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Anti-smoking education -

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Norman Swan: Smoking, though, still is the king hit of risk factors and the fact is that if you're not smoking before the age of 20, you're unlikely ever to take it up. So stopping adolescents from smoking is crucial.

One way is to keep on increasing the price of cigarettes as kids don't have a lot of money to spend. Pack warnings are also a vehicle for anti-smoking messages. And yet another popular way is through education. The trouble with education about almost any risk factor is that there's almost no evidence it does any good. Most kids know that smoking's bad for you. They just don't care much.

But researchers at the University of Pittsburgh have found success in coming at the issue from the side by teaching kids media literacy to understand how the media manipulate them.

Here's Brian Primack, who's Associate Professor of Medicine and Paediatrics at the University of Pittsburgh.

Brian Primack: We did this study because a lot of tobacco control programs in the United States and worldwide are not as effective as we would like. So there is a need to innovate in this area. A lot of the traditional types of education that deal with showing people black lungs and things like that sometimes are effective among some individuals but haven't been as effective as we would like.

Norman Swan: Particularly with young people.

Brian Primack: Particularly with young people who are the people who are going to be first of all those who are focused on by the industry because they can potentially be long-term smokers, and because those people are more impressionable by a lot of the marketing tactics.

Norman Swan: So what are the marketing tactics these days, given that tobacco advertising is largely illegal or hidden?

Brian Primack: It's a very good question because even though we don't see it as directly, they are actually spending more money than ever according to Federal Trade Commission reports. So where is that money going? Well, a lot of it is going to things that have replaced traditional advertising. So, for example, in 1998 there was a big ban on billboard advertising in the United States as part of the master settlement agreement. Well, what they immediately started to do was just to create smaller sized point-of-sale advertisements which are now very, very common. And that actually ended up benefiting the industry in many ways because they are cheaper to make and they are able to target them at specific areas. Another example is that there are many, many more coupons, many, many more promotions than we've seen in the past. So these are the types of things that are able to target the market. So even though it may not be as visible to you and I, it actually is still a tremendous amount of marketing money.

Norman Swan: And of course these things tend not to happen in Australia where point-of-sale advertising is banned nationally. But there is also use in the media, such as in movies.

Brian Primack: Yes, and use in movies is an example of a very important exposure. There have been many studies done over the past decade or two which have shown very surprising results. People have found in very well done studies, longitudinal, that exposure to smoking in movies, for example, may be even more powerful than things that we think of as the most traditional exposures. For example, if your parents smoke, if your friends smoke.

However, if you think about this conceptually it does make sense. If your parents smoke you are likely to see a lot of the positives, but you are also likely to see a lot of the negatives. If there's a kid at school who smokes, you may think of that as interesting and forbidden fruit and cool, however you may also think that kid is a loser, and so that may not be so influential. But if your favourite movie star lights up at a time in the movie that's particularly dramatic and they are backlit and they look wonderful, that could actually be a more potent exposure. So it's important that people understand that at least in the past the industry has been behind some of those movie exposures.

Norman Swan: And what did you do in this media literacy study?

Brian Primack: In this study we randomised 64 classrooms in three different high schools to receive either a strong traditional program that was considered state-of-the-art…

Norman Swan: So 'scare the heck out of you'?

Brian Primack: That type of program, exactly, versus a media literacy program that was more innovative, more subtle in terms of the 'scare the heck out of you' aspects, but talked more about how the industry operates and also just teaching young people to analyse and evaluate the messages that they see.

Norman Swan: What was the outcome you were looking for; taking up smoking in the first place, stopping even though you'd started as a kid?

Brian Primack: That's a very good question, and this is a very early study, so our outcomes at this point are much more proximal. There are things like your attitudes towards smoking, whether you intend to smoke in the future. Because this was a relatively short-term study because this is so relatively new in this area. What we will want to do in the future is actually look longer-term at uptake of smoking, established smoking down the road and that type of thing.

Norman Swan: And what did you find?

Brian Primack: What we found is that both programs were valuable in different ways, which makes sense because we weren't comparing a strong program to absolutely nothing, or the gold program to the brown program or something like that. We were comparing two valuable programs. So attitudes, for example, towards smoking were reduced by both programs. However, we found that young people liked the media literacy program much more. They were more likely to say that it really changed their minds about smoking, of course to say that they changed their minds about advertising. They said it was more likely to keep their attention and that type of thing. And then there also was a reduction in the amount of intention to smoke in the future among the highest risk group.

Norman Swan: So they became more sceptical?

Brian Primack: They became more sceptical, yes. We had measures of exactly that type of critical thinking, and there were differences in those outcomes as well.

Norman Swan: So what you don't know is whether it lasts.

Brian Primack: Very true, we don't know, and that will be very important to see because most educational programming that we do, it tends to start to disappear over time, unless there is some kind of sustained education.

Norman Swan: And how old were they?

Brian Primack: They were in the 9th and 10th grades, which is around 14 to 15 years old here.

Norman Swan: So a maximum age of smoking acquisition really.

