Journal of Adolescent Health 54 (2014) 481e486
www.jahonline.org Original article
Are Tobacco Control Policies Effective in Reducing Young Adult Smoking? Matthew C. Farrelly, Ph.D. a, *, Brett R. Loomis, M.S. a, Nicole Kuiper, M.P.H. b, Beth Han, Ph.D., M.P.H. c, Joseph Gfroerer c, Ralph S. Caraballo, Ph.D. a, Terry F. Pechacek, Ph.D. a, and G. Lance Couzens a a b c
RTI International, Research Triangle Park, North Carolina Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta, Georgia Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, Rockville, Maryland
Article history: Received June 18, 2013; Accepted September 23, 2013 Keywords: Smoking; Young adults; Smoke-free air laws; Cigarette prices; Tobacco control programs
A B S T R A C T
Purpose: We examined the influence of tobacco control program funding, smoke-free air laws, and cigarette prices on young adult smoking outcomes. Methods: We use a natural experimental design approach that uses the variation in tobacco control policies across states and over time to understand their influence on tobacco outcomes. We combine individual outcome data with annual state-level policy data to conduct multivariable logistic regression models, controlling for an extensive set of sociodemographic factors. The participants are 18- to 25-year-olds from the 2002e2009 National Surveys on Drug Use and Health. The three main outcomes are past-year smoking initiation, and current and established smoking. A current smoker was one who had smoked on at least 1 day in the past 30 days. An established smoker was one who had smoked 1 or more cigarettes in the past 30 days and smoked at least 100 cigarettes in his or her lifetime. Results: Higher levels of tobacco control program funding and greater smoke-free-air law coverage were both associated with declines in current and established smoking (p < .01). Greater coverage of smoke-free air laws was associated with lower past year initiation with marginal significance (p ¼ .058). Higher cigarette prices were not associated with smoking outcomes. Had smoke-freeair law coverage and cumulative tobacco control funding remained at 2002 levels, current and established smoking would have been 5%e7% higher in 2009. Conclusions: Smoke-free air laws and state tobacco control programs are effective strategies for curbing young adult smoking. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Although 88% of adult smokers initiated smoking before age 18 years [1], public health researchers and the tobacco industry also consider young adulthood to be a formative period for smoking patterns [2]. Leaving the home to live independently gives youth more autonomy to make choices about their lifestyle, including health habits. The tobacco industry has studied young Disclaimer: The findings and the conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. * Address correspondence to: Matthew C. Farrelly, Ph.D., RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709. E-mail address: [email protected] (M.C. Farrelly).
IMPLICATIONS AND CONTRIBUTION
This study provides unique insights into cigarette smoking during a critical life stage for establishing long-term health habits. We demonstrate that funding for state tobacco control programs and smoke-free air laws have been effective measures for reducing smoking among young adults.
