth. However, the effects were only significant if the ban was strongly enforced, i.e., “when teenagers perceived that most or all students obeyed the rule.”[22]

Conclusion

The rather pessimistic general assessment of curricular programs in schools has been echoed in other reviews. The recent National Cancer Prevention Policy of Australia quotes a World Bank evaluation of such initiatives: “Even programs that have initially reduced the uptake of smoking appear to have only a temporary effect; they can somewhat delay initiation of smoking but not prevent it.”[23] This does not mean that efforts to develop effective approaches in the important setting of schools should come to an end. On the contrary, innovative approaches should continue to be explored. One recent clinical trial showed promise: when the curriculum extended to “field work” with student involvement in environmental tobacco smoke advocacy, the prevalence of regular smoking among senior students dropped from 25% to 20%.[24]

The best approach to school-based interventions will likely be comprehensive, including, for example, smoke-free school policies. As will be discussed more fully below, social norms in schools are as important as in other situations. School cultures which have an emphasis on discipline and respect for authority have shown better results in reducing smoking prevalence.[25]

 

Clinical Interventions and Management

Neither the hospital nor the physician’s office has been a primary focus of smoking prevention. Some reviews of interventions aimed at preventing uptake of smoking among adolescent do not even include the clinical category.[26] In fact, a 2003 systematic review of teen smoking prevention only found 4 suitable studies, 2 with interventions related to clinical care and 2 to dental care. Only one study showed a significant difference in smoking prevalence at 12 months (5.1% compared to 7.8% in the control group).[27]

 

Regulatory and Economic Interventions

Controlling Sales to Minors

Legislative / taxation approaches have proven useful in curbing youth smoking.

Age restrictions on the purchase of tobacco products vary around the world, with the main difference being upon whom the sanction for non-compliance falls. The focus has been placed either on the retailer not to sell to minors, or on the young person not to buy or use tobacco products. There is mixed data on the results of such interventions, offering both negative[28],[29],[30],[31] and positive[32],[33] conclusions, and the debate promises to be lively for some time to come.[34],[35],[36]

The 2004 Cochrane review on interventions for preventing tobacco sales to minors identified 30 studies in this area, of which 13 were of sufficient quality to include in their review. The reviewers found that giving retailers information was less effective in reducing illegal sales than active enforcement and/or multi-component educational strategies. The 3 papers most relevant to the issue of youth smoking rates, however, showed little effect from limiting tobacco sales to minors. The main problem may be the inability to achieve “sustained levels of high compliance” among retailers.[37] All authorities agree that monitoring and enforcement (which tend to be expensive) are vital to any successful retail policy. The most recent research and discussion seems to be around the impact on youth smoking when high compliance by retailers can be demonstrated.[38] Programs such as Toronto’s Not to Kids! campaign, which have shown some improvement in retailer non-compliance rates, have yet to be evaluated in terms of their actual effect on youth smoking.[39]

One of the responses by the tobacco industry to legal challenges and public pressures has been to develop and disseminate programs such as “Operation ID” and “Operation ID/School Zone”. A review of such programs by the Ontario Medical Association found numerous concerns about the approach and outcomes associated with these programs. They conclude that “since none of (these programs) occupy a legitimate position in best practice-based tobacco control strategy, the OMA recommends that all groups, associations and other interested parties which have formally endorsed them, be asked to withdraw their endorsement”.[40]

Taxation

Not even the strongest proponents of retail restrictions see them as the final answer. Prohibitions of sales to minors should only be viewed as a complement to other proven strategies. In particular, taxation policies are crucial, being as effective with youth as they are with adults (see below). Bridge and Turpin, in the recent report entitled The Cost of Smoking in British Columbia and the Economics of Tobacco Control,[41] note that the most detailed study of the relationship between price and youth smoking showed a “price elasticity” that varies inversely with age; what this means is that price seemed to have the greatest impact on discouraging young experimenting smokers who were not yet addicted. Also, the impact was 6 times higher in terms of discouraging occasional smoking compared with reducing daily smoking, which again bodes well for an intervention targeted at tentative, experimenting smokers.[42] Reports by the US Surgeon General and several others confirm that price is more likely to affect the decision to start smoking than to affect the behaviour of current smokers.[43]

