Pattern and pace of change in social norms in Massachusetts

Giulia Norton(Presented by Tandiwe Njobe)

National Conference on Tobacco or Health

November 2002

Research supported by the MA DPH

Research questions

Did social norms change in ways favorable to tobacco control objectives in Massachusetts?

[Did the Massachusetts Tobacco Control Program (MTCP) bring about any changes in social norms?]

Background and support for research

Addressing social norms is an intermediate objective of tobacco control programs:

e.g., Massachusetts and California founded their tobacco control strategies on changing social norms around tobacco use in order to change behavior

California explicitly seeks to change “social norms.”

“The goal of this ‘social norm change’ approach is to create a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible… to push tobacco use out of the charmed circle of normal, desirable practice to being an abnormal practice.”

California Department of Health Services / Tobacco Control Section. A Model for Change: the California Experience in Tobacco Control. October 1998.

Massachusetts also seeks to change “social norms.”

Interventions

Social Norms

Desired Outcome Behavior

Massachusetts Model

Tobacco tax increase (passed in 1992, funding MTCP)

Media campaign

Local, regional, and statewide program services via community groups, health care settings, schools, etc.

Individual behavior choices: cessation and primary prevention

[Changing] community and worksite tobacco control [smoking] policies

Change social norms regarding tobacco use

Reducing exposure to environmental tobacco smoke

Analytical Approach

Question: Did Massachusetts social norms change in ways that favor tobacco control objectives (and potentially indicate an effect of the MTCP)?

Analysis: Use time trends to demonstrate changing behaviors and expectations around tobacco use in 2 domains:

Domain 1: Whether tobacco use is normal and customaryDomain 2: Whether exposure to ETS is normal or expected

Social Norm Domain 1

Whether tobacco use is normal and customary

1. Are fewer adults perceived to smoke?

2. Is it less acceptable for adults to smoke?

3. Is it less acceptable for children to smoke?

4. Has support for restrictions on marketing to youth increased?

Social Norm Domain 2

Whether exposure to ETS is normal, or expected.

1. Do more people believe ETS is harmful to non-smokers?

2. Do more adults support banning smoking in public places?

3. Are more adults protected from ETS at work?4. Do more people ban smoking at home?5. Are more kids protected from ETS at home?6. Do more people ask acquaintances not to smoke?

Methods

• Data – Massachusetts Tobacco Survey (1993)– Massachusetts Adult Tobacco Survey (1995 –

2000)– n = 19,000+

• Multivariate analyses Social norm = f(time, demographics, other

control variables)

Predictor Variable of Interest

• Time– Key predictor variable – Is there a trend

showing change?– Measure is at best suggestive rather than

conclusive of MTCP effect– Two specifications

• Continuous variable by month and year

• Series of dummy variables for fiscal year

Covariates

• Demographics – Age – Race/ ethnicity– Gender– Education

• Other control variables– Children under 12 living the household– Teenager (12 – 17 years) living in household– Respondent works (indoors)

Analysis

• Most analyses were also stratified for smokers and non-smokers– So the estimated time trend does not result from

declining prevalence

• Model controlled for changing demographics over time

Social norms have become more pro-tobacco control in Massachusetts.

• Pattern of change is gradual yet favorable to tobacco control strategies

• Statistically significant positive trends in 13 of 23 indicators, across both domains

• Improvements observed for both non-smokers and smokers

• Particularly striking is support for public and household-level policies restricting ETS

Results Domain 1 : Tobacco use is normal and customary

Indicator of change Items tested

# tests Trend p<0.05

Fewer adults smoke 1 2 1

Less acceptable for adults to smoke

1 1 0

Less acceptable for children to smoke

2 2 0

Support for restrictions on marketing to youth

8 8 3

Results Domain 2 : Exposure to ETS is normal and customary

Indicator of change Items tested

# tests Trend p<0.05

More people believe ETS is harmful to non-smokers

2 4 0

More support for bans on smoking in public places

5 10 4

More adults are protected from ETS at work

1 2 1

More people take action against ETS

4 8 5

More Massachusetts adults think smoking should be banned in restaurants.

0%

10%

20%

30%

40%

50%

60%

70%

1995 1996 1997 1998 1999 2000

Non-smokers (trend p<.01) Smokers (trend n.s.)Non-smokers Smokers

… and think smoking should be banned in public buildings.

0%

10%

20%

30%

40%

50%

60%

70%

1995 1996 1997 1998 1999 2000

Non-smokers (trend p<.01) Non-smokersSmokers (trend p<.1) Linear (Smokers (trend p<.1))

… and think smoking should be banned in shopping malls.

0%10%20%30%40%50%60%70%80%

1995 1996 1997 1998 1999 2000

Non-smokers (trend<.01) Smokers (trend n.s.)Non-smokers Smokers

Taking action: Mass. adults banning visitors from smoking in their home.

0%10%20%30%40%50%60%70%80%

1995 1996 1997 1998 1999 2000

Non-smokers (trend p<.01) Smokers (trend p<.01)Non-smokers Smokers

… and banning household members from smoking in their home.

0%

10%

20%

30%

40%

50%

60%

1995 1996 1997 1998 1999 2000

Non-smokers (trend n.s.) Smokers (trend p<.01)Non-smokers Smokers

Discussion

• Change is pervasive yet gradual across the domains– Massachusetts patterns towards tobacco free

social norms consistent with California (1996 – 1998) and National Social Climate Survey (2000-2001)

– Changing beliefs and behaviors at the societal level involves a more lengthy process

Discussion continued…..

• Change is evident among smokers and non smokers– For some indicators (such as banning

household members from smoking in the home) the extent of change is greater for smokers than non-smokers.

Closing thoughts….

• Trend is consistent with tobacco control objectives but without comparison group we cannot say how much of the trend is attributable to the MTCP

• Further research needed to measure the extent and pace at which tobacco control programs can reshape social norms

For more information contact:

Giulia NortonAbt Associates Inc.,55 Wheeler StreetCambridge, MA 02138-1168

Email: Giulia_Norton@abtassoc.com