Comparing effects of tobacco use prevention modalities: need for complex system models

Abstract

Many modalities of tobacco use prevention programming have been implemented including various policy regulations (tax increases, warning labels, limits on access, smoke-free policies, and restrictions on marketing), mass media programming, school-based classroom education, family involvement, and involvement of community agents (i.e., medical, social, political). The present manuscript provides a glance at these modalities to compare relative and combined impact of them on youth tobacco use. In a majority of trials, community-wide programming, which includes multiple modalities, has not been found to achieve impacts greater than single modality programming. Possibly, the most effective means of prevention involves a careful selection of program type combinations. Also, it is likely that a mechanism for coordinating maximally across program types (e.g., staging of programming) is needed to encourage a synergistic impact. Studying tobacco use prevention as a complex system is considered as a means to maximize effects from combinations of prevention types. Future studies will need to more systematically consider the role of combined programming.

Translating research into prevention of high-risk behaviors in the presence of complex systems: definitions and systems frameworks

“…That said, perhaps evidence on the effectiveness of youth access is mixed because the context in which it is evaluated differs, e.g., were other interventions targeting social acceptability of smoking among youth and addressing enforcement of youth access restrictions present? These macrodynamics threatening success of tobacco prevention initiatives are compounded by the complexity of individual-level factors affecting tobacco use among teens, At the level of T0, an understanding of the interaction between individual-level risk factors (e.g., genetics and physiological response to nicotine) and a variety of factors operating at other levels or within other systems (e.g., peer and family influence, economic and marketing systems, educational and counter-educational systems, and, state/federal regulatory systems) [21,23] should inform T1 prevention planning. And there is wide variation between cause and effect across individuals and groups.…”

“…Health risks are not linear over the life course or by dose, nor are the effects of triggers on the risk of relapse among an experimenting teen trying to break their budding addiction. Youth access to tobacco is also a very important and relevant factor that must be understood-but in the context of broader systems forces [23]. Defining Bdynamic complexity s described above, tobacco use illustrates characteristics of a dynamically complex problem [24,25].…”

“…Failure to appreciate dynamic complexity may lead to the development, implementation, and dissemination of interventions that are not particularly synergistic [23,27] or that make outcomes worse despite the investment [24,25,28,29]. In the context of limited public health resources and resistance to policy [25], knowing which effective interventions to prioritize, integrate, and disseminate, is challenging.…”

“…To address detailed implementation needs and feasibility of such interventions, it is critical to get the actual implementers (teachers, principals) involved. Key issues to discuss at this stage might include the following: motivation and attitudes of staff, training of implementers, and the quality of intervention design (e.g., complexity, relative advantage, compatibility, observability, trialability [23,63]). Similarly, when considering intervention dosage to support cessation, it is important to get key stakeholders involved to strengthen the dosage of cessation support and extend the reach of a social marketing campaign.…”

“…There may be synergies between strategies whereby one amplifies or attenuates the effect of others, depending on when and the extent to which it is implemented [23,27]. A simulated system dynamics model has significant potential to enhance understanding of how organizational dynamics (e.g., within a school) may impact the effectiveness of interventions (e.g., school-based tobacco prevention).…”