adults with a goal of making smoking socially acceptable [2]. From 1990 to 2005, the prevalence of young adult smoking increased and then decreased; since then, it has been stable [1,3]. Data from the 2000 National Youth Tobacco Survey highlight that age 18 years is still very much a transition period for smoking patterns. In that survey, 21% of 18-year-olds were established smokers who had smoked at least 100 cigarettes in their lifetime and had smoked 20 out of the past 30 days [4]. However, an additional 11% had smoked at least 100 cigarettes in their lifetime and had smoked on 1e19 days in the past month (7%) or had not smoked in the past month (4%). Another 40% of 18-year-olds had at least experimented with cigarettes. These statistics suggest
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2013.09.015
482
M.C. Farrelly et al. / Journal of Adolescent Health 54 (2014) 481e486
that a large proportion of young adults are at risk of becoming established smokers. More recently, data from the National Survey on Drug Use and Health (NSDUH) show that smoking initiation increased from 2002 to 2009 among those aged 18 years and older [5]. Studies have found that some tobacco industry marketing efforts are focused on young adults [2,6] in the form of bar promotions [7], tobacco industry-developed “lifestyle” magazines [8], and advertisements for tobacco products and bar events in the alternative press (e.g., weekly newspapers) with high readership among young adults [9]. Ling and Glantz [2] call for increased tobacco control efforts targeting young adults. They note that tobacco control policies such as cigarette excise tax increases and smoke-free air laws are associated with reductions in smoking prevalence among young adults. A few national studies have examined the influence of cigarette prices and smoke-free air policies on smoking among young adults. Farrelly et al. found that higher cigarette prices were associated with lower smoking prevalence and decreased daily consumption among young adults aged 18 to 24 years: a 10% increase in price was associated with a 3% decrease in smoking prevalence [10]. In a similar study, Farrelly et al. found that a 10% increase in price was associated with a 2.7% to 3.2% decrease in prevalence among U.S. 18- to 24-year-olds from the Tobacco Use Supplements to the Current Population Surveys [11]. Based on longitudinal follow-up surveys of high school seniors from the Monitoring the Future Surveys, Tauras found that higher prices discouraged progression to heavier smoking [12] and increased cessation among young adults [13]. Tauras found that smoke-free workplace laws discourage young adults from progressing to heavier smoking [12]. Another study showed that 100% smoke-free workplace voluntary policies are associated with decreased smoking prevalence and consumption among young adults aged 19 to 24 years [14]. Finally, another study examined the effect of funding for tobacco control programs on young adult smoking prevalence [11]. A recent study found evidence of a sustained and steadily increasing long-run impact of tobacco control program spending on cigarette sales in states [15]. Farrelly and colleagues found that cumulative expenditures for state tobacco control programs was associated with a decreased prevalence of smoking among 18- to 24-year-olds [11]. The current paper is the first study that we are aware of to examine simultaneously the influence of cigarette prices, smokefree air laws, and funding for state tobacco control programs on young adult smoking behaviors. Our analysis merges data on state-level tobacco control policies with data from the 2002e2009 NSDUH, an annual household-based survey with national and state representative samples of young adults aged 18 to 25 years. Methods NSDUH is a national survey of illicit drug, alcohol, and tobacco use by the U.S. civilian, noninstitutionalized population aged 12 years or older that has been conducted since 1971. The 2002e2009 NSDUH employed a state-based design with an independent, multistage area probability sample within each state and the District of Columbia. The design oversampled youths and young adults, so that each state’s sample was approximately equally distributed among three age groups: 12 to 17 years, 18 to 25 years, and 26 years or older. Response rates for 18- to 25-yearolds ranged from 80%e85% during the study period. This study
focuses on young adults aged 18 to 25 years. The NSDUH data collection protocol was approved by RTI International’s institutional review board. Smoking outcomes We examined three smoking outcomes: (1) never smokers who initiated smoking in the past year; (2) current smokers; and (3) established smokers. Each outcome variable was a dichotomous indicator equal to 1 if the respondent met the criteria for the given outcome, and 0 otherwise. Young adults were considered to have initiated smoking in the past year if the date of reported first cigarette use was within 12 months from the date of the survey interview. A current smoker was one who had smoked on at least 1 day in the past 30 days. The common question for defining current smoking among adults (“Do you now smoke cigarettes every day, some days, or not at all?”) was not available in the 2002e2009 NSDUH. An established smoker was one who had smoked one or more cigarettes in the past 30 days and smoked at least 100 cigarettes in his or her lifetime. State tobacco control programs and policies We examined the influence on smoking outcomes of annual measures of state average cigarette prices, cumulative state funding for tobacco control programs, and the percentage of the state population covered by smoke-free air laws. The state average annual retail price per pack of cigarettes came from The Tax Burden on Tobacco [16]. Following previous analyses of tobacco