|INCREASING TEEN SAFETY BELT USE|
D. Other Promising Public Health Approaches Aimed at Risky Youth Behaviors
Prevention efforts targeted at youth traditionally rely on education and persuasion approaches. Because schools are the primary institutions with access to youth under the age of 20, the most common prevention strategy has been education—especially school-based prevention.36 13 This approach focuses on changing knowledge and beliefs, teaching new skills, and/or modifying other individual-level factors (e.g., increase self-esteem, stress management, or personal commitment).
Much research has been conducted to determine the effectiveness of school-based strategies.131 164 70 14 99 66 According to Caulkins, Pacula, Paddock, and Chiesa,21 the benefits of school-based drug prevention are several times greater than the costs. They estimate that society benefits by $840 on an average student’s participation in drug prevention, compared with a program cost of $150 per participating student.
Researchers now contend that educational approaches—especially those in schools—do not provide an answer to the problem. Young people are affected by a broad range of societal influences, such as peers, family, media, and the government. Thus, environmental approaches, particularly those focused on policy development, have been considered promising. However, these two seemingly polar approaches—educational and environmental—are perhaps best when paired together. Goodstadt examined the effectiveness of both approaches and determined that (1) neither traditional alcohol, tobacco, and other drug (ATOD) education curricula nor school policies by themselves can effectively prevent ATOD abuse, and (2) education and school policies must incorporate the norms of the community into planning and implementation.
In reviewing literature on high-risk adolescent behaviors (generally ATOD), several themes emerge:
One framework that has received considerable attention is the theory of risk reduction and protective factors. Risk factors include biological, psychological/behavioral, and social/environmental characteristics. One often tested and supported hypothesis derived from this framework is that the more risk factors a youth experiences, the more likely it is that the youth will experience ATOD use and related problems in adolescence or young adulthood. The more the risk in a child’s life can be reduced, the less vulnerable that child will be to subsequent health and social problems. Protective factors, such as solid family bonds and the capacity to succeed in school, have the potential to safeguard youth from ATOD use. Research on protective factors examines positive characteristics and circumstances in a person’s life and attempts to find ways to strengthen and sustain them. The domains in which risk and protective factors exist are at every level of which an individual interacts with others and the society (i.e., individual, peers, family, school, community, or society).
In a recent Prevention Researcher publication,130 Cheryl Perry of the University of Minnesota notes that models driven by social psychology and empirical findings on antecedents of drug use generally identify three levels of risk factors critical to the development of effective prevention programs. These include: (a) environmental, (b) personality, and (c) behavioral. The author continues to discuss that longitudinal research increasingly supports a broad-based, multi-level, three-factor prevention approach rather than concentrating on a single factor or subset of risk factors. The social influence model suggests that primary prevention programs are most effective when (1) the target behavior of the intervention has received increasing societal disapproval, such as cigarette smoking, (2) multiple years of behavior health education are planned, and (3) community-wide involvement or mass media complement a school-based, peer-led program.
With respect to school-based prevention programming, Hansen70 found that successful programs tended to include social influence approaches. In other words, most programs included a variation of tactics that were aimed at not just the student, but the environment around the student. Specifically, he identified that effective school-based prevention programs included some combination of normative beliefs, personal commitment, information, and resistance skills strategies. Affective approaches (e.g., self-esteem, decision making, stress management, and goal setting) were least likely to be successful.
Bosworth’s recent examination into prevention programs13 found evidence that some strategies are actually ineffective. These include scare tactics, providing only information on drugs and their effects, self-esteem building, values clarification, large assemblies, and didactic presentation of materials. Bosworth notes that ATOD prevention needs to target all students and that because risk factors are present years before initiation, prevention activities must start early, in elementary school, and be periodically reinforced as students encounter new social situations and pressures to use substances. Further, programs designed to meet the developmental needs of the students also should be offered at each grade level with care not to over-saturate students to the point where they discount the information. Content areas that were identified as necessary for an effective curriculum include: normative education, social skills, social influences, perceived harm, protective factors, and refusal skills. These principals can certainly be applied to the teen safety belt issue. Normative education and positive peer pressure, along with environmental strategies (e.g., enforcement) may be more effective than scare tactics, for example.
Most smokers begin to smoke at an early age and are smoking on a regular basis by 18.168 169 While there are some health risks at early ages (e.g., to pregnant women), most of the major health risks, such as for lung cancer and heart disease, occur after age 40. However, because of the addictive qualities of cigarettes, smokers have difficulty quitting. Relative to teen safety belt use, the health risks are probably larger, but in the more distant future.
