A comprehensive school-based smoking prevention program

Perceptions about the harmfulness of tobacco among adults in Uganda: Findings from the 2013 Global Adult Tobacco Survey

INTRODUCTION

Preferential option for some tobacco products over others might be attributed to inherent misconceptions about the harmfulness of tobacco. We analysed data from Uganda’s Global Adult Tobacco Survey (GATS) to assess misconceptions about the harmfulness of tobacco and associated factors.

METHODS

Data were obtained from the 2013 Uganda Global Adult Tobacco Survey (GATS) of persons in Uganda of age ≥15 years among 8508 participants selected using a multi-stage sampling design to provide nationally representative estimates of the adult population. Participants were asked about perceptions of the harmfulness of smoking, using smokeless tobacco and whether all kinds of cigarettes are equally harmful. Weighted logistic regression analysis was used to find factors associated with the dependent variables.

RESULTS

Among daily smokeless tobacco users, 98 (62%) were unaware that smokeless tobacco causes serious illness. Compared with participants without formal education, participants with primary education were less likely to be unaware that smoking causes serious illness (AOR=0.64, 95% CI: 0.48–0.84) as were participants with secondary education (AOR=0.28, 95% CI: 0.19–0.42) and participants with University education or higher (AOR=0.26, 95% CI: 0.11–0.58). Compared with participants who did not use any smokeless tobacco products, participants who used smokeless tobacco products less than daily were more likely to be unaware that smokeless tobacco causes serious illness (AOR=1.39, 95% CI: 0.54–3.61) as were participants who used smokeless tobacco products daily (AOR=5.87, 95% CI: 3.67–9.40). Compared with participants who did not use any smoked tobacco products, participants who used smoked tobacco products less than daily were more likely to believe that all cigarettes are equally harmful (AOR=2.40, 95% CI: 1.32–4.37) as were participants who used smoked tobacco products daily (AOR=3.08, 95% CI: 2.37–4.00).

CONCLUSIONS

There is a high level of unawareness about the harmfulness of tobacco use particularly among tobacco users. The National Tobacco Control Program should prioritise public awareness and education about the dangers of tobacco use in the Tobacco Control Policy and National Tobacco Control Strategic Plan.

TOBACCO USE PATTERNS AMONG MILITARY RECRUITS

All recruits reporting to a regimental centre between 01 Jan 98 to 31 Mar 99 (n=1049), were administered a questionnaire about their own and their family's tobacco use practices. The prevalence of smoking among recruits was 43%, while that of smokeless tobacco use was 34.1%. There was a significant association between parental tobacco use and peer pressure on the tobacco habits of recruits. Knowledge about harmful effects of tobacco use did have a role in restraining the tobacco habit among recruits.

Toward a humanistic model in health communication

Since the key to effective health communication lies in its ability to communicate well, some of its core problems are those that relate to the sharing of meaning between communicators. In elaborating on these problems, this paper offers two key propositions: one, health communication has to pass through the filter of a particular world view that creates a discrepancy between expected and actual message reception and response. Two, the assumption of a rational human actor made implicitly by most health psychological models is a contestable issue, as many times message recipients do not follow a cognitive judgment process. The phenomenon of resisting health messages by reasonable people asks the question whether we ought to rethink our adherence to a particular vision of human health as many times the adverse reaction to behaviour modification occurs as the result of a particular dialogical or discursive situation. At the same time, most motivational decisions in people's daily routines are automatic and use a concept known as self-identity to give stability to their behaviour patterns. Finally, health communication as part of organised government practices adheres to predominant value perspectives within health promotion practice that affect the manner in which health issues become problematised. This paper proposes a humanistic model that aims to pay attention to the intricacies of human communication by addressing all of the above problems in turn. It interprets the sharing of meaning element in human communication and addresses the question of how the idea of health is created through discourse. As such, it offers a complementary and constructive paradigm and set of approaches to understand health, its meanings and communication.

The Prevention of Adolescent Smoking

The multiple increased health risks that are associated with smoking make primary prevention of the adoption of the habit by adolescents crucial. Smoking is a behavior that is fostered by environments in which peers and family members smoke and by large scale media campaigns advertising tobacco products. There are also well-defined psychological, behavioral and developmental characteristics that place adolescents at risk of experimenting with smoking. In order to foster nonsmoking, prevention programs have traditionally focused on education about the health risk of the habit. To enhance the effectiveness of these efforts, new programs have incorporated social inoculation strategies, which identify and analyze the pressures to smoke that adolescents face. They demonstrate and practice resistance techniques that enable students to withstand these pressures. In addition, general coping and social skills training have been added. These focus on problem-solving and decision-making skills, assertiveness training, relaxation techniques, and communication strategies. By preparing adolescents to deal with nonspecific problem situations, it is felt that they will be more competent and capable of resisting allforms of substance abuse. In addition, prevention programs have been reinforced by community and legislative efforts to decrease the rate of smoking in the general population.

Effectiveness of school-based smoking prevention curricula: systematic review and meta-analysis

OBJECTIVE

To assess effectiveness of school-based smoking prevention curricula keeping children never-smokers.

DESIGN

Systematic review, meta-analysis.