Brian Primack: Exactly, we'd focused on that particular time because that is really when people take up smoking and start to get more established smoking.

Norman Swan: And any difference between girls and boys, because at least in the Australian context more girls are taking up smoking.

Brian Primack: It's a very good question and we did specifically look at that and we did not find differences in females or males in this particular study, but it is very important to look at because there are different risk factors for females versus males.

Norman Swan: And in your media literacy training did you talk about body image and smoking, because one of the reasons girls smoke is they think they are going to be thinner, and thinness is something which is projected by the media.

Brian Primack: Yes, and there is a specific module of the program that talks about advertising to special populations, and females is one of those. And during that we specifically focused on what types of techniques are they using to attract females.

Norman Swan: Did it have a sort of collateral effect on other kinds of advertising? Because kids are exposed at prime time to unhealthy foods, calorie-rich, nutrient-weak foods. Did you actually assess whether or not they became sceptical about other things that were unhealthy in their environment?

Brian Primack: That's an excellent question and we did. We had two different scales to measure media literacy. One was media literacy specifically related to smoking, smoking media literacy. The second was general media literacy. And there were changes that were statistically significant in general media literacy as well as smoking related media literacy, but the ones for general media literacy were not as strong, and that's probably because we were focusing on smoking-related images. But your point is very well taken, that this is a paradigm that we could apply to many other areas that involve the media and involve health education.

Norman Swan: So how resource intensive was it? Is it a sustainable program in schools?

Brian Primack: It is sustainable in some ways, but it will be a challenge in others. It's sustainable in that many of the teachers actually enjoyed this more than they do the traditional programming, and so in that way we feel like it might be more likely to be sustained over time. However, it still is resource rich, it still is the type of thing that teachers don't come in knowing, that they still need to be taught. And for that reason one the things we are doing as a next step is actually creating an online completely computerised version that will have implementation fidelity, and perhaps then people will just be able to go to the website, log in, that may take fewer resources. So we've been testing that, and that program does seem to be promising in early stages. We still have a lot more work to do.

Norman Swan: Tell me about this growing phenomenon in the United States of hookah bars and kids smoking tobacco via water pipes.

Brian Primack: It has become more popular over the past decade or so.

Norman Swan: So describe the phenomenon.

Brian Primack: So the phenomenon is that there are these apparatus called a hookah, a water pipe, a nargile, a bong, and they were used in the '60s and '70s, you may recall, to smoke marijuana and other substances…

Norman Swan: I never inhaled.

Brian Primack: Oh of course. But they are making a big comeback to smoke purely tobacco, which is completely legal. Some of the reasons behind the comeback are that there is a lot of negativity about cigarette smoking because we've had so many educational programs that deal with cigarettes. And so people are looking for alternatives, and this seems more pleasant to many young people. The water cools it down and makes it less harsh and irritating. The locations are very beautiful and covered in rugs, there are cushions on the floor, it's a very social kind of phenomenon where many people can share the same hookah. And so for those reasons it seems to be catching on.

Norman Swan: And flavoured tobacco.

Brian Primack: The tobacco is always flavoured, the tobacco is called shisha, sometimes it's called mu'assel, which is Arabic for 'with honey' because it's also sweetened, usually with the glycerin, but yes, you can get strawberry and cherry and chocolate flavour and piña colada flavour, which is very interesting in the United States because we now have laws that you are not allowed to create cigarettes with youth oriented flavouring such as that. So if you want a mango flavoured smoke, then your only way to get that is going to be at the hookah bar.

Norman Swan: And of course in the United States you're not allowed to drink until you are 21, so this is almost like a surrogate for drinking.

Brian Primack: Exactly, there is this a very important period of time between 18 and 21 where tobacco sale is legal, but alcohol is not. And that is the period of time that young people are in colleges and universities and a very important time for social phenomena such as this.

Norman Swan: So if they were smoking opium, people would be pretty upset because you get hooked on opium, but it wouldn't take too many hookah pipes for you to get hooked on nicotine, which is probably a more potently addictive drug.

Brian Primack: That's right, theoretically as few as eight cigarettes of nicotine can change the brain in functional MRI actually looking at changes in the brain. And one hookah-smoking session delivers between two and three times the nicotine of a single cigarette. And so what that would mean is even if you go just a few times with some friends, you may be getting enough nicotine to sensitise the brain. What we need to do is the research then looking and seeing prospectively if those people really do transition to cigarettes or to stronger doses or more frequent doses of water pipe. And so that's something we will be looking at.

Norman Swan: So hookahs is a gateway drug to cigarettes.

Brian Primack: It may be. It may also be a gateway drug to other types of drugs because simply the practice of learning how to take the substance, in this case tobacco, but stick it in the bowl, light a piece of charcoal and put that on top…

Norman Swan: You light some charcoal? Just for some extra carcinogen.

Brian Primack: That's right, and people are concerned about that. In fact we've had some case reports of young people actually going to the emergency department after smoking hookah tobacco with carbon monoxide poisoning.

Norman Swan: My God! Brian Primack, who is Associate Professor of Medicine and Paediatrics at the University of Pittsburgh.