The effect of tobacco control policies on smoking behavior may provide guidance in the type of policies that might encourage teen safety belt use. An array of strategies has been adopted in attempts to stem smoking behaviors. Interventions will be considered in two categories: (1) those directed at youth, and (2) those directed at the general population. In a concluding section, general lessons that may apply to teen safety belt use will be given.
a. Strategies Aimed at Youth
National, State and local community media campaigns have been directed at decreased smoking and/or increased health-enhancing attitudes among minors.103 177 83 57 Following implementation of a comprehensive State campaign in Florida, Bauer, Johnson, Hopkins, and Brooks9 found that cigarette use among middle schoolers declined by 40 percent and among high schoolers by 16 percent over a two-year period. School education programs and community programs accompanied the media campaign in Florida.
The success of media campaigns has been found to depend on the content, other policies in effect, and the intensity of ads.106 108 53 Studies of the Massachusetts and California media campaigns report that different contents proved successful. The more successful campaigns employ a social-marketing approach in which multiple themes are directed at specific demographic groups (e.g., Hispanics, African Americans, etc.), followed by consumer testing and feedback, and responsiveness to that feedback.104 111 Those campaigns, which are part of more comprehensive programs, such as those in California, Florida, and Massachusetts, also tend to be more successful. The media attention from other tobacco control policies reinforces the message of the tobacco control media campaigns. Campaigns of greater intensity (e.g., expenditures per capita, or advertisement per person) and of longer duration also tend to be more successful.
Like early mass media campaigns, early school education programs were often geared toward educating students about the harms of smoking. More recent programs have focused with somewhat greater success on teaching life skills, and about the socio-political climate surrounding tobacco use.
The studies of school education policies yield mixed results.23 85 103 168 169 Some studies find reductions in prevalence rates as high as 50 percent, and effects sustained as long as 5 years, but many of the better studies fail to find any long-term beneficial effect.132 Those that indicate success generally find that they affect attitudes and lead to some short-term change in use. Most of the studies that find success examine younger students (age 12–15) and do not examine later smoking behaviors, such as those after graduating from high school.
Youth access policies aim to enforce laws that prohibit the sale of cigarettes to minors. Enforcement by States and local communities may involve some combination of compliance checks, penalties, publicity, and bans on self-service displays and/or vending machines.
Reviews by Levy and Friend109 and Forster and Wolfson54 report consistent evidence from a large number of studies that youth access policies reduced the percentage of stores selling to youth. Studies indicate greater retail compliance rates when there are self-service and vending machine bans, sufficient compliance checks, strict penalties, merchant awareness programs, and community mobilization. However, the studies provide limited evidence that youth access policies are effective in terms of reducing smoking prevalence, 109 159 50 except in some cases when retail compliance is high (i.e., above 90 percent). Two of the studies93 55 reporting reductions in smoking rates involved programs with heavy community participation, suggesting the need for supportive tobacco policies. Studies indicate that youth generally obtain cigarettes from non-retail sources, such as theft, older peers, and parents.57 As retail sales to youth are reduced, youth further switch to non-retail sources, 107 58 50 suggesting the need for other policies to also target these other sources.
Youth access policies are usually directed at retailers selling to youth, and hence the application to teen safety belt use is less clear. However, an important lesson from these policies is that, like media campaigns and school education programs, they are more successful when part of a broader campaign. This suggests that there are synergies from multiple policies. A higher intensity of individual programs also appears to improve their success at reducing risky behaviors.
b. Strategies Aimed at the General Population
Another policy found to reduce smoking is clean air laws.83 169 109 By limiting smoking in public places, clean air laws reduce opportunities to smoke. They also reduce smoking by reinforcing social norms against smoking. While clean air laws do not have a direct analogue in safety belt campaigns, they both can be considered parts of broader campaigns to reinforce social norms against unhealthy behaviors; policies that encourage safety belt use are part of a broader strategy to encourage traffic safety.
One of the policies most consistently found to be effective in efforts to reduce smoking in the general population is raising cigarette taxes.123 185 28 83 105 169 Tax increases generally yield at least commensurate increases in cigarette price,97 163 which, in turn, reduces the quantity smoked per smoker and induces some smokers to quit. Studies also indicate that youth are particularly sensitive to price increases. This result follows from economic theory, which suggests greater effects, because cigarettes costs are a larger portion of youth’s disposable income.
While taxes also do not have a direct analogue to strategies to increase safety belt use, tax studies suggest the importance that economic factors can have in influencing risky behaviors. This tendency would suggest that more severe and more certain fines or differential insurance rates may be an effective strategy, especially among youth, in encouraging safety belt use by imposing higher costs on non-users.