control programs [11,17] we constructed a measure of per capita cumulative funding for state tobacco control programs using the state’s total population as the denominator. To compute cumulative funding, each year’s annual funding was added to all previous years of funding (beginning in 1985 and ending in 2009), which were discounted at a rate of 25% per year [11,15]. This measure was then converted to per capita terms by dividing state cumulative funding by the state’s total population. Cumulative funding was used to measure the persistence of investment in tobacco control programs such that funding for tobacco control in a given year continued to affect smoking outcomes in subsequent years. Funding includes state excise tax funding and general funds designated for tobacco control programs as well as funding from national sources, such as the National Cancer Institute’s American Stop Smoking Intervention Study (ASSIST), the Centers for Disease Control and Prevention’s (CDC’s) Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program, the Robert Wood Johnson Foundation’s SmokeLess States program, and the CDC’s National Tobacco Control Program, which combined ASSIST and IMPACT in 1999. Data on state funding for tobacco control come from a database maintained by RTI International. These data are collected from state reports and communication with state tobacco control programs. The data reflect actual expenditures, when available; otherwise, we include appropriations. For simplicity, we refer to tobacco control funding throughout. For both state tobacco control program cumulative funding and cigarette prices, we adjusted for inflation using the U.S. Bureau of Labor Statistics’ Consumer Price Index. Our measure of smoke-free air laws was represented by the annual percentage of the state population covered by state or local smoke-free air laws that ban smoking in at least one of the following locations: workplaces, restaurants, or bars [18]. State
M.C. Farrelly et al. / Journal of Adolescent Health 54 (2014) 481e486
and municipality population data were obtained from the U.S. Census Bureau [19]. In each year of the study period, the population of the municipalities with smoke-free air laws for workplaces, restaurants, or bars was summed and the total divided by the annual state population to calculate the percentage of the state that is covered by smoke-free air laws. Control variables Individual-level control variables included categorical indicators for the following basic demographic characteristics: gender (male, female); race/ethnicity (non-Hispanic white, nonHispanic black, non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Other Pacific Islander, nonHispanic Asian, non-Hispanic 2 or more races, or Hispanic); age (18, 19, 20, 21, 22, 23, 24, or 25 years); and U.S.-born (yes, no). We controlled for annual family income (
www.jahonline.org Original article
Are Tobacco Control Policies Effective in Reducing Young Adult Smoking? Matthew C. Farrelly, Ph.D. a, *, Brett R. Loomis, M.S. a, Nicole Kuiper, M.P.H. b, Beth Han, Ph.D., M.P.H. c, Joseph Gfroerer c, Ralph S. Caraballo, Ph.D. a, Terry F. Pechacek, Ph.D. a, and G. Lance Couzens a a b c
RTI International, Research Triangle Park, North Carolina Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta, Georgia Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, Rockville, Maryland
Article history: Received June 18, 2013; Accepted September 23, 2013 Keywords: Smoking; Young adults; Smoke-free air laws; Cigarette prices; Tobacco control programs
A B S T R A C T
Purpose: We examined the influence of tobacco control program funding, smoke-free air laws, and cigarette prices on young adult smoking outcomes. Methods: We use a natural experimental design approach that uses the variation in tobacco control policies across states and over time to understand their influence on tobacco outcomes. We combine individual outcome data with annual state-level policy data to conduct multivariable logistic regression models, controlling for an extensive set of sociodemographic factors. The participants are 18- to 25-year-olds from the 2002e2009 National Surveys on Drug Use and Health. The three main outcomes are past-year smoking initiation, and current and established smoking. A current smoker was one who had smoked on at least 1 day in the past 30 days. An established smoker was one who had smoked 1 or more cigarettes in the past 30 days and smoked at least 100 cigarettes in his or her lifetime. Results: Higher levels of tobacco control program funding and greater smoke-free-air law coverage were both associated with declines in current and established smoking (p < .01). Greater coverage of smoke-free air laws was associated with lower past year initiation with marginal significance (p ¼ .058). Higher cigarette prices were not associated with smoking outcomes. Had smoke-freeair law coverage and cumulative tobacco control funding remained at 2002 levels, current and established smoking would have been 5%e7% higher in 2009. Conclusions: Smoke-free air laws and state tobacco control programs are effective strategies for curbing young adult smoking. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Although 88% of adult smokers initiated smoking before age 18 years [1], public health researchers and the tobacco industry also consider young adulthood to be a formative period for smoking patterns [2]. Leaving the home to live independently gives youth more autonomy to make choices about their lifestyle, including health habits. The tobacco industry has studied young Disclaimer: The findings and the conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. * Address correspondence to: Matthew C. Farrelly, Ph.D., RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709. E-mail address: [email protected] (M.C. Farrelly).
