Abstract
Denormalization is an array of actions implemented to induce and reinforce the public perception of a health-compromising behavior as socially unacceptable. Active and second-hand tobacco use has substantial adverse effects on children's health. Tobacco has been marketed by associating its use with glamor, success, athleticism, and independence. Strategies for denormalization of tobacco use are designed to influence social norms to promote reduction of smoking behavior in our society. The social ecological model provides the theoretical framework on which these activities are based. Changing social norms about tobacco control requires a multilevel perspective that considers additive and interrelated effects on several levels—from the patient to the community. Models for changing social norms about tobacco have focused on reducing tobacco marketing, counter-marketing, restricting smoking in public places, reducing tobacco availability, and supporting tobacco dependence treatment services. As advocates for children's health, pediatricians can and should promote denormalization of tobacco use in their physician–patient communications, personal examples set, and in public policy advocacy activities. Pediatric health-care providers can promote denormalization of tobacco use through the following strategies: serve as a role model for a tobacco-free lifestyle, routinely address tobacco issues with pediatric patients, and provide treatment and/or referrals for tobacco prevention and cessation resources. Beyond the clinic, pediatric professionals can support tobacco-free ordinances in their communities and participating in state and national tobacco control campaigns. Wherever possible, training of medical students, residents, fellows, and other pediatric professionals in tobacco counseling and advocacy would contribute to further resources for denormalization of tobacco.
Magnitude of the Tobacco Epidemic
Smoking is a pediatric disease: 80% of adult smokers become addicted to nicotine as teenagers. 3 If an individual has not begun smoking by age 20, it is unlikely that he or she will ever start smoking. 4 Controlling the tobacco epidemic requires a commitment to prevention of smoking and tobacco use among children and adolescents. 3
For middle- and high-school students in the 1990s, peak prevalence rates for current smoking were 21% for those in 8th grade and 31% in 12th grade. 5 Reports of smoking prevalence declined over the past decade with current smoking estimated at 6% to 27% among those in 8th and 12th grades. 5 Reductions in smoking prevalence since 2007 have been minimal. 9 Smokeless tobacco is considered an escalating threat among adolescents with past month use for those in 10th and 12th grades at 6.5% and 8.4%, respectively. 5 These results signal the need to continue to emphasize tobacco prevention strategies among new cohorts of children and adolescents.
Risk Factors That Influence Children's Tobacco Use
A concise overview will be introduced to organize a description of the complexities of tobacco use behaviors among children and adolescents using the social ecological model perspective. 6 The model embraces human development as being influenced by and embedded among interacting ecological subsystems and settings. Both risk factors and protective factors shape and motivate behavior. 7 The ecological subsystems and settings that may impact tobacco use among children and adults have been labeled “levels of influence.” They are specified as intrapersonal, interpersonal, institutional, community, and public policy. A nonexhaustive list of determinants of tobacco use among young persons is presented based on a review of the literature (Table 1).
SHS, second-hand smoke.
The social ecological model provides an important framework for describing public health problems.30,31 Pediatricians and others dedicated to improving child health can use the model to identify the levels and targets for future interventions aimed at patients, communities, and populations. School- and community-based studies have examined the effectiveness of innovative tobacco prevention programs and achieved varying degrees of success.24,32 Targeting several levels of influence simultaneously for interventions offers the potential for improving child health and is a promising area of future research. 33 A limitation of social ecological models and other multidimensional models is that they do not have the requisite detail needed to guide behavioral interventions. 34
Social Norms
Social norms are defined as phenomena where group members exchange behaviors and act according to the shared customs and traditional ways of their group and population referents. 35 Successful norms communicate and reinforce survival-related actions such as positive social interactions and acquiring food and shelter. Unsuccessful norms can lead group members to engage in incorrect, inaccurate ways, including maladaptive behaviors. 35 Behavioral theorists have viewed the construct of social norms as part of a path linking an individual's attitude toward a behavior as being predictive of engaging in that behavior (eg, as proposed by Azjen and Fishbein). 36 There is tension among researchers about the behavior change theories being used correctly since most models emphasize changes on the individual rather than the population level. 37 Researchers from the communications literature have recognized that social norms can support changes in policy; however “the literature is silent on how or why.” 37
History of Tobacco Use Normalization
When tobacco was introduced to Europeans, it became a socially acceptable pastime with unknown health consequences. 38 With the advent of cigarette manufacturing in the 1880s, a proliferation of cigarette brands ensued accompanied by competitive advertising campaigns to solicit new customers. A half-century ago, smoking was considered normal in society; 42% of adult Americans smoked. 39 Smoking advertisements promoted cigarettes as enjoyed by doctors, successful professionals, and attractive and athletic young persons. Smoking was perceived as increasing one's status. Smoking was (and remains) glamorized in advertising and movies. 38
After documentation of premature death associated with smoking emerged, the tobacco industry deflected concerns associated with smoking by hiring influential consultants who masked the health risks. 38 Political forces coordinated efforts to halt regulation of tobacco by the government. Once the health problems with smoking surfaced, the tobacco industry modified certain cigarette brands to reduce exposures to tar and nicotine. A rapid increase in excess mortality from cardiovascular disease and cancer triggered the report about health hazards associated with smoking authored by the Surgeon General on Smoking and Health in 1964. 39
