September 2005

Grant Results

SUMMARY

From 2000 to 2002, researchers at Dartmouth-Hitchcock Medical Center examined attitudes toward tobacco and alcohol products in very young children and their relationship to parental attitudes and behavior toward the same products.

In the study, researchers asked 120 children aged two to six to pretend they were one of four dolls inviting a friend—another doll—over to watch a movie and have something to eat. To get provisions for the friend's visit, the child also 'drove' the doll to the store, which was set up like a grocery store with shelves, refrigerator cases and a checkout counter, where the child could select from a variety of miniature products, including foods, drinks, alcoholic beverages (beer and wine) and cigarettes.

Key Findings
An article on the study was published by the Archives of Pediatric & Adolescent Medicine (September 2005). It reported the following findings:

  • Children purchased an average of 17 of the 70 products in the experiment's store.
  • Close to two-thirds of the children (62 percent) bought alcohol and correctly identified it.
  • They were more likely to buy alcohol if their parents drank at least once a month.
  • Twenty-eight percent of the children bought and correctly identified cigarettes.
  • Children were more likely to buy cigarettes if their parents smoked.
  • Children were more likely to purchase alcohol if they watched movies rated for older audiences (PG-13 and R).
  • Parental messages about smoking and alcohol did not predict whether children purchased tobacco and alcohol products.
  • Children mimicked the use of these products by adults almost as if it were scripted.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $88,344.

 See Grant Detail & Contact Information
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THE PROBLEM

Past evidence suggests, according to the principal investigator Madeline A. Dalton, Ph.D., that attitudes toward smoking develop in young children, and are shaped implicitly through observations of parental smoking and media portrayals. However, many of the methods and outcome measures in the long history of smoking prevention research focused on explicit attitudes, and children who easily recall tobacco control messages often become smokers.

Using standard survey methods to measure attitudes in very young children poses problems: they cannot read, have difficulty understanding multiple choice questions and are highly suggestible to the way questions are phrased. The field needs new methods to measure attitudes about tobacco and alcohol in very young children.

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RWJF STRATEGY

Reducing the harm from tobacco use has long been a central theme of RWJF's programs on substance abuse, with particular focus on preventing children from starting to smoke (see Grant Results on RWJF's Tobacco Policy Research and Evaluation Program and Substance Abuse Policy Research Program).

Since 1992, RWJF has supported more than 660 grants in the tobacco area, beginning with the Tobacco Policy Research and Evaluation Program and moving on to establish and support the National Center for Tobacco-Free Kids. Prior to this study, RWJF funded other studies that examined the role of advertising and parental behavior in adolescent perceptions of smoking. See Grant Results on ID# 022935 (advertising/promotion influence on adolescent perceptions of smoking), ID# 024413 (research on the initiation of teenage smoking), ID# 031704 (effects of television liquor advertising) and ID# 031587 (the role of tobacco marketing and counter-advertising on smoking initiation among youth).

The seminal study by DiFranza and colleagues that appeared in the Journal of the American Medical Association in 1991, showed Joe Camel on a par with Mickey Mouse for recognition among very young children. Like that study, the one funded under this grant held promise for findings that could galvanize public opinion.

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THE PROJECT

To examine attitudes toward tobacco and alcohol products in very young children and their relationship to parental attitudes and behavior toward the same products, investigators at Dartmouth-Hitchcock Medical Center in Hanover, N.H., developed and validated a new methodology.

Using role-playing scenarios, researchers asked 120 children aged two to six to pretend they were one of four dolls inviting a friend—another doll—over to watch a movie and have something to eat. The researcher, acting as the friend, commented that there was nothing to eat and suggested that the child take his or her doll to the store to get some things. The child then 'drove' the doll to the store, which was set up like a grocery store with shelves, refrigerator cases and a checkout counter, where the child could select from a variety of miniature products, including foods, drinks, alcoholic beverages (beer and wine) and cigarettes.

To verify that children knew what they were buying, they were asked to identify the products at the checkout. As parents waited while their children participated in this role play, they completed a questionnaire asking about their behavior and attitudes toward alcohol and tobacco. Researchers also interviewed parents about messages they had conveyed to the child about alcohol and tobacco use.