Circumstantial evidence in Canada strongly supports the effectiveness of price in controlling youth smoking; in the 1980s smoking prevalence among young people declined by half, a trend which sharply reversed when taxes on cigarettes were cut in the 1990s.[44]

There is a range of data on the expected impact of taxation; a 10% price increase could reduce teenage smoking prevalence from 6 to 10%; even the lower estimate is in excess of the effect for the general population.[45] The International Union of Health Promotion and Education[46] concurs on the central role of taxation policy: “Imposing sufficiently high taxes on tobacco products is the most successful and important tobacco control intervention for preventing youth access to and consumption of tobacco products.”[47]

Advertising Control

Although banning the public promotion / marketing of tobacco products, and especially ending advertising directed at teenagers, may seem to be a war that has been largely won in Canada, several battlefronts remain. There is strong circumstantial evidence for the effectiveness of marketing tobacco (and therefore for the importance of maintaining and expanding bans on such business practices). A key fact is that in 2000 almost $9 billion was spent by the US tobacco industry on advertising and other types of promotion, with the presumption closely following that the various companies must have a strong rationale to support such expenses.[48]

Unlike other areas of tobacco control, experimental studies cannot ethically be conducted. The relevant Cochrane review therefore depends on observational studies. In all nine papers examined, the non-smoking adolescents who were more aware of tobacco advertising were more likely to have experimented with cigarettes or become smokers at follow-up.[49] For example, Biener and Siegel found that 46% of non-smoking adolescents who owned a tobacco promotion item, and had a favourite brand advertisement, were established smokers 4 years later.[50] Again, the inference is that curtailing marketing, especially to impressionable teens, is an effective means of tobacco control.

Smoking in Movies

Another arena receiving increasing attention as part of a tobacco control policy is the portrayal of smoking in films. Increasingly, movie stars are receiving payment for endorsing or using cigarettes on screen, in so-called product placements. Georgina Lovell[51] quotes a letter from Sylvester Stallone to Brown & Williamson in which he agrees to a sum of $500,000 for the use of Brown & Williamson cigarettes in at least five feature films.

Results of a number of cross-sectional studies[52],[53],[54] suggest that adolescents are more likely to try smoking if their favourite movie stars smoked on screen. A key longitudinal cohort study by Dalton et al[55] found a strong relationship between exposure to smoking in movies and the initiation of smoking in adolescents. After controlling for baseline characteristics, they found that the 25% of adolescents exposed to the highest number of smoking occurrences in movies were 2.7 times more likely to initiative smoking than the 25% of adolescents exposed to the lowest number of smoking occurrences.

Based on this evidence, Dr. Glantz of the Center For Tobacco Control Research in San Francisco met with the Ontario Film Review Board in October, 2004, to propose that movies portraying smoking should be given an 18A rating, i.e., any young person seeing the subliminal pro-smoking message would at least have to have an adult accompanying them. Glantz suggests that “smoking scenes in movies are the number one recruiter of new, young smokers in the United States—390,000 American teens every year.”[56]

More recently, the American Lung Association has begun to rate movies using icons of lungs, black for movies depicting heavy smoking and pink for when none of the characters smoke.[57]

The final policy category which affects young people, bans on smoking in public places, will be handled below under the topics of workplace interventions and environmental tobacco smoke.

 

Comprehensive Strategies

Increasingly, it is becoming clear that the division between the above categories can be an artificial one. The trend is towards comprehensive, more fully integrated approaches, though this does make it difficult to scientifically isolate the effect of individual component strategies. Florida has been singled out for investing a large proportion of its settlement with the tobacco industry in a very effective youth anti-smoking campaign. It combined counter-marketing advertising, community-based activities, education and training, and an enforcement program that was able to reduce tobacco use among middle school students from 18.5 to 15.0% and among high school students from 27.4 to 25% between 1998 and 1999. A key focus of the campaign was denormalizing tobacco and the tobacco industry, removing the “glamour” of smoking in the eyes of youth.[58] The funding for Florida’s Youth Tobacco Control Program, however, has been consistently eroded since the initial large start-up grant.[59]

Social Denormalization

It is clear that youth can be considered an “at-risk” population[60] and that preventing the uptake of smoking among the young is vital. Primary prevention has focused on discouraging experimentation with cigarettes and / or deterring regular use. The importance of these goals cannot be overestimated as communities continue to move towards the denormalization of smoking. If this “tipping point” for tobacco control has not already been achieved, then it may at least be in sight. The challenge is to maintain economic and other policy pressures that will solidify the movement towards making not smoking the expected social reality in developed countries, and then see that movement extend to other parts of the world, and to other aspects of health promotion. Influencing new generations will undoubtedly be both a key and consequence of such social normalization of healthy living.

