Tobacco Truths: The Impact of Role Models on Children s Attitudes toward Smoking

Transcription

1 Tobacco Truths: The Impact of Role Models on Children s Attitudes toward Smoking Kathryn S. Meier, MPH, CHES The present study assessed the impact of parents, peers, siblings, cigarette advertising, and sponsorship as role models influencing attitudes toward smoking and smoking behavior in seventh- and eleventh-grade students. The participants completed an anonymous questionnaire concerning their current and future smoking behavior, attitudes toward a cigarette advertising ban, general attitudes toward smoking, and smoking status of parents and siblings. Fifty-one percent of the smokers reported that they are not likely to be smoking in the future. Smokers were found to have less negative attitudes than never smokers. Seventh-grade students who admitted to being triers or smokers had less negative attitudes toward smoking than eleventh-grade students. Parent smoking had no impact on attitudes. However, if a sibling smoked, the respondents attitudes toward smoking were less negative. Students appeared to be more aware of sport sponsorship than conventional advertising. Most never smokers favored a total cigarette advertising ban, versus only 35% of smokers. Results from this study suggest that intervention programs need to address nicotine addiction and be in place before grade seven. Investigation is further warranted in the shaping of attitudes toward smoking. INTRODUCTION AND BACKGROUND Cigarette smoking is the single most important preventable environmental factor contributing to illness, disability, and death in the United States. Currently, the age that children begin to smoke continues to decline. Approximately 60% of smokers start by age 13 and fully 90% start before age 20. The American Lung Association has estimated that there are three million smokers between This project and study were made possible through a grant from the New Jersey State Department of Health to the Middletown Township Health Department and is based on a masters fieldwork project completed by the author in the Graduate Program in Pubhc Health at UMDNJ-Robert Wood Johnson Medical School and Rutgers University The author is mdebted to the Middletown Township Health Department and to the administrators, teachers, and students of the Middletown Township School System for their enthusiastic support and cooperation. The author gratefully acknowledges Dr Joyce Morris for her encouragement, support, and helpful suggestions. A very special thank you goes to Mark Robbms for the inspiration and strength he provided continuously throughout this project Kathryn S. Meier is with the Rhode Island Lung Association. Address reprint requests to Kathryn S. Meier, MPH, Rhode Island Lung Association, 10 Abbott Park Place, Providence, RI Health Education Quarterly, Vol. 18(2): (Summer 1991) 1991 by SOPHE Published by John Wiley & Sons, Inc. CCC /91/ $04.00

2 174 the ages of 12 and 17. The younger the age at which children start smoking, the less likely they will ever quit. 2 Because of the disappointing relapse results often seen in adult smoking cessation programs, many health professionals are now focusing on prevention programs for preteens and adolescents. One theoretical basis to explain why children begin this unhealthy habit is Social Learning Theory pioneered by Albert Bandura. According to Bandura,3 much social learning occurs on the basis of casual or directed observation of other people in every day situations. He states that learning in young children depends extensively on the behavioral modeling that pervades their daily lives. One major source of this social learning is the abundant and varied modeling provided by visual media, which he contends, plays an influential role in shaping human thought and action. From this theory, cigarette advertisements can be viewed as powerful modeling sources shaping our children s ideas and behavior. Studies have shown that role models have a significant influence on smoking onset in children. The smoking behaviors of adults and peers who are personally known to the child, as well as those media figures on television, movies, and in cigarette advertising are believed to influence adolescent smoking behavior. These models provide images of typical smokers and influence adolescents attitudes and beliefs about the consequences and social acceptability of smoking. In a study by Gordon,~ it was reported that 51.5% of a group of teenage smokers responded that the media was a major influence in their decision to smoke. Of the children who had tried smoking, but had not yet become habitual smokers, 23.5% stated that their decision to try smoking was highly influenced by the media. According to Advertising Age, tobacco conglomerates Philip Morris Companies and RJR-Nabisco rank second and third respectively among the largest purchasers in the United States of advertising space. The rankings include only those &dquo;measured&dquo; media such as print, billboards and broadcast media, and do not include in-store promotions, free sampling, and sponsorships. Philip Morris Companies spent about $1.4 billion dollars for advertising in 1987 while RJR- Nabisco spent $1.09 billion These companies know only too well that their economic future lies in recruiting children via advertising. As stated earlier, the vast majority of smokers-an estimated 90%-start smoking as young children and become addicted at an early age. The reality is that the cigarette industry needs to have over two million children start smoking each year, well over 5000 per day, simply to replace the adult smokers who die or quit smoking, in order to keep the aggregate number of smokers from falling.b Cigarette companies claim that they do not advertise to children yet their ads clearly tell another story. Tobacco companies have begun a massive campaign to influence youngsters to associate cigarette smoking with the healthy, athletic, and glamorous lifestyles they aspire to, and to underestimate the dangers of smoking. Deceptive, manipulative advertising influences millions of children to start smoking every year. Many will eventually die as a result. According to Joe B. Tye2 of STAT (Stop Teenage Addiction to Tobacco), cigarette advertisers create imagery designed to instill a mental association between use of a product and satisfaction of fundamental psychological needs of