IMPLICATIONS AND CONTRIBUTION
This study provides unique insights into cigarette smoking during a critical life stage for establishing long-term health habits. We demonstrate that funding for state tobacco control programs and smoke-free air laws have been effective measures for reducing smoking among young adults.
adults with a goal of making smoking socially acceptable [2]. From 1990 to 2005, the prevalence of young adult smoking increased and then decreased; since then, it has been stable [1,3]. Data from the 2000 National Youth Tobacco Survey highlight that age 18 years is still very much a transition period for smoking patterns. In that survey, 21% of 18-year-olds were established smokers who had smoked at least 100 cigarettes in their lifetime and had smoked 20 out of the past 30 days [4]. However, an additional 11% had smoked at least 100 cigarettes in their lifetime and had smoked on 1e19 days in the past month (7%) or had not smoked in the past month (4%). Another 40% of 18-year-olds had at least experimented with cigarettes. These statistics suggest
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2013.09.015
482
M.C. Farrelly et al. / Journal of Adolescent Health 54 (2014) 481e486
that a large proportion of young adults are at risk of becoming established smokers. More recently, data from the National Survey on Drug Use and Health (NSDUH) show that smoking initiation increased from 2002 to 2009 among those aged 18 years and older [5]. Studies have found that some tobacco industry marketing efforts are focused on young adults [2,6] in the form of bar promotions [7], tobacco industry-developed “lifestyle” magazines [8], and advertisements for tobacco products and bar events in the alternative press (e.g., weekly newspapers) with high readership among young adults [9]. Ling and Glantz [2] call for increased tobacco control efforts targeting young adults. They note that tobacco control policies such as cigarette excise tax increases and smoke-free air laws are associated with reductions in smoking prevalence among young adults. A few national studies have examined the influence of cigarette prices and smoke-free air policies on smoking among young adults. Farrelly et al. found that higher cigarette prices were associated with lower smoking prevalence and decreased daily consumption among young adults aged 18 to 24 years: a 10% increase in price was associated with a 3% decrease in smoking prevalence [10]. In a similar study, Farrelly et al. found that a 10% increase in price was associated with a 2.7% to 3.2% decrease in prevalence among U.S. 18- to 24-year-olds from the Tobacco Use Supplements to the Current Population Surveys [11]. Based on longitudinal follow-up surveys of high school seniors from the Monitoring the Future Surveys, Tauras found that higher prices discouraged progression to heavier smoking [12] and increased cessation among young adults [13]. Tauras found that smoke-free workplace laws discourage young adults from progressing to heavier smoking [12]. Another study showed that 100% smoke-free workplace voluntary policies are associated with decreased smoking prevalence and consumption among young adults aged 19 to 24 years [14]. Finally, another study examined the effect of funding for tobacco control programs on young adult smoking prevalence [11]. A recent study found evidence of a sustained and steadily increasing long-run impact of tobacco control program spending on cigarette sales in states [15]. Farrelly and colleagues found that cumulative expenditures for state tobacco control programs was associated with a decreased prevalence of smoking among 18- to 24-year-olds [11]. The current paper is the first study that we are aware of to examine simultaneously the influence of cigarette prices, smokefree air laws, and funding for state tobacco control programs on young adult smoking behaviors. Our analysis merges data on state-level tobacco control policies with data from the 2002e2009 NSDUH, an annual household-based survey with national and state representative samples of young adults aged 18 to 25 years. Methods NSDUH is a national survey of illicit drug, alcohol, and tobacco use by the U.S. civilian, noninstitutionalized population aged 12 years or older that has been conducted since 1971. The 2002e2009 NSDUH employed a state-based design with an independent, multistage area probability sample within each state and the District of Columbia. The design oversampled youths and young adults, so that each state’s sample was approximately equally distributed among three age groups: 12 to 17 years, 18 to 25 years, and 26 years or older. Response rates for 18- to 25-yearolds ranged from 80%e85% during the study period. This study