Some States (e.g., Arizona, California, Massachusetts, and Oregon) have had large impacts on adult smoking rates through comprehensive campaigns.22 24 26 The campaigns involved increased taxes, clean air laws, media campaigns, and cessation treatment programs, again suggesting the importance of multiple approaches. This suggests that through role modeling and increased attention to traffic safety, general safety belt use campaigns may be an effective way of reaching youth.
c. General Lessons
a. Model Programs, Interventions, and Strategies That Have Potential Application to Increase Teen Safety Belt Use
Although there is some disagreement about what exactly constitutes a harm-reduction approach to drug and alcohol use, e.g. 84 generally, harm-reduction policies are intended to prevent alcohol-related problems by targeting heavy (risky) drinking, drinking in risky situations, or the relationship between drinking and problem outcomes, without necessarily affecting overall consumption.137 147 As with public health policies, some harm-reduction policies may rely on deterrence. However, the focus of the deterrence is on specific problematic drinking behaviors (e.g., drinking and driving, or intoxication). Other harm-reduction policies may not depend on deterrence, but rather provide the means for young people to avoid risky drinking situations (e.g., safe rides programs). Traditionally, drinking prevention for youth has relied largely on educational and persuasional approaches. Such approaches focus on changing knowledge and beliefs, teaching new skills, or modifying other individual-level mediating factors. However, educational and persuasional approaches cannot provide a complete answer to the problem of drinking by young people. This limitation arises, in part, because people are immersed in a broader social context in which alcohol is readily available and glamorized.113 In contrast, policy approaches address: (a) formal legal and regulatory mechanisms, rules, and procedures for reducing the consumption of alcohol or risky drinking behaviors; and (b) enforcement of these measures.68 165 Policy approaches to prevention have considerable promise for addressing the harms associated with drinking and other risk behaviors by changing the environment. In particular, policy strategies can be used to reduce alcohol availability, directly deter drinking by increasing the personal costs associated with it, and communicate norms regarding acceptable and unacceptable drinking practices.
Although often presented as two distinct approaches to reducing and preventing youth alcohol problems, clearly distinguishing between public health and harm-reduction policies is often difficult. Some policies are implemented to reduce overall consumption, but may also reduce heavy drinking or drinking in risky situations. Similarly, policies based on a harm-reduction approach may also lead to a decrease in overall consumption. In attempting to place policies into this typology, it is necessary to focus on the primary target of a specific policy. Hence, for the purpose of this report focusing on teens, policies implemented to reduce availability of alcohol to young people or deter young people from drinking in order to reduce overall consumption are considered public health approaches, whereas policies specifically targeting risky drinking, drinking in specific risky situations, or specific drinking-related risky behaviors are considered harm-reduction approaches.
In addition to problems of distinguishing between public health and harm-reduction policies, there is no consensus as to what constitutes alcohol policy. In this paper, alcohol policy is used only to refer to (a) formal legal and regulatory mechanisms, rules, and procedures for reducing the consumption of alcohol or risky drinking behaviors, and (b) enforcement of these measures.68 165 Alcohol policies may be implemented at the national level, State or provincial level, local level, or even at the institutional level.
b. Policy Strategies for Reducing Alcohol-Related Problems That May Be Relevant to Safety Belt Use Warning Labels and Signs
In the context of safety belt use by young people, warning labels could be required in advertising for motor vehicles, in the driver’s compartment of all motor vehicles, and on roadside signs. To some extent, this approach is already being taken. Safety belt use reminders, for example, are now used on some highway and freeway on ramps. Stronger messages indicating that safety belt use can reduce serious injuries and death could be designed and required, particularly in advertising for motor vehicles. The effectiveness of such warnings, however, is doubtful given the experiences with alcohol.
Safety belt use by young and novice drivers could be mandated even more strongly than for adults. For example, a zero-tolerance program for nonuse of safety belts by youth could be implemented, with immediate loss of license or other administrative penalties resulting for non-compliance. As with zero-tolerance drinking-and-driving programs, enforcement and strategic media campaigns to increase young peoples’ awareness of the law and of its enforcement efforts could significantly increase the effectiveness of zero-tolerance safety belt laws.
Graduated Driver Licensing
Safety belt provisions could also be incorporated into GDL laws. As with zero tolerance, such provisions could require stricter penalties for nonuse among young and novice drivers. In addition, as with alcohol, GDL laws could be used to provide cause for stopping young drivers and ascertaining compliance with safety belt laws.
Random Breath Testing/Sobriety Checkpoints
Enforcement and public awareness seem to be key to the success of these programs. Moore, Barker, Ryan, and McLean119 found that men and those under 30 years old perceived it was unlikely they would be apprehended for drinking and driving despite RBT programs. However, the perceived likelihood of apprehension increased with exposure to RBT, notably when that exposure was recent. Additional studies4 76 82 115 158 discuss the reasons for differing results in different areas of Australia after the implementation of RBT laws. They conclude that lack of enforcement in areas showing low effect was one reason for the observed differences. In contrast, however, there is also some evidence that drinking drivers may change their driving patterns and use minor and relatively less safe roads when enforcement of RBT is intense and publicity is high, thus increasing their chances of a crash.18 Generally, these results suggest that random breath testing is a promising strategy if it is well advertised and enforced. However, studies specifically focusing on the impact of RBT on young drivers apparently do not exist. Still, there is reason to believe that when enforced, the efficacy of this approach also applies to young people.