3 175 the target population. They use sophisticated market research to ascertain the aspired values and lifestyles of the target population, and use this to create advertising that links a certain product with those values and lifestyles. The influence of media on children s smoking behavior has critical public policy implications for smoking prevention programs. The intervention design of &dquo;tobacco Truths,&dquo; of which the survey examined here is one component, is based upon the theory of social modeling where observational learning and direct reinforcement are combined to create a stronger and more influential program for behavior change than modeling alone. In this view, Burke et al.7 found that competition and rewards, in an adolescent smoking prevention program, have a positive effect on knowledge gained and smoking intentions. Dr. Aitken,g~9 conducting research in London, has reported that younger children favor an advertising ban while older children, smokers, and triers do not favor such a ban. PURPOSE The goal of the present study was to assess the impact of parents, peers, siblings, cigarette advertising, and cigarette sponsorship as role models and their effect on attitudes toward smoking and smoking behavior in seventh- and eleventh-grade students. This survey was part of a larger grant funded intervention project designed to raise students awareness about deceptive cigarette advertising. This article will examine only the preintervention survey data from the &dquo;tobacco Truths&dquo; project. The specific objectives of the survey were to discover (1) the current self-reported smoking status of the students, (2) family influence on attitudes toward smoking, (3) awareness of cigarette advertising, (4) awareness of sport sponsorship by cigarette companies, (5) attitudes toward a total cigarette advertising ban, and (6) general attitudes about smoking. SAMPLE The Middletown Township public school system, which is the largest school district in Monmouth, has two high schools (grades 9-12) with a total population of 3,431 and three middle schools (grades 6-8) with a total population of 2,134. Results from this survey were predicated on responses obtained from 1,085 students who were present in school the day the survey was distributed. The students surveyed were seventh- (N 445) and eleventh- (N 640) grade students, representing 63% of the total seventh-grade population and 84% of the total eleventh-grade population in Middletown Township schools. Seventhgrade students were chosen because this age cohort is at the age of initiation students were chosen because for experimentation with smoking. Eleventh-grade of their prior exposure to a previous intervention regarding smoking and advertising.

4 176 METHODS Community Description The Township of Middletown, Monmouth County, New Jersey, has the largest population (72,000) of any community in Monmouth County. The community s demographic makeup is predominately white and middle class. Middletown Township is primarily a residential community that is interspersed with shopping malls and small businesses. Measures This survey was adapted from the Survey of Youth Smoking Behavior and the Cigarette Advertising Interview Form.9 Items concerned self-reported smoking status, family member smoking status, awareness of cigarette advertisements, awareness of sport sponsorship, attitudes regarding an advertising ban, and general attitudes about smoking. The participants completed an anonymous questionnaire concerning their current and future smoking behavior, awareness of cigarette advertising and sport sponsorship, attitudes toward a cigarette advertising ban, and general attitudes toward smoking. Information about the smoking status of the participants parents and siblings was also obtained. Confidentiality of the participants was assured by completion of a six-digit identification code that only the student would be able to decipher and would be able to repeat at a later date for posttesting. The code was derived by the student following standardized instructions. The survey was pretested with a group of seventh grade also reviewed by professionals in child development and survey validity. students and was research for PROCEDURES Surveys were distributed and completed by the students between October 12, 1988 and December 2, Access to students was obtained through the cooperation of school administrators in accordance with the larger grant project. The surveys were distributed to each school s principal along with instructions for the teacher who would be conducting the survey in his/her class. All surveys were conducted in English classes under the supervision of that teacher. RESULTS AND DISCUSSION Of the 1085 completed surveys, 42% were completed by seventh grade students and 58% by eleventh-grade students. The mean age for seventh-grade students was years, and the mean age for eleventh-grade students was years. The male to female ratio was approximately 1 : in both groups of students. It is important to note that these data were collected from predomi-