DATA

MEDLINE (1966+), EMBASE (1974+), Cinahl, PsycINFO (1967+), ERIC (1982+), Cochrane CENTRAL, Health Star, Dissertation Abstracts, conference proceedings.

DATA SYNTHESIS

pooled analyses, fixed-effects models, adjusted ORs. Risk of bias assessed with Cochrane Risk of Bias tool.

SETTING

50 randomised controlled trials (RCTs) of school-based smoking curricula.

PARTICIPANTS

Never-smokers age 5-18 (n=143,495); follow-up ≥6 months; all countries; no date/language limitations.

INTERVENTIONS

Information, social influences, social competence, combined social influences/competence and multimodal curricula.

OUTCOME MEASURE

Remaining a never-smoker at follow-up.

RESULTS

Pooling all curricula, trials with follow-up ≤1 year showed no statistically significant differences compared with controls (OR 0.91 (0.82 to 1.01)), though trials of combined social competence/social influences curricula had a significant effect on smoking prevention (7 trials, OR 0.59 (95% CI 0.41 to 0.85)). Pooling all trials with longest follow-up showed an overall significant effect in favour of the interventions (OR 0.88 (0.82 to 0.95)), as did the social competence (OR 0.65 (0.43 to 0.96)) and combined social competence/social influences curricula (OR 0.60 (0.43 to 0.83)). No effect for information, social influences or multimodal curricula. Principal findings were not sensitive to inclusion of booster sessions in curricula or to whether they were peer-led or adult-led. Differentiation into tobacco-only or multifocal curricula had a similar effect on the primary findings. Few trials assessed outcomes by gender: there were significant effects for females at both follow-up periods, but not for males.

CONCLUSIONS

RCTs of baseline never-smokers at longest follow-up found an overall significant effect with average 12% reduction in starting smoking compared with controls, but no effect for all trials pooled at ≤1 year. However, combined social competence/social influences curricula showed a significant effect at both follow-up periods.

SYSTEMATIC REVIEW REGISTRATION

Cochrane Tobacco Review Group CD001293.

Exploring an effective tobacco prevention programme for Indian adolescents

OBJECTIVES

Tobacco use is among the most significant public health issues faced by the world today. It is estimated that approximately 5500 adolescents start using tobacco every day in India, adding to the four million youths aged <15 years who are already regular users. School-based smoking prevention programmes have been shown to increase knowledge about the negative effects of tobacco and prevent tobacco use, but the majority of evidence on effectiveness comes from Western countries. This study investigated the impact of a school-based short-term educational intervention regarding tobacco use on adolescents' knowledge, attitudes, intentions and behaviours (KAIB) in Bangalore, India.

STUDY DESIGN

An intervention trial was conducted among 720 adolescents aged 15-16 years in Bangalore, India.

METHODS

Educational interventions were imparted to all study subjects in a phased manner, along with two interactive sessions held six months apart. The impact of the programme was measured using questionnaires administered before the first intervention (pre-intervention) and after the second intervention (post-intervention).

RESULTS

Mean (±standard deviation) pre-intervention KAIB scores of the subjects were 5.9 ± 1.87 (knowledge), 23.6 ± 3.15 (attitude) and 18.9 ± 3.27 (practice), which improved to 7.8 ± 2.01, 26.7 ± 2.43 and 12.3 ± 2.52, respectively, postintervention. The differences in mean KAIB scores were significant (P < 0.0001, df = 1400), suggesting that the intervention had a major positive impact.

CONCLUSION

School-based short-term educational intervention programmes are effective for preventing and reducing tobacco use among Indian adolescents.

Multilevel mediation analysis: The effects of omitted variables in the 1-1-1 model

Multilevel mediation analysis examines the indirect effect of an independent variable on an outcome achieved by targeting and changing an intervening variable in clustered data. We study analytically and through simulation the effects of an omitted variable at level 2 on a 1-1-1 mediation model for a randomized experiment conducted within clusters in which the treatment, mediator, and outcome are all measured at level 1. When the residuals in the equations for the mediator and the outcome variables are fully orthogonal, the two methods of calculating the indirect effect (ab, c - c') are equivalent at the between- and within-cluster levels. Omitting a variable at level 2 changes the interpretation of the indirect effect and will induce correlations between the random intercepts or random slopes. The equality of within-cluster ab and c - c' no longer holds. Correlation between random slopes implies that the within-cluster indirect effect is conditional, interpretable at the grand mean level of the omitted variable.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

Adolescents' attitudes toward antimarijuana ads, usage intentions, and actual marijuana usage

The association of adolescents' appraisals of the antimarijuana TV ads used in the National Youth Antidrug Media Campaign with future marijuana use was investigated. The 12- to 18-year-old respondents (N = 2,993) were first classified as users, resolute nonusers, or vulnerable nonusers (Crano, Siegel, Alvaro, Lac, & Hemovich, 2008). Usage status and the covariates of gender, age, and attitudes toward marijuana were used to predict attitudes toward the ads (Aad) in the first phase of a multilevel linear analysis. All covariates were significantly associated with Aad, as was usage status: Resolute nonusers evaluated the ads significantly more positively than vulnerable nonusers and users (all ps < .001), who did not differ. In the