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FINDINGS

An article on the study was published by the Archives of Pediatric & Adolescent Medicine (September 2005). It reported the following findings:

  • Children purchased an average of 17 of the 70 products in the experiment's store. Purchases reflected both items expected to be popular among children (37.5 percent purchased Lucky Charms®, 66.7 percent cake and 41.7 percent Reese's® candy) and items adults would typically buy (38.3 percent purchased chicken, 76.7 percent fresh fruits or vegetables and 42.5 percent ketchup).
  • Close to two-thirds of the children (62 percent) bought alcohol and correctly identified it. Terms such as "booze" and "daddy's juice" were counted.
  • They were more likely to buy alcohol if their parents drank at least once a month. They bought alcoholic beverages more often than juice or milk and almost as often as soda.
  • Twenty-eight percent of the children bought and correctly identified cigarettes. Terms such as "smokes" were counted. They purchased Marlboros® and Camels® as often as hotdogs, french fries and animal crackers.
  • Children were more likely to buy cigarettes if their parents smoked.
  • Children were more likely to purchase alcohol if they watched movies rated for older audiences (PG-13 and R). Children's cigarette purchases were not significantly related to movie watching after controlling for other factors.
  • Parental messages about smoking and alcohol did not predict whether children purchased tobacco and alcohol products.
  • Children mimicked the use of these products by adults almost as if it were scripted. After leaving the grocery store, children three to six years of age returned to the dining room and living room set-up with the dolls and were free to play with their purchases. The study cites instances in which a six-year-old suggested that the dolls go outside after dinner to smoke a cigarette; a four-year-old served "champagne" because it was a birthday party; and a four-year-old girl said the boys (male dolls) were going to stay home and drink beer while the girls (female dolls) went shopping.

Limitations

Dalton points out the following limitations on study results:

  • Because the study involved an all-white sample of children, most from rural mid- to high-income families, findings may not generalize to other populations.
  • Researchers did not examine how product placement in the store may affect children's choices.

Communications

Researchers presented findings of a pre-test of this project's methods at a November, 2000 meeting of the American Public Health Association. An article on the study was published in the September 5, 2005 issue of the Archives of Pediatrics & Adolescent Medicine. See the Bibliography for more details.

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CONCLUSIONS

Dalton drew the following conclusions:

  • Children as young as two years of age have assimilated and will imitate smoking and alcohol use by incorporating these behaviors into their play. By modeling the use of these products, the media and adult behavior may be transmitting information to children about the characteristics of 'appropriate' or 'normative' responses to social situations. This information may be building implicit pro-smoking and pro-alcohol attitudes among young children.
  • Most tobacco and alcohol prevention projects begin during adolescence, when the initiation of these behaviors usually begins. This study suggests that attitudes, which may be instrumental in promoting these behaviors, form many years earlier.
  • Adults may be reluctant to introduce the topic of alcohol or tobacco to young children because they are afraid it may be suggestive or put ideas in their heads that they didn't have before. This research shows that young children are already forming attitudes about smoking and drinking during their preschool years. This highlights the need to develop preventive programs for younger children.

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SIGNIFICANCE TO THE FIELD

Few studies have examined preschooler's attitudes toward alcohol and tobacco. Findings from this study are consistent with the few studies in alcohol, and confirm that children do develop attitudes and ideas at a very young age.

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LESSONS LEARNED

  1. When recruiting for a study that requires a substantial commitment of time, monetary incentives and a convenient location help. A feasibility study for this project took place at a medical center where most subjects were enrolled and participated on the same day as a pediatric appointment. For the study itself, which required a one-hour commitment, parents had to make an appointment and come to an unfamiliar location, resulting in approximately half of those who scheduled appointments not showing up. (Principal Investigator)
  2. Allocate project money to pay for a capable and motivated project manager. In this study the principal investigator dealt with survey development, human subjects approval and other tasks that in a larger study a project manager would have accomplished. A project manager would have brought the study to completion faster and more smoothly. (Principal Investigator)

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AFTER THE GRANT

The project director anticipates applying to the National Institutes of Health to fund a full-scale study with a more representative group of children and parents.

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GRANT DETAILS & CONTACT INFORMATION

Project

Evaluating Children's Attitudes about Alcohol and Tobacco Use in Young Children

Grantee

Dartmouth-Hitchcock Medical Center (Hanover,  NH)

  • Amount: $ 88,344
    Dates: January 2000 to December 2002
    ID#:  037642

Contact

Madeline A. Dalton, Ph.D.
(602) 650-8320
Madeline.A.Dalton@Dartmouth.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Dalton MA, Bernhardt AM, Gibson JJ, Sargent JD, Beach ML, Adachi-Mejia AM, Titus-Ernstoff L and Heatherton TF. "Use of Cigarettes and Alcohol by Preschoolers While Role-playing as Adults. 'Honey, Have Some Smokes.'" Archives of Pediatrics and Adolescent Medicine, 159(9): 854–859, 2005. Abstract available online.

Survey Instruments

Dartmouth-Hitchcock Medical Center, Kids Go Shopping: Dartmouth's Study of Young Children's Attitudes. Lebanon, NH.

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Report prepared by: Antonia Sunderland
Reviewed by: James Wood
Reviewed by: Molly McKaughan
Program Officer: Tracy C. Orleans

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