The outcome consequences of defunding the Minnesota youth tobacco-use prevention program
Introduction
The late 1990s was a period of optimism within the tobacco control community. Before this, only a few states had tobacco control programs funded at a level to support an expectation of measurable success [1], [2]. With the independent settlements arrived at with a few states, plus the Master Settlement, it was believed efforts to launch larger and more meaningful anti-tobacco programs was at hand [3]. Since these settlements, few state tobacco control programs have been funded to their recommended levels, and most recently, state tobacco control programs have been legislative targets for budget cuts and even complete elimination [4], [5]. This has occurred in states where programs have been evaluated in depth, and there is outcome-based evidence demonstrating their effectiveness [6], [7], [8]. Because severe budget cuts have been so recent, and because they have led to the elimination of program surveillance and evaluation, little, if anything, is known about how reduced and/or eliminated funding has impacted states that had successful tobacco control programs [9].
In this paper we examine how program elimination impacted tobacco control program outcomes in Minnesota, a state that had a successful anti-tobacco youth prevention program. We employ the CDC logic model for the development and evaluation of tobacco control programs as an organizing frame of reference [10], [11]. This model postulates that exposure to anti-tobacco messages and involvement in anti-tobacco activities (immediate outcomes) reduces susceptibility to smoking, promotes anti-tobacco attitudes/beliefs, reduces intentions to smoke (intermediate outcomes) and with time, reduces the prevalence of cigarette use (ultimate outcome). Because of the relatively short time the program existed, we focus on immediate and intermediate outcomes. If program elimination had no impact on tobacco-use prevention, we would expect little or no change in measures of campaign message confirmed awareness during and after the campaign. Similarly, we would expect little or no change in susceptibility to smoking, attitudes/beliefs about tobacco and smoking or intentions to smoke. That is, just as the CDC logic model leads to hypotheses stating that immediate and intermediate outcomes precede reductions in tobacco use, we hypothesize that program dismantling results in reduced exposure to anti-tobacco program components and an increase in pro-tobacco precursors of tobacco use [12].
Section snippets
Minnesota's target market program
Funding for The Minnesota Tobacco Use Prevention and Local Public Health Endowment came from a share (about 8%) of the state's Master Settlement funds. A portion of these funds (about 20 million dollars annually) were allocated for a youth targeted tobacco-use prevention program grounded in the CDC logic model [13]. The program was modeled after the successful Florida Truth campaign. It adopted an industry manipulation message strategy, was branded and provided for substantial youth leadership
Samples and design
Demonstrating the success of prevention programs is difficult. In part, this stems from the relatively high and rapid expectations people set, and, in part, by the methodological difficulties (and costs) of demonstrating what would have happened in the absence of a prevention program. In the case of Minnesota's TM program, a repeated cross-sectional design was implemented. It called for four surveys to be conducted between the summer of 2002 and the winter of 2003. Surveys were planned around
Results
Table 1 contains data for the five measures of confirmed awareness of the program. Specifically, data are presented for one confirmed measure of each campaign component and two composite measures of confirmed program awareness. Overall, the data strongly suggest the “effects” of ending the program operated quickly. For example, TMO was the first component of the campaign to be eliminated. It was cut about 3 weeks after the defunding decision and only about 6 weeks prior to the third survey. The
Discussion
In discussing the results presented above, it is important to keep four points in mind. First, we do not have data for a pre-campaign baseline. As noted above, this is quite likely more important when considering the intermediate than the immediate outcomes. This reflects the fact that the campaign components and brand did not exist prior to the campaign. It would have been ideal to have pre-campaign measurements for the intermediate outcomes. The lack of these is off-set to some extent by the
Acknowledgments
The authors wish to express their appreciation to the Minnesota Department of Health for allowing us open access to the data collected under a contract with the Tobacco Research and Evaluation Center. We also want to thank Terry Pechacek, PhD; Associate Director for Science, Office on Smoking and Health, CDC for his encouragement and the meticulous and valuable comments he made on an earlier draft.
References (30)
- et al.
Assessing the reliability and validity of anti-tobacco attitudes/beliefs in the context of a campaign strategy
Prev. Med.
(2004) Cognitive susceptibility to smoking and initiation of smoking during early childhood: a longitudinal study
Prev. Med.
(1998)State programs can reduce tobacco use
(2000)- CDC. Best practices for comprehensive tobacco control programs-August 1999. Atlanta GA: US Department of Health and...
- US Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, GA: CDC,...
- Campaign for Tobacco-Free Kids, American Lung Association, American Cancer Society, American Heart Association,...
- CDC. Investment in Tobacco Control: State: State Highlights. Atlanta, Ga: US Department of Health and Human Services,...
The effectiveness of state-level tobacco control interventions: a review of program implementation and behavioral outcomes
Annu. Rev. Public Health
(2002)Tobacco control in the wake of the 1998 Master Settlement Agreement
N. Engl. J. Med.
(2004)- et al.
State expenditures for tobacco-control programs and the tobacco settlement
N. Engl. J. Med.
(2002)
Tobacco use prevention and local public health endowment: report on 2001 activities
Cited by (30)
Identifying misclassification in youth self-reported smoking status: Testing different consent processes of biological sample collection to capture misclassification
2015, Drug and Alcohol DependenceCitation Excerpt :This measure was coded none versus one or more (0 = none; 1 = one or more). This is a validated CDC recommended item shown to predict susceptibility to uptake (Sly et al., 2005). Youth who did not submit a biological sample and those who did but had an indirect explanation of its use had a similar number of interviews, while the third group (biological request using a direct explanation of its use) had a substantially fewer interviews (Table 1).
Exposure to school and community based prevention programs and reductions in cigarette smoking among adolescents in the United States, 2000-08
2012, Evaluation and Program PlanningCitation Excerpt :However, the funding was substantially cut since 2003 (Dietz et al., 2010). A few studies have examined the impact of this funding cut at the local levels (Dietz et al., 2010; Gingiss & Boerm, 2009; Ibrahim & Glantz, 2007; Niederdeppe, Farrelly, Hersey, & Davis, 2008; Pizacani et al., 2009; Sly et al., 2005). However, information is lacking regarding the overall impact of this funding cut on prevention programs and the effect of tobacco control at the national level.
Use of mass media campaigns to change health behaviour
2010, The LancetCitation Excerpt :Some studies have used time series analyses12 or natural experiment designs that exploit variation in degree of exposure to the media campaign and adjust for exposure to other tobacco control policies, and have found beneficial independent effects of campaigns.13,14 The achievement of adequate exposure to media campaigns seems important for reducing population tobacco use; withdrawal of media campaigns has been associated with a decline in beneficial effects.10,12,15,16 This outcome is unsurprising while influences that promote tobacco use remain (eg, marketing and the addictive nature of tobacco).
Memory issues pertaining to social marketing messages about behavior enactment versus non-enactment
2009, Journal of Consumer PsychologySmoking Patterns in Oregon Youth: Effects of Funding and Defunding of a Comprehensive State Tobacco Control Program
2009, Journal of Adolescent HealthThe reach of a youth-oriented anti-tobacco media campaign on adult smokers
2008, Drug and Alcohol Dependence