Influences and Strategies to Prevent Tobacco Use and Exposure and Physical Inactivity

PREVENTION
Level of Influence / TOBACCO USE / PHYSICAL INACTIVITY
Individual / Behavior - Smoking and other tobacco product use (including e-cigarettes)
Focus on preventing
  • Initiation among youth and young adults
  • Tobacco related disparities among population groups
  • Tobacco use among workers
/ Behavior - Physical Inactivity - Sedentary behavior
Focus on preventing
  • Low levels of activity and inadequate moderate activity (not meeting the required 10 minute bouts of moderate physical activity for health)
  • Too much sitting (e.g., extensive time sitting in an automobile, time in front of television (i.e., screen time), other screen time [e.g., computer, video games], work, school [e.g., sitting])

Physical Environment /
  • Prevent Environmental Tobacco Smoke [ETS]) - Second and Third-hand smoke (i.e., residual nicotine in walls, furniture, etc.) for non-smokers(Clean Indoor Air Policies)
  • Eliminate easy access to products
  • Licensing tobacco retailers
  • Restricting number & density of tobacco retailers
  • Policy ending self-service displays
  • Point of purchase – product placement
/ Assess and address
  • Environmental infrastructures - built environment & transportation - that inhibit or make access to basic lifestyle related PA behavior (i.e., walking, biking) difficult and unsafe
  • Lack of access to places to participate in leisure-time activity/play
  • Policies that create barriers to physical environments (e.g., restricted access to play grounds; lack of snow removal, lack of enforcement of bike-pedestrian safety)

Social Environment /
  • Marketing to vulnerable populations (i.e., youth,women, and minorities); exposure to tobacco products
  • Affordability – Increasing the unit price (Taxes – state and federal, minimum price laws, restricting discounts and coupons)
  • Tobacco sales (restrictions)
  • Free tobacco samples, coupons
  • Sale of certain products (e.g., e-cigarettes, snuff)
/
  • (Indirect) Over marketing of products that inadvertently increase sedentary behaviors – automobiles, television, computers, cell phones, video games, (sports – spectator status)
  • “Normalization” of sedentary, low active lifestyles
  • Lack of enforcement of breaks in workplace and schools

Policy / Example policies that support continued tobacco use:
  • Exceptions/Exemptions to certain public structures (e.g., airports, casinos)
  • Advertising exceptions
/ Example policies that inadvertently support physical inactivity and create barriers to PA:
  • Allowing builders to opt out of sidewalks
  • Inadequate policies for PE including allowing wide range of waivers
  • Policies prohibiting walking or biking to school
  • Lack of policies limiting screen time

Influences and Strategies to PromoteTobacco Free and Active Living

PROMOTION
Level of Influence / TOBACCO FREE LIVING / ACTIVE LIVING
Individual / Behavior - Smoking Cessation
  • Quitting among adults and youth
  • Worksite assistance programs
  • Health care plan assistance
/ Behavior - Physically active lifestyles that include moderate PA behavior; moderate sedentary time
  • Individually adapted health behavior change programs
  • Settings based programs – Childcare, Schools, Worksites, Health care, Faith-based
  • Fitness Center, Health Club, Community Center, Senior Center programs (& subsidized membership)
  • School-based physical education

Physical Environment /
  • Smoke-free environments (e.g., parks, playgrounds, and other outdoor public places)
  • Smoke free multi-unit housing (or other built environment complexes)
  • No-smoking signage
/
  • Creation of or enhanced access to places/physical environments where participating in lifestyle and moderate PA behavior iseasy,appealing, and safefor all users (acrosslifespan and abilities). Heavy focus on built environment influences.
  • Comprehensive planning
  • Bike/Pedestrian plans
  • Neighborhood design
  • Sidewalks/Connectivity
  • Safe Routes to School
  • Public transit options (& Incentives)
  • Parks and Recreation sites (& reduced price for use)
  • Trails
  • Bike storage
  • Shower/Changing Facilities
  • Access to facilities for activity (i.e., joint use)
  • Community and street scale urban design land use
  • City planning, zoning, transportation
  • Building codes
  • Mixed-use development
  • Economic Development/Redevelopment
  • Connectivity to destinations
  • Health Impact Assessment

Social Environment /
  • State and local coalition support and promotion; Community mobilization
  • National Quit-line, free telephone support for cessation
  • Internet based interventions
  • Smoke-free environments (e.g., restaurants and bars, airports, worksites, multi-unit housing, mental health facilities, and other public places)
  • Counter advertising - Shifting social norms about smoking behavior – image of smokers - socially undesirable; Communicating “social disapproval” of smoking
  • Media Advocacy promoting tobacco-free norm (NCI ASSIST)
  • Retailer education about laws prohibiting sales to minors
/
  • Multi-sector involvement
  • Local and State coalition support and promotion
  • Community-wide campaigns (Media)
  • Point-of-decision prompts
  • Social support interventions in community settings
  • Settings based policies – Childcare, Schools; Worksites
  • Safe Routes to School (Education support component)
  • Informational campaigns
  • Counter marketing – “normalizing” active living; Shifting social norms about being sedentary (“socially-unacceptable”)