An influential US report concluded:

Cigarette control policies that discourage smoking by teenagers may be the most effective way of achieving long-run reductions in smoking in all segments of the population. A tax hike would continue to discourage smoking for successive generations of young people and would gradually affect the smoking levels of older age groups…[and] aggregate smoking and its associated detrimental health effects would decline substantially.[61]

An encouraging aspect of tobacco control among adolescents is the synergies that can be derived from adult cessation programs (see the next subsection).[62] It is well-known that parental (and sibling) smoking is a risk factor for adolescent initiation.[63] Research has shown that when parents quit, the odds of their children taking up smoking were significantly reduced.[64] Likewise, teenagers are able to understand and act on cessation advertising directed to adults; there is evidence from the Australian National Tobacco Campaign that adolescents responded similarly to adults, leading to the following somewhat surprising conclusion: an adult cessation focus may even be more effective that one directly targeting teens.[65]

A related phenomenon is the positive “multiplier effect” of peers on teenage smoking. If fewer teens are smoking, fewer other teens want to emulate them. As Grossman and Chaloupka noted in reference to tax policy: “a rise in price curtails youth consumption directly and then again indirectly through its impact on peer consumption.”[66]

A smoke-free home is also effective in preventing smoking uptake, more so than other place-based restrictions (such as bans in school or public places). One cross-sectional survey concluded: “Banning smoking in the home, even when parents smoke, gives an unequivocal message to teenagers about the unacceptability of smoking.”[67]

All of the above agencies and forces spur on the efforts to achieve a “tipping point” in tobacco control.


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[10] The two Cochrane reviews included 5 of the same studies.

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[12] Thomas R. School-based programmes for preventing smoking Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.

[13] Thomas R. School-based programmes for preventing smoking Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.

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[15] An earlier meta-analysis of studies from 1974 to 1991 showed that school-based programs likely would produce at most a 5% reduction in teen smoking, or perhaps as high as 20-30% under optimum conditions. Rooney BL, Murray DM. A meta-analysis of smoking prevention programs after adjustment for errors in the unit of analysis Health Education Quarterly 1996; 23(1) 48-64.

[16] Dent CW, Sussman S, Stacy AW et al. Two-year behavior outcomes of project towards no tobacco use Journal of Consulting & Clinical Psychology 1995; 63(4): 676-7.

[17] Thomas R. School-based programmes for preventing smoking Cochrane Tobacco Addiction Group Cochrane Database of Systematic Reviews. 3, 2004.

[18] Source: http://www.hc-sc.gc.ca/hecs-sesc/cds/publications/substanceyoungpeople/chapter4_2.htm (accessed November 2004).

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[21] Lynam DR, Milich R, Zimmerman R et al. Project DARE: no effects at 10-year follow-up Journal of Consulting & Clinical Psychology 1999; 67(4): 590-3.

[22] Wakefield MA, Chaloupka FJ, Kaufman NJ et al. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. British Medical Journal. 2000; 321(7257):333-7. See also Trinidad DR, Gilpin EA, Pierce JP. Compliance and support for smoke-free school policies. Health Education Research. 2004 [Epub ahead of print].

[23] Jha P, Chaloupka F. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington: World Bank, 1999.

[24] Winkleby MA, Feighery E, Dunn M et al. Effects of an advocacy intervention to reduce smoking among teenagers. Archives of Pediatrics & Adolescent Medicine. 2004; 158(3):269-75.

[25] Aveyard P, Markham WA, Lancashire E et al. The influence of school culture on smoking among pupils. Social Science & Medicine. 2004; 58(9):1767-80.

[26] NHS Centre for Reviews and Dissemination. Preventing the uptake of smoking in young people Effective Health Care 1999; 5(5): 1-12. Available at http://www.york.ac.uk/inst/crd/ehc55.pdf (accessed December 2004).