5 nantly white, middle class seventh- and eleventh-grade students. To extrapolate these findings to any populations differing in economic or racial variables would be an error. 177 Attitudes Toward Smoking Scale A 16-item Likert scale was used to assess general attitudes toward smoking in the study population. For this analysis, the individual mean score was used for the correlations. The maximum obtainable score was five, the minimum was one. The higher the mean score, the more positive the subject s attitude is toward smoking. The majority of students had negative attitudes toward smoking with a mean scale score of 1.99 (SD 0.67, N 1040) (Table 1). Smoking Behavior Students were classified into one of three categories: Never smokers, triers, and smokers. Triers are defined as those students who smoked only once or a few times, but not associating themselves as regular smokers. Assessment by gender revealed that 53% of the smokers were female, 58% of the triers were male, and 53% of never smokers were female. The finding that more females than males were smoking is as expected and supports 1985 data that slightly more females than males engage in daily smoking, while more males are triers. Table 1. Attitudes Toward Smoking Scale-Item Means a 1 strongly disagree, 5 strongly agree.

6 178 When examined by grade, 75% of seventh graders reported being never smokers while only 28% of eleventh graders reported being never smokers. Sixteen percent of seventh graders and 19% of eleventh graders reported trying smoking. When examining students who reported smoking more than once, only 9% of seventh-grade students were in this category, while 53% of eleventhgrade students could be classified this way. This finding, that more older students than younger students were smokers was expected and these data suggest that cigarette smoking has become widely accepted by the eleventh grade. Approximately one-third of the 19% who reported smoking at least a half a pack a day stated that they smoke more than half a pack a day. Of the 260 subjects reporting the cigarette brand they were currently smoking, Marlboro was by far the most popular brand, as 78% reported it was their brand, whereas only 4% reported smoking the second most popular brand, Newport. Table 2 shows students assessment of the probability of smoking in the future, based upon their current smoking status. The finding that over 50% of the students currently smoking believe that they will probably not be smoking in the future suggests that they assume that it will be easy for them to quit smoking when they decide to quit. Given our current understanding of addiction to nicotinell and the generally poor success rates of adult smoking cessation programs,l2 it is likely that this belief is a naive one. Of particular concern are those students who are uncertain of their future smoking status. Correlates of Smoking Attitudes The data were examined in a two-way analysis of variance. Main effects for grade and sex as well as a grade by sex interaction on attitudes toward smoking were tested. A main effect was found for grade showing that, in general, eleventh-grade students had less negative attitudes toward smoking than seventhgrade students [F (1101, 1) 52.25, p <.0001]. A main effect for gender was also found suggesting that male students had less negative attitudes toward smoking than female students [F (1101, 1) 4.64, p <.05]. The anticipated grade by sex interaction, however, was not significant. A three-way ANOVA was completed to examine the effect of smoking status (never smokers, triers, and smokers) and grade (seventh and eleventh) on attitudes toward smoking. A main effect for status was found [F (1008, 2) , p <.0001]. Post hoc analysis of the smoking attitude means by Table 2. Student Assessments of Future Smoking Statusa d (n 1065).

