A Pilot Study to Evaluate a Tobacco Diversion Program

By 1998, 42 states had implemented legislation to prohibit the purchase, possession, or use of tobacco by minors, a 24% increase since 1995.1,2 In response, communities have developed tobacco education classes, known as tobacco diversion programs, offered in lieu of, or in addition to, other penalties for youths cited for tobacco use. Despite the proliferation of these programs, little is known about their effect on youths' tobacco use.

Since September 1998, adolescents who are cited for a first or second tobacco violation in Hennepin County, Minn, have the option of paying a fine ($50 for the first offense, $75 for the second offense), attending a tobacco diversion program ($25 fee), or scheduling a court hearing. Youths who attend the tobacco diversion program satisfy the conditions of the citation and the misdemeanor is removed from their record. The tobacco diversion program consists of a single 2 1/2-hour class to teach youths about the realities of tobacco use and to encourage them to think about their smoking behavior and quitting. The program uses open discussions, visual aids, and participatory exercises and provides resources for smoking cessation.

From January to July 1999, we completed interviews with 112 adolescents (74.7% of those whose parents granted permission and 33.2% of all those cited during the period). Interviews were completed after the citation but before the youths participated in the tobacco diversion class. Follow-up interviews were completed with 95 of them 3 months later. In Table 1 ▶, we report the baseline demographic characteristics and the knowledge, attitudes, and behavior related to tobacco use among adolescents who attended the tobacco diversion program compared with those who paid the fine. We observed only minor differences between the 2 groups in tobacco use and readiness to quit at 3 months (data not shown).

TABLE 1.

—Characteristics of Youths Who Attended Tobacco Diversion Class Compared With Those Who Elected to Pay Citation Fine

Characteristic	Attended Class(n = 39)	Paid Fine(n = 73)	P
Demographic
White, %	89.7	79.5	.17
Female, %	41.0	32.9	.39
Mean age, y (SE)	15.7 (0.2)	15.6 (0.1)	.54
Enrolled in school, %	94.9	95.9	.80
Received mostly A's and B's, %	35.9	48.0	.22
Personal, social, and environmental
Reported that >40% of high school students smoked, %	74.4	80.8	.43
Reported that >40% of good friends smoked, %	89.7	61.6	<.01
Reported that >40% of adults smoked, %	82.1	67.1	.09
Father smokes, %	53.9	41.1	.20
Mother smokes, %	46.2	43.8	.81
Mean no. of known smokers (SE)	3.2 (0.2)	2.9 (0.2)	.20
Tobacco use
Mean age at first cigarette, y (SE)	11.4 (0.4)	12.4 (0.2)	.30
Mean Fagerstrom score (SE)	4.1 (0.3)	3.4 (0.2)	.03
Mean no. of physical effects reported (SE)	2.6 (0.2)	1.8 (0.2)	.01
Smoking status, %
Less than monthly	5.1	23.3
Monthly	2.6	6.9
Weekly	10.3	12.3
Daily, ≤1/2 pack	48.7	35.6
Daily, >1/2 pack	33.3	21.9	.08
Stage of change among 93 youths who smoked in past 30 days, %
Precontemplation	35.9	19.2
Contemplation	38.5	31.5
Action	25.6	49.3	.04

The limitations of our study included its small sample size, self-selection of adolescents for either the class or the fine, and lack of a nonintervention comparison group. Nevertheless, our results raise important questions regarding tobacco diversion programs as a public health strategy for reducing smoking among youths. The active enforcement of laws aimed at youths' possession of tobacco and incentives associated with diversion to a tobacco education program have the potential for reaching large numbers of smoking youths, especially those who might not otherwise volunteer. Yet we found that only about 35% of those in our sample elected that option. If youths view attendance in a tobacco diversion program as punishment or coercive, they may be less willing to participate or to be receptive to the program's messages. Other factors limiting the program's potential impact include its short duration and lack of effective smoking cessation strategies designed for adolescents.3

Adolescents who receive a citation for smoking experience immediate significant consequences. Thus, tobacco diversion programs may do no better than the citation in changing smoking behavior and may be a questionable use of resources. Although we interviewed youths within 30 days of their citation, 23.3% of those who paid the fine reported no smoking in the past month compared with 5.1% of those who attended the class. They may have quit or underreported smoking to avoid further consequences. Youths attending the class were more likely than those paying the fine to report indicators of addiction (e.g., earlier age at first cigarette, higher mean Fagerstrom score,4 more physical effects from smoking). While they may have participated in the class for help with smoking, the lower financial consequences of diversion could also have enabled their purchase of needed tobacco.

The effect of laws aimed at youths' possession of tobacco and associated penalties for adolescent smoking has not been studied. Before there is further implementation, we urge researchers to address the concerns raised here—that is, program reach, inappropriate financial incentives for smoking, and the effect of receiving a citation on smoking—in addition to conducting much-needed research on the efficacy of tobacco diversion programs to reduce smoking among adolescents.