Sobriety checkpoints in the United States can be implemented under proscribed circumstances as determined by State laws, often involving pre-notification about when and where they will be implemented. Breath tests at such checkpoints can usually be given only if there is probable cause to suspect that a driver has been drinking.128 Even under these restricted circumstances there is some evidence that they reduce drinking and driving and related traffic crashes. An evaluation of a Tennessee checkpoint program,100 for example, found a 20 percent decrease in alcohol-related fatal crashes and a 6 percent reduction in single-vehicle nighttime crashes that were maintained up to 21 months after implementation of the program. Sobriety checkpoints can potentially be used to help detect safety belt nonuse among young drivers and motivate use. In this case, checking for safety belt use could be incorporated into standard procedures implemented at such checkpoints.
A similar situation probably exists with regard to safety belt use. That is, the difficulty of enforcing even primary safety belt laws for young people may undermine their effectiveness.
c. Conclusions and Implications for Youth Safety Belt Use
Based on the available evidence, the most effective alcohol policies appear to be:
Implementation, enforcement, and public awareness are essential to the success of any policy approach to preventing youth drinking problems. The case for safety belt use is likely to be similar. No policy can be effective unless it is adequately implemented and enforced, and there is awareness of both the policy and the enforcement efforts on the part of the intended targets.e.g. 68 78 79 172 Awareness and knowledge of policies on the part of those charged with enforcement is also important for effective implementation.51
Another potentially important element in effective policy is public support. The difficulty of implementing effective polices in the face of public opposition may be considerable given perceptions on the part of law enforcement officers and community leaders that there is little community support for such activities.174 176 Public support for policies may be greater for those policies that are least effective in reducing underage drinking and drinking problems. Surveys in Canada and the United States, for example, indicate that public support may be strongest for interventions such as reducing service to intoxicated patrons and treatment.e.g. 3 60 140 There is also considerable public support for policies targeting promotion such as providing warning labels and banning or restricting alcohol advertising. These surveys indicate that there may be less support for more demonstrably effective policies targeting access such as increasing the drinking age or increasing taxes. Nonetheless, other recent research shows considerable support for policies targeting underage drinking.75 Thus, a majority of Americans favor increasing taxes to fund prevention programs, and limiting drinking in public places. The difficulty of implementing effective polices in the face of public opposition—or perceived public opposition on the part of policymakers--may be considerable. The strategic use of media, however, can help overcome such resistance and elicit public support for effective environmental interventions.e.g. 81 These lessons can be transferred to the safety belt issue for teens by building public pressure to enforce use laws and changing teen norms on this behavior.
To help professionals in the field become better consumers of prevention programs, the Substance Abuse Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention (CSAP), created the Models Program directory, which is reviewed by the National Registry of Effective Prevention Programs (NREPP). NREPP reviews and identifies science-based prevention programs. All the programs included on the NREPP list are theoretically driven by the risk and protective factors framework. The rating criteria for inclusion into the NREPP directory include: intervention fidelity, process evaluation, sampling strategy and implementation, attrition, outcome measures, missing data, data collection, analysis, other plausible threats to validity, replications, dissemination capability, cultural and age appropriateness, integrity, and utility. The list currently includes nearly 50 programs. Each program identifies its target population and the domains in which the program is appropriate (i.e., individual, school, peer, community, etc.). Additionally, program activities and key findings are listed to assist in the learning and selection of programs. The 2003 Model Program list is included in Appendix D.
The CDC has also responded to the need for information concerning successful ways to improve public health. The CDC convened an independent, nonfederal Task Force on Community Preventive Services to examine existing scientific studies and make recommendations. The topics that are reviewed include: Alcohol; Cancer; Diabetes; Mental Health; Motor Vehicle Occupant Injury; Nutrition; Oral Health; Physical Activity; Sexual Behavior; Socio-cultural Environment; Substance Abuse; Tobacco; Vaccine Preventable Diseases, and; Violence Prevention. The Task Force completes systematic reviews of the available literature and provides recommendations on use or nonuse of interventions based on the strength of the evidence. The findings and recommendations are published in the Morbidity and Mortality Weekly Report Recommendations and Reports series and the American Journal of Preventive Medicine; the recommendations are also posted on the Community Guide Web site (www.thecommunityguide.org).