Growing Up Tobacco Free Preventing Nicotine Addiction in Children and Youths (1994) / Chapter Skim
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5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS
5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS
Pages 143-174
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From page 143... ...
Moreover, the purpose of schooling to prepare young people for future productive adult roles is compatible with the goal of health promotion. However, many schools are ill-equipped to conduct effective smoking prevention programs and unmotivated to do so, and only a few preventive efforts have been mounted by the schools themselves.
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From page 144... ...
Recent publication of the Centers for Disease Control and Prevention's Guidelines for School Health Programs to Prevent Tobacco Use and Addictioni and reviews calling for a national agenda for school health promotions give further impetus to supporting schools as the locus for tobacco prevention efforts. Comprehensive prevention and health promotion programs that prevent the initiation and use of tobacco products can assist in attaining Healthy People 2000 objectives.3 A review of school-based tobacco prevention programs and programs that integrate prevention into the context of a community effort to reduce tobacco use is a useful basis for developing the model for a comprehensive policy to prevent addiction to tobacco among children and youths.
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From page 145... ...
The message often was presented in a manner intended to arouse fear. Comprehensive reviews of the programs conducted in the 1970s based on the information-deficit model showed that the model had not deterred the adoption of cigarette smoking by youths.4 Providing knowledge of the health consequences of smoking is a basic and necessary step, but it is not sufficient to change the behavior of most youths, for three reasons.
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From page 146... ...
The third approach, resisting social influences, recognized the importance of the social environment as an influence of tobacco use, and researchers posed the question: If adolescents were to develop skills that allow them to identify and resist social influences, would they refrain from using tobacco? The assumption was that adolescents who smoke lack the skills to counteract (a)
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From page 147... ...
To date, no single theory comprehensively encompasses all of the factors or accounts for a large proportion of the variance in smoking behavior. Prevention programs have targeted social influences that are most proximal to smoking behavior, but these interventions have not affected more distal factors.
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The approach, which may involve up to twenty classroom sessions, includes resistance skills, behavioral research, role playing, self-control, decision making, problem solving, and self-reward, as well as components devoted to increasing selfesteem, self-confidence, autonomy, and assertiveness.24 Electiveness of School-Based Smoking Prevention Programs Research on smoking prevention has by its nature had to contend with various threats to validity posed by methodologic issues of mixed units of analysis (individual student versus school or classroom) , attrition of the subject (student)
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From page 149... ...
Peer-led programs and programs dealing with social influences were more effective than other models.26 Tobler later confirmed these findings with more rigorous analytic methods.27 The Rundall and Bruvold meta-analysis of 47 studies of schoolbased smoking intervention programs examined knowledge, attitude, and behav ioral outcomes of social influence programs versus traditional programs; the social influence programs were more likely to affect attitudes and behavior.28 Rooney examined 90 school-based tobacco use prevention programs conducted from 1974 through 1989 that sought to develop skills to resist social influences. The meta-analysis took into account the clustering of students in schools and used the school as the unit of analysis.
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Program Structural Elements. Eight structural elements are considered both necessary and sufficient for effective school-based smoking prevention programs.
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To date, the dissemination and diffusion of prevention programs have been documented, but there are no data on their impact on smoking rates. In Minnesota, 81 schools were invited to receive one of four recommended smoking prevention programs and to participate in a study.
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From page 152... ...
and that make repeated interventions necessary.48 Evidence for the efficacy of community interventions comes from both large-scale multicommunity studies of heart disease prevention and largescale studies that focus explicitly on smoking and drug use. Three studies have shown consistent effects on reducing tobacco use by teens, each using experimental designs that have overcome some, but not all, of the methodologic problems of school-based prevention programs.
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Current randomized community interventions will provide further evaluation of the degree to which communitywide programs enhance or extend the effects of school-based programs on adolescent smoking. Researchers have debated whether smoking prevention programs should be integrated into drug prevention programs or stand alone as independent interventions.
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From page 154... ...
School-based prevention programs that identify the social influences prompting youths to smoke and that teach skills to resist such influences hav demonstrated consistent and significant reductions or delays in adolescent smoking. These programs usually target youths in the seventh to ninth grades, when smoking experimentation and initiation is foremost.
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Unique aspects of SLT use and a review of prevention programs are presented below. Unique Aspects of Smokeless Tobacco Use Five unique aspects of smokeless tobacco use should be considered in the development and evaluation of prevention and cessation programs.
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From page 156... ...
Seldom have SLT prevention programs been implemented independently of other substance use prevention efforts or more general tobacco use prevention efforts. The rationale for this integration is that smokeless tobacco products are used primarily by males, prevalence may be lower for SLT than for cigarette use, and concern about use of snuff or chewing tobacco is often less than for hard drugs and cigarette smoking.
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From page 157... ...
and that a combination of both is probably best for deterring use of SLT.66 The Southern California and Oregon studies suggest that a tobacco prevention program can be successful in reducing SLT use by embedding the smokeless program in a school-based tobacco prevention intervention provided to seventh and ninth grade students. Other school-based interventions, however, have not been as successful in deterring adolescents' use of SLT.