Since that report was published, cigarette advertising has ceased, sponsorships of sporting events by tobacco have been limited, and adult smoking rates have decreased by 50%. In 2007, the current use of cigarettes for those older than 24 years was about 20% (prevalence varies among the states). 40 Tobacco industry survival depends on marketing tobacco to young persons who might potentially become customers. 41 Promotions by the tobacco industry have induced children and adolescents to initiate tobacco use. Tobacco use remains a norm disproportionately concentrated among persons in low socioeconomic groups, who may be unemployed and can be medically underserved. 42
Tobacco Use Denormalization
The social norm change model postulates that the thoughts, values, mores, and actions of individuals are tempered by the community in which they live. 43 Denormalization is a population-based strategy of programs and actions implemented to reinforce to the public that tobacco use is not a mainstream activity. Denomalization strategies are designed to influence social norms and promote interest in abstinence, intentions to quit, and cessation.42,44–47 Social denormalization strategies seek to change the broad social norms around using tobacco—changing tobacco use from acceptable and desirable to unaccepted and undesirable. Tobacco industry denormalization seeks to expose the tobacco industry as a powerful, deceptive, and dangerous enemy of health, responsible for tobacco-related disease, and using manipulative tactics to promote its deadly and highly addictive product.43,46
Using this model to structure its tobacco control program, California has focused on 4 strategies. 48 The first involved countering pro-tobacco influences in the community by reducing the marketing of tobacco products in retail, tobacco industry sponsorship of local events, and depiction of tobacco products in the media. The second strategy involved reducing exposure to SHS through restricting smoking in public places, workplaces, and private places that serve the public. The third strategy pertained to reducing the availability of tobacco (ie, enforcement of laws prohibiting the sale of tobacco to minors, elimination of free tobacco product sampling, licensure of tobacco retailers, and establishment of tobacco-free pharmacies). The fourth strategy included support of tobacco dependence treatment services, financing the state Smokers' Helpline and community-based cessation programs. With these strategies, California has reduced adult smoking prevalence by 35% and decreased per capita cigarette consumption by 60.8% with a budget that is a small fraction of what the tobacco industry spends on promoting its toxic product in California. 48
Mass media marketing campaigns designed to change social norms have been highly effective among adolescents. Health education messages delivered by digital media and mobile telephones are well received because young persons are comfortable with technology.4,49,50 Effective campaigns for young persons have framed the tobacco industry as manipulative, motivated by greed, and unconcerned about the addictive nature and health hazards of tobacco use.27,42 In a review of focus groups on antitobacco marketing, messages about industry manipulation appeal to expressing independence among young people. Massachusetts showed the industry as “money-hungry companies that intentionally and willfully target youth with manipulative and deceptive tactics to get them addicted so they become customers for life (or until tobacco kills them).” A California advertisement portrays a man fishing and tossing caught fish onto the dock; the narrator reveals that tobacco companies are using nicotine to hook more smokers ending with the line, “The Tobacco Industry. They profit. You lose.” 51
Antitobacco messages have shown effectiveness in offsetting peer pressure to use tobacco at a young age. 52 One example of a successful component of denormalization effort is the Truth campaign. It targeted youths and used mass media advertisements to convey that using tobacco is not a cool image. 53 Youth exposure to Truth campaign advertisements was associated with reduced smoking and in intentions to smoke compared to those not exposed to the intervention.53,54 In contrast, recall of the tobacco industry sponsored, “Think Don't Smoke” campaign was associated with increased intention to smoke among middle and high school students. 55 Several policy-related strategies have been used to reinforce antitobacco social norms. The strategies include banning tobacco, limiting the sale and advertising of tobacco, focusing attention about an individual's choice to use tobacco, and reiterating these messages. 44 As previously discussed, another facet is tobacco industry denormalization, where the morality of the industry leadership is presented as unethical since the industry sells products that cause cancer.27,51
Pediatric Health-Care Providers Can Promote Denormalization of Tobacco Use
Physician communication can help to promote social norms. In 2005, >160 million office visits were conducted among children from birth to the age of 15 years. 56 If delivery of prevention and cessation messages occurred at office visits, this could result in millions of antitobacco messages. The American Academy of Pediatrics recommends that pediatricians model tobacco-free behavior at home, at work, at play, and in vehicles. Tobacco products, advertisements, and promotional items should not be displayed either in the office (such as in waiting room magazines) or in personal settings. 57
Pediatricians Counseling Children and Adolescents
The American Academy of Pediatrics recommends that prevention counseling for patients begin at age 5 and include strategies for tobacco refusal. 57 Ask the child to make a commitment to being a lifelong nonsmoker. Messages should be age-appropriate and personally relevant. Risks of bad breath, yellowed fingers, smelly clothes, and rewards of better performance in sports and money saved may be more relevant to a teen than risk of future lung disease, cancer, or premature death. 58
Pediatricians should be proactive about initiating dialogue about tobacco use; young patients are often reluctant to initiate these discussions. 59 One study found that pediatric patients reported greater positive perceptions of physicians when sensitive health behaviors were discussed. 60 Messages relayed to patients in the pediatrician's office may be complementary with other antitobacco messages received from other sources.