focuses on young adults aged 18 to 25 years. The NSDUH data collection protocol was approved by RTI International’s institutional review board. Smoking outcomes We examined three smoking outcomes: (1) never smokers who initiated smoking in the past year; (2) current smokers; and (3) established smokers. Each outcome variable was a dichotomous indicator equal to 1 if the respondent met the criteria for the given outcome, and 0 otherwise. Young adults were considered to have initiated smoking in the past year if the date of reported first cigarette use was within 12 months from the date of the survey interview. A current smoker was one who had smoked on at least 1 day in the past 30 days. The common question for defining current smoking among adults (“Do you now smoke cigarettes every day, some days, or not at all?”) was not available in the 2002e2009 NSDUH. An established smoker was one who had smoked one or more cigarettes in the past 30 days and smoked at least 100 cigarettes in his or her lifetime. State tobacco control programs and policies We examined the influence on smoking outcomes of annual measures of state average cigarette prices, cumulative state funding for tobacco control programs, and the percentage of the state population covered by smoke-free air laws. The state average annual retail price per pack of cigarettes came from The Tax Burden on Tobacco [16]. Following previous analyses of tobacco control programs [11,17] we constructed a measure of per capita cumulative funding for state tobacco control programs using the state’s total population as the denominator. To compute cumulative funding, each year’s annual funding was added to all previous years of funding (beginning in 1985 and ending in 2009), which were discounted at a rate of 25% per year [11,15]. This measure was then converted to per capita terms by dividing state cumulative funding by the state’s total population. Cumulative funding was used to measure the persistence of investment in tobacco control programs such that funding for tobacco control in a given year continued to affect smoking outcomes in subsequent years. Funding includes state excise tax funding and general funds designated for tobacco control programs as well as funding from national sources, such as the National Cancer Institute’s American Stop Smoking Intervention Study (ASSIST), the Centers for Disease Control and Prevention’s (CDC’s) Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program, the Robert Wood Johnson Foundation’s SmokeLess States program, and the CDC’s National Tobacco Control Program, which combined ASSIST and IMPACT in 1999. Data on state funding for tobacco control come from a database maintained by RTI International. These data are collected from state reports and communication with state tobacco control programs. The data reflect actual expenditures, when available; otherwise, we include appropriations. For simplicity, we refer to tobacco control funding throughout. For both state tobacco control program cumulative funding and cigarette prices, we adjusted for inflation using the U.S. Bureau of Labor Statistics’ Consumer Price Index. Our measure of smoke-free air laws was represented by the annual percentage of the state population covered by state or local smoke-free air laws that ban smoking in at least one of the following locations: workplaces, restaurants, or bars [18]. State
M.C. Farrelly et al. / Journal of Adolescent Health 54 (2014) 481e486
and municipality population data were obtained from the U.S. Census Bureau [19]. In each year of the study period, the population of the municipalities with smoke-free air laws for workplaces, restaurants, or bars was summed and the total divided by the annual state population to calculate the percentage of the state that is covered by smoke-free air laws. Control variables Individual-level control variables included categorical indicators for the following basic demographic characteristics: gender (male, female); race/ethnicity (non-Hispanic white, nonHispanic black, non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Other Pacific Islander, nonHispanic Asian, non-Hispanic 2 or more races, or Hispanic); age (18, 19, 20, 21, 22, 23, 24, or 25 years); and U.S.-born (yes, no). We controlled for annual family income (