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Summary Points 1. Smokeless tobacco prevention programs have modest effects on reducing SLT initiation and use by middle school and high school boys.
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The data available show that adolescent smokers do make repeated attempts to quit smoking, but usually fail. Two large national population surveys provide data on a few aspects of adolescent smoking cessation: the High School Seniors Survey (sponsored by the National Institute on Drug Abuse)
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checked "medication to make quitting easier" as a suggestion for smoking cessation, whereas only 8C%o checked "stop smoking class or program."77 Cessation Intervention Programs Although the primary goal of smoking prevention programs, reviewed earlier in this chapter, is to prevent smoking initiation and the progression from experimentation to regular smoking, occasionally an added effect is that some smokers participating in these programs reduce the amount of cigarettes they smoke.78 Nevertheless, the impact of prevention programs on students who are experimental or regular smokers is small and inconsistent.79 Furthermore, smoking prevention programs typically are implemented for middle-school children, and the small number of regular smokers in this population tends to preclude meaningful cessation analyses.~° Cessation Interventions in Schools A number of smoking cessation programs and materials have been developed and implemented in schools, but evaluation has typically been anecdotal or descriptive. Two school-based cessation programs evaluated in 1983, one using trained peer leaders8i and one using a cognitive behavioral group approach,82 reported no quits.
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a misdemeanor for persons under age 18 and thereby force school authorities to take action against students caught smoking on school grounds. Non-School-Based Interventions Although recruitment was more successful in an HMO-based smoking cessation program, the outcome was not.87 Adolescents between 14 and 17 years of age who were members of a large health maintenance organization (HMO)
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From page 162... ...
More than half of adolescent smokers want to quit, try to quit, and fail to quit. A survey by the Gallup Organization reported that 38% of youths ages 12 to 17 had some interest in youth-targeted smoking cessation programs.89 Research is needed to discover from youths the kinds of assistance they will respond to and some of the barriers that keep them from seeking assistance in quitting tobacco use.
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From page 163... ...
In one study, more than one-third of current male adolescent SLT users reported unsuccessful quit attempts.97 In a national probability sample, 39% of adult SLT users reported having made unsuccessful attempts to quit.98 Given the addictive nature of nicotine, reversing the trend of SLT use requires the development of interventions to first motivate youths to quit using snuff and chewing tobacco, then to help them stop using tobacco. Studies of Cessation of Smokeless Tobacco Use Despite the evidence of negative health consequences from use of SLT, research on cessation of smokeless tobacco use has been minimal; to date, only a few studies have been reported in the scientific literature.
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However, participants not achieving abstinence reported reduction of 45% in their daily use of SLT from baseline levels. The participants reported that in addition to the group sessions, the telephone calls and support by the counselor were key elements in their quitting.~°~ The study, conducted in 16 high schools in Illinois and California, described above in the smoking cessation section, also included a component for cessation of SLT use.
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At 6- and 12month follow-up the biochemically confirmed quit rates were 16% and 14% with no difference between groups.~05 There are no published reports to date on the use of nicotine skin patches as an adjunct to behavioral treatment for users of smokeless tobacco. Clinic-Based Interventions Given that most smokers do not go to cessation programs to quit but many respond to a prompt from a health care provider,~06 health care settings might be an attractive avenue for promoting cessation of SLT use.
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Studies report co-use of SLT and cigarettes at prevalences between 12% and 30% for all regular SLT users.~09 Since the addictive element in tobacco is nicotine, individuals who quit using snuff or chewing tobacco might increase their use of cigarettes, and vice versa. For adolescents who use both substances, a decrease in the use of one tobacco product may lead to a direct increase in their use of the other tobacco product.ll° There is no net gain in the health risk status of those individuals.
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From page 167... ...
RECOMMENDATIONS Over the past 20 years, school-based prevention programs have evolved a focus on the social influences that are most proximal to a young person's decision to initiate and use tobacco products. Research has consistently demonstrated that a brief school intervention that focuses on social influences and teaches refusal skills can have a modest but significant effect in reducing onset and level of tobacco use.
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A comprehensive program to reduce tobacco use is not a new idea. The Committee recognizes that most schools and communities do not have comprehensive tobacco prevention programs in place.
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Lichtenstein, et al. "How Generalizable Are the Effects of Smoking Prevention Programs?
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"A Meta-analysis of Adolescent Smoking Prevention Programs." American Journal of Public Health 83:6 (1993)
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"Essential Elements of School-Based Smoking Prevention Programs." Journal of School Health 59:5 (May 1989)
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"Preventing Adolescent Drug Use: Long-Term Results of a Junior High Program." American Journal of Public Health 83:6 (June 1993)
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Maccoby. "High School Smoking Prevention: The Relative Efficacy of Varied Treatments and Instructors." Adolescence 18:71 (1983)
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"Conducting Smokeless Tobacco Cessation Clinics." Letter. American Journal of Public Health 76:2 (1986)
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