Policies / Example policies that support smokefree environments and deter behavior:
  • Tobacco-free settings and campuses including smoke free mental health facilities, multiunit housing
  • Increase in taxes and pricing of products
  • Advertising, discount, and coupon restrictions
/ Example policies that promote and support physical activity behavior:
  • Physical activity requirements in childcare settings
  • Physical education requirements in schools; School-based physical education and wellness policies
  • Joint use to public facilities like schools
  • Worksite policies encouraging/enforcing PA break time
  • Complete Streets

Key Informant Summary of Tobacco Prevention and Control Social Change Influences1with Physical Activity Comparisons

Influence / Tobacco Prevention and Control / Physical Activity Promotion
Examples of Movement Stimuli /
  • Dangers of secondhand smoke
  • Surgeon General Reports on tobacco (10 since 1964)
  • Mandate for annual reports on tobacco
  • Credible spokespeople
  • Generating a negative reaction by the public
  • An established enemy
  • Grassroots movements
  • Scientist educating government
/
  • Surgeon General Report (1996)
  • Health risks of physical inactivity
  • Health enhancements of physical activity
  • CDC/ACSM report 1995 (Pate et al.)
  • Physical Activity Guidelines for Americans (USDHHS, 2008a)
  • Obesity epidemic
  • Recent – Surgeon General’s Call to Action on Walking and Walkable Communities (Sept. 2015)

Original Objectives /
  • Spread word that tobacco is a health hazard
  • Control tobacco use
/
  • Spread word about health risks of physical inactivity
  • Clarify benefits from moderate levels of activity

Planning & Goal-setting Process /
  • Top down approach based on science/authority
  • Comprehensive state initiative via local health departments
  • Prescriptive legislation
/
  • Top down approach based on science
National level (recent):
  • National Physical Activity Plan, 2010
  • National Coalition for the Promotion of Physical Activity
  • Some state plans and policy agendas

Sparkplugs and Organizations Instrumental in Development / Select Examples
  • C. Everett Koop, former Surgeon General
  • President Clinton
  • David Kessler, Former FDA Commissioner
  • Joseph Califano, Secretary, Department of Health Education & Welfare
/ Select Examples
  • Robert Wood Johnson Foundation (e.g., Active Living by Design)
  • Trust for America’s Health
  • Michele Obama “Let’s Move”
  • President Clinton, Alliance for a Healthier Generation
  • (Senator Tom Harkin)
  • Thomas Friedan, CDC Director, Winnable Battles
  • Convergence Partnership
  • YMCA (i.e., Achieve & Pioneering Healthier Communities)
  • NFL “Play 60”
  • Nike (Fitness – “Just do it”)

Role of Government / Select Examples
  • Legislation: airline smoking ban, mandate for annual tobacco report
  • Generating key reports
  • President adopting issue
  • Forming National Clearinghouse for Smoking and Health (1965) and Office on Smoking and Health
  • Coalition Development
  • Zoning laws/public safety ordinances
/ Select Examples
  • Centers for Disease Control and Prevention – Division of Nutrition, Physical activity, and Obesity
  • Federal funding
  • Generating key reports, statistics
  • Transportation fund allocation
  • Complete streets, zoning and safety regulations

Importance of Legislation /
  • Warnings on tobacco packages
  • Banning ads (1971)
  • Clean indoor legislation
  • Tax Doubling (1980s)
  • Smoke-free Workplaces
/
  • Affordable Care Act (Funding for large scale interventions; Prevention focus)
  • Transportation bill

Opposition /
  • Tobacco Industry
  • Manufacturers
  • Farmers
/
  • No clear opponent or “enemy;” however, industries inadvertently promoting sedentary behavior – Transportation, Automobile, Television, Computer, Gaming, Spectator Sports
  • Possible - Builders, Planners, Public

Most Effective Strategies/Interventions / Select Examples
Individual level
  • Tobacco control programs
  • Education
  • Smoking Cessation
Social Environment
  • Use of media
  • Grassroots efforts; local groundwork
  • Capacity building
  • Coalitions
  • Focusing on Secondhand smoke
  • Social norm change
Policy
  • Lawsuits
  • FDA Investigation
  • Public policy change
/ Select Examples(Brownson et al. 2006; Keener et al. 2009)
Individual level
  • Extracurricular Physical Activity
  • Reduced screen time
  • Point of decision prompts
Physical Environment
  • Access to facilities
  • Enhance infrastructure for bicycling and walking
  • Public Transportation
Social Environment
  • Community wide campaigns
  • Safety
Policy
  • School-based physical education
  • Complete Streets
  • Urban planning
  • Transportation

Selected Funding Sources /
  • The Tobacco Settlement
  • CDC
  • Robert Wood Johnson Foundation
  • State taxes
  • National Cancer Institute
  • American Legacy Foundation
/
  • CDC (limited, state level [20-28 states]; CPPW, CTG Initiatives; Funding to national organizations like the YMCA)
  • Robert Wood Johnson Foundation
  • Kaiser Permanente
  • W.K. Kellogg Foundation

Economos, C., Brownson, R., DeAngelis, M., Novelli, P., Foerster, S., Tucker-Foreman, C., et al., (2001). What lessons have been learned from other attempts to guide social change? Nutritional Reviews, 59(3), S40-S56

J. Vrazel, Leverage Points Consulting, May 2016