1. 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

2. 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?]

3. 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

4. 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.

5. Massachusetts also seeks to change “social norms.” Interventions Social Norms Desired Outcome Behavior

6. Massachusetts Model

7. 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 customary Domain 2: Whether exposure to ETS is normal or expected

8. 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?

9. 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?

10. 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)

11. 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

12. 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)

13. 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

14. 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

15. Results Domain 1 : Tobacco use is normal and customary Indicator of changeItems tested # testsTrend p<0.05 Fewer adults smoke121 Less acceptable for adults to smoke 110 Less acceptable for children to smoke 220 Support for restrictions on marketing to youth 883

16. Results Domain 2 : Exposure to ETS is normal and customary Indicator of changeItems tested # testsTrend p<0.05 More people believe ETS is harmful to non-smokers 240 More support for bans on smoking in public places 5104 More adults are protected from ETS at work 121 More people take action against ETS 485

17. More Massachusetts adults think smoking should be banned in restaurants.

18. … and think smoking should be banned in public buildings.

19. … and think smoking should be banned in shopping malls.

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

21. … and banning household members from smoking in their home.

22. 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

23. 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.

24. 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

25. For more information contact: Giulia Norton Abt Associates Inc., 55 Wheeler Street Cambridge, MA 02138-1168 Email: Giulia_Norton@abtassoc.com