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

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

Influences and Strategies to Prevent Tobacco Use and Exposure and 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

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
  • 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
  • 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