[27] Christakis DA, Garrison MM, Ebel BE et al. Pediatric smoking prevention interventions delivered by care providers: a systematic review American Journal of Preventive Medicine 2003; 25(4): 358-62.

[28] Woollery T, Asma S, Sharp D. Clean indoor-air laws and youth access restrictions. In: Jha P, Chaloupka F, eds. Tobacco control in developing countries. Oxford: University Press; 2000.

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[31] Levy D, Friend K. A simulation model of tobacco youth access policies Journal of Health Politics, Policy and Law 2000; 25(6): 1023-48.

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[33] Cummings K, Hyland A, Saunders-Martin T et al. Evaluation of an enforcement program to reduce tobacco sales to minors American Journal of Public Health 1998; 88(6): 932-6.

[34] Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking Pediatrics 2002; 109(6): 1088-92.

[35] Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes Tobacco Control 2002; 11(1): 3-6.

[36] DiFranza JR. Is it time to abandon youth access programmes? Tobacco Control 2002; 11(3): 282; author reply 283-4.

[37] Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors Cochrane Database of Systematic Reviews, 2004.

[38] DiFranza JR. Is it time to abandon youth access programmes? Tobacco Control 2002; 11(3): 282; author reply 283-4.

[39] Source: http://www.city.toronto.on.ca/not_to_kids/nottokids_info.htm (accessed November 2004).

[40] Ontario Medical Association position statement. More Smoke and Mirrors: Tobacco industry-sponsored youth prevention programs in the context of comprehensive tobacco control programs in Canada, February 2002. Available at www.oma.org/phealth/smokeandmirrors.html (accessed November 2004).

[41] Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Health Canada, February 2004.

[42] A 10% price increase produced an 18% reduction in occasional smoking, but only a 3% reduction in daily smoking. Harris JE, Chan SW. The continuum-of-addiction: cigarette smoking in relation to price among Americans aged 15-29 Health Economics 1999; 8(1): 81-6.

[43] Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Health Canada, February 2004.

[44] Stephens T, Pederson LL, Koval JJ et al. The relationship of cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada. American Journal of Public Health 1997; 87(9): 1519-21.

[45] Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Health Canada, February 2004.

[46] The IUHPE is a leading global network working to promote health worldwide and contribute to the achievement of equity in health between and within countries. One of its key recent publications is Model Legislation for Tobacco Control: a policy development and legislative drafting manual.

[47] Source: http://www.fctc.org/modelguide/lsection09.html#98 (accessed November 2004).

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[50] Biener L, Siegel M. Tobacco marketing and adolescent smoking: More support for a causal inference American Journal of Public Health 2000; 90: 407-11.

[51] Lovell G. You Are The Target: Big Tobacco: Lies, Scams – Now The Truth, 2002 Chyran Communication, Vancouver, British Columbia.

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[56] News report. Available at http://www.newswire.ca/en/releases/archive/October2004/29/c6409.html (accessed November 2004).

[57] Cobb C. Anti-smoking campaign targets films. The Vancouver Sun, December 20, 2004, pg A8.

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[59] Source: http://www.cancer.org/docroot/COM/content/div_FL/COM_4_5x_Florida_Tobacco_Control_Program.asp?sitearea=COM (accessed November 2004).

[60] There are a number of factors common to society and youth culture that can promote smoking, including stress, the accessibility and availability of tobacco products, perceptions that tobacco use is normative, the model, influence and approval of peers and lack of knowledge of health consequences. US Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A Report of the Surgeon-General, 1994.

[61] Grossman M, Chaloupka FJ. Cigarette taxes. The straw to break the camel's back Public Health Reports 1997; 112(4): 290-7.

[62] Hill D. Why we should tackle adult smoking first Tobacco Control 1999; 8(3): 333-5.

[63] The Cancer Council Australia. National Cancer Prevention Policy, 2004-06.

[64] Farkas AJ, Distefan JM, Choi WS et al. Does parental smoking cessation discourage adolescent smoking? Preventive Medicine 1999; 28(3): 213-8.

[65] The Cancer Council Australia. National Cancer Prevention Policy, 2004-06.

[66] Grossman M, Chaloupka FJ. Cigarette taxes. The straw to break the camel's back. Public Health Reports 1997; 112(4): 290-7.

[67] Wakefield MA, Chaloupka FJ, Kaufman NJ et al. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study British Medical Journal 2000; 321(7257): 333-7.