Referral for antitobacco prevention and cessation programs designed for children and adolescents may be beneficial. 61 In ASPIRE rates of smoking initiation were significantly lower (1.9% vs. 5.8%, p < 0.05) compared to a control group in an evaluation of the program. 62 ASPIRE is available in English and Spanish and can be accessed at http://www.mdanderson.org/aspire.
Tobacco Dependence Treatment and Denormalization
Highly effective tobacco dependence treatment is available.58,63 Close to half of current smokers have tried to quit. 58 Easy and widespread availability of effective tobacco dependence treatment can aid in reducing smoking rates. Decreasing the role models of smoking behavior can help to decrease the perception that smoking is normal in society. Barriers to widespread availability of effective tobacco dependence treatment include medication cost and inadequate health insurance coverage. 64 Extending financing and availability of tobacco dependence treatments would help contribute to reducing smoking rates and thus denormalization.
Despite the facts that tobacco dependence starts in childhood, is common, and has severe adverse health effects, and highly effective treatments are available, competencies for providing tobacco use prevention and cessation are not required by most pediatric specialty groups. 65 No requirements exist for the education and training about tobacco use prevention and cessation for pediatric specialty trainees, with the exception of adolescent medicine. 66 Leadership for ensuring that medical students, residents, and specialists demonstrate proficiency in tobacco use prevention and cessation may facilitate reduction in smoking rates and reduction in perception of smoking as normal behavior.
The pediatric clinic is a good setting for interventions since parents see pediatricians on average 4 times annually (more frequently than their own family physicians). 67 Most tobacco-dependent parents of children with asthma are considering smoking cessation. 68 The majority of parents are favorably disposed toward pediatrician advice about smoking cessation. Many parents who smoke would accept referral from their child's physician to a telephone tobacco dependence treatment program or Quit Line (see General & Referral Resources, Table 2). The vast majority of parents who smoke and who are willing to consider use of medication to treat tobacco dependence would accept that recommendation and/or prescription from their child's doctor. 69
Beyond the Clinic
Pediatric physicians can be important advocates for community health and health-related public policy.3,70,71 Pediatric physicians can participate in community groups and provide advice to community advocates, legislators, and the media. 72 Pediatricians can encourage and support the advocacy efforts by local, regional, and national professional associations. 71
Summary and Conclusions
Tobacco dependence is a severe chronic illness that starts in childhood. It is the number one cause of preventable morbidity and mortality among adults in the United States. Tobacco dependence is actively promoted by the tobacco industry, with promotional efforts focused on making smoking socially acceptable and associating smoking with attractiveness, independence, camaraderie, self-confidence, freedom, athleticism, and success. Denormalization is a population-based strategy of programs and actions to exclude tobacco use from being a socially acceptable activity. Denormalization strategies focus on creating a climate in which tobacco use becomes less desirable, less acceptable, and less accessible. Focusing on the paradigm of social norm change, the California Tobacco Control Program has reduced adult smoking prevalence by 35% and decreased per capita cigarette consumption by 60.8%. Pediatric health-care providers can play an important role in tobacco use denormalization in their counseling of children and their parents, the example set in their personal behaviors, and their involvement and advocacy in their communities.
Footnotes
Acknowledgment
No financial support sponsored this article.
Author Disclosure Statement
No financial disclosures were reported by the authors of this article.
Work was performed at M.D. Anderson Cancer Center.