7 status utilizing the Student-Newman-Keuls test revealed that smokers had significantly less negative attitudes toward smoking than triers who had, in turn, significantly less negative attitudes toward smoking than never smokers. This result was in the expected direction. This analysis also revealed a main effect for grade [F (1008, 1) 7.03, p <.01] in which seventh-grade students had less negative attitudes toward smoking than eleventh grade students. This finding was contrary to expectations. These results were clarified as a status by grade interaction on attitudes toward smoking was found [F (1008, 2) 5.52, p <.01]. Analysis of means suggests no differences in attitudes toward smoking according to grade when students have never smoked. However, when students admit to being triers or smokers, seventh-grade students were seen to have significantly less negative attitudes toward smoking than eleventh-grade students. It must be noted that all mean attitude scores examined here ranged from the mildly to moderately negative range. Thus, it appears that as students progress from the seventh to the eleventh grades, attitudes toward smoking among triers and smokers become more negative despite a greater prevalence of smokers in eleventh graders. 179 Attitude Scale Correlations Spearman correlations were calculated to examine the associations of smoking frequency and amount with attitudes toward smoking. Attitudes toward smoking were positively correlated with frequency of smoking [r 0.56, p <.0001] and positively correlated with amount of smoking [r 0.48, p <.0001]. Family Influence on Smoking Attitudes In the aggregate sample, 56% of the respondents reported that a close relative (mother, father, or sibling) living with them was a smoker. Forty-nine percent of the sample reported that either their mother or father was a smoker, and 19% reported that at least one sibling smokes. A series of two-way ANOVAs were used to test the influence of parental or sibling smoking on the respondents attitudes toward smoking. Further, it was thought that the sex of the relative who smoked might differentially impact upon attitudes toward smoking of same sex rather than opposite sex respondents. Thus, four two-way differentially impact upon attitudes toward smoking of same sex rather than opposite sex respondents. Thus, four two-way ANOVAs were completed (1) mother smoking vs. mother does not smoke by male vs. female respondent, (2) father smoking vs. father does not smoke by male vs. female respondent, (3) sister smoking vs. sister does not smoke by male vs. female respondent, (4) brother smoking vs. brother does not smoke by male vs. female respondent.

8 180 When mothers smoked, students were seen to have marginal but significantly less negative attitudes toward smoking [F (1035, 1) 3.15, p < 10, x,, 2.03]. This finding was not seen when fathers smoked. In addition, the respondents attitudes toward smoking were significantly less negative when sisters smoked [F (1035, 1) 17.74, p <.0001, xs 2.22] and when brothers smoked [F(1035, 1) 20.78, p < 0001, Xb 2.27]. No main effects for gender of respondents or any sibling by gender interactions were found to be significant. This finding of the smoking behavior of family members impacting on attitudes toward smoking is as predicted. However, the highly significant finding of sibling influence over that of parental influence was not anticipated. It appears that smoking behavior of siblings may have a greater impact on the respondents attitudes toward smoking than the smoking behavior of parents. Awareness of Advertising and Sport Sponsorship When asked if there were any cigarette advertisements that they liked, 7% of seventh-grade females and 13% of seventh-grade males responded affirmatively, while 22% of eleventh-grade females and 19% of eleventh-grade males responded affirmatively to the same question. The prediction that more girls than boys would be aware of cigarette advertisements was not upheld at the seventh-grade level. In fact, almost twice as many boys reported cigarette advertisements they liked than girls. However, this discrepancy disappeared and was slightly reversed at the eleventh-grade level. When asked if they were aware of cigarette sponsorship of sporting events, 20% of the nonsmokers responded yes, while 28% of the triers and 32% of the smokers also responded yes. When separated by grade and sex, 15% of the seventh-grade females and 19% of the seventh-grade males reported being aware of cigarette sport sponsorship, while 21 % of eleventh-grade females and 42% of the eleventh-grade males reported being aware of cigarette sport sponsorship. This finding of males being more aware of sport sponsorship than females was as predicted and appears to reflect the increasing amount of cigarette advertising expenditures on promotional activities, particularly male dominated sporting events. When both seventh- and eleventh-grade students were asked whether cigarette advertising should be banned, 85% of the never smokers thought it should, 61 % of the triers thought it should be banned, while only 35% of smokers thought it should be banned. These findings were in the expected direction. Seventy-six percent of all seventh-grade males thought cigarette advertising should be banned and 89% of all seventh-grade females thought it should be banned, while only 50% of all eleventh-grade males and 52% of eleventh-grade females thought it should be banned. This dramatic decrease in favoring an advertising ban between eleventh- and seventh-grade students is ironic given the generally more negative attitudes toward smoking reported by the eleventh to ad- graders. This result also suggests that as students have more exposure vertising over the years, they may become more complacent towards this environmental influence. Finally, respondents who thought cigarette advertising should be allowed had less negative attitudes toward smoking [t (393, 1) 16.81, p <.0001].

9 181 CONCLUSIONS AND RECOMMENDATIONS There are many factors that influence children s attitudes toward smoking and smoking behavior and this study has examined several elements involving family, peers, and advertising as role models influencing behavior and attitudes. Results from this study, showing that 25% of seventh graders have already had some experience with tobacco and 51 % of smokers believing they are not likely to be smoking in the future, support the need for intervention programs. It appears that school health curriculums need to mandate instruction units addressing nicotine as an addictive drug and exploring the difficulties in quitting. These lessons should be part of a comprehensive K-12 program and begin well before the seventh-grade level. Another element to be addressed in such a curriculum should be methods to dispel the glamour of smoking. This may be especially critical in the younger grades, as evidenced by the students in the present study who were likely to have less negative views of smoking, especially if they were triers or smokers. The unexpected finding of sibling influence on the students attitudes toward smoking, apparently beyond that of parental influence, has been supported by other research&dquo; and warrants further investigation. Perhaps the sibling, because of their relationship to the child as a family member as well as a peer, serves as a strong role model for children s more positive attitudes toward smoking. Other studies of parental influence on children s attitudes toward smoking and smoking behavior have also not found a strong relationship Public health concern about tobacco advertising and promotion is based on the premise that these activities encourage the initiation of smoking and increase consumption, especially by children. This study points out the need to continue to examine how tobacco is promoted to children and at what age they become particularly vulnerable to the messages. The impact of sponsorship cannot be overlooked. With 42% of eleventh-grade males being aware of sport sponsorship, it is clear that further investigation is needed in the area of promotion versus conventional advertising and their effects on children s attitudes toward smoking and smoking behavior. In this study, the number of eleventh-grade smokers far exceeded the number of seventh-grade smokers. Yet, while the number of smokers increases with the grade level, their attitudes toward smoking seem to become more negative. However, the eleventh-grade students were also less favorable toward a cigarette advertising ban. It is unlikely that there is a simple rationale for these seemingly contradictory results. Some reasons for these findings may be the eleventh graders increased tolerance to cigarette advertising, reinforcement for their own smoking behavior and/or behavior they believe that others have a right to conduct, and greater awareness of First Amendment issues. Given our current knowledge on the censorship power of the tobacco industry and the findings of this study, we need to include information regarding the tobacco industry s advertising and promotional practices in our tobacco and nicotine educational programs. If we are to make a significant impact upon children s attitudes toward smoking, further investigation is warranted regarding the effect of role models, including advertising and siblings. If we are to achieve our goal of a smoke-free society during the next decade, the prevention and elimination of tobacco addiction must become a priority for the nation.

10 182 References 1. Smoking and Health: A Report of the Surgeon General. Department of Health, Education, and Welfare, DHEW Pub No (PHS) , Tye J: RJ Reynolds targets teens with sophisticated marketing campaign. Tobacco and Youth Reporter 2:1,3-4, Bandura A: Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J., Prentice-Hall, Gordon N: Never smokers, triers, and current smokers: Three distinct target groups for school-based antismoking programs. Health Education Quarterly 13: , Bailey W: Cigarette companies among top advertising buyers. Tobacco-Free Young America Reporter 4:6, Warner K: Selling Smoke: Cigarette Advertising and Public Health. Washington, D.C., American Public Health Association, Burke J, Naughton M, Becker S, Arbogast R, Lauer R, Krohn M: The short-term effects of competition and rewards in an adolescent smoking prevention program. Health Education Quarterly 14: , Aitken P, Leathar D, Squair S: Children s awareness of cigarette brand sponsorship of sports and games in the UK. Health Education Research: Theory and Practice 1: , Aitken P, Leathar D, O Hagan F, Squair S: Children s awareness of cigarette advertisements and brand imagery. British Journal of Adduction 82: , Gritz ER: Which Women Smoke and Why? In Not Far Enough: Women vs. Smoking, DHHS (NIH) Pub. No , The Health Consequences of Smoking, Nicotine Addiction: A Report of the Surgeon General. Department of Health and Human Services, DHHS (PHS) Pub. No , Shiffman S, Read L, Maltese J, Rapkin D, Jarvik, M: Preventing relapse in exsmokers : A self-management approach, in Marlatt A, Gordon J. (eds.), Relapse Prevention, New York, Guilford Press, Krohn MD, Naughton MJ, Lauer, RM: Adolescent cigarette use: The relationship between attitudes and behavior. Morbidity and Mortality Weekly Report 36(4S): 25S-34S, Hirschman RS, Leventhal H, Glynn K: The development of smoking behavior: Conceptualization and supportive cross-sectional survey data. Journal of Applied Social Psychology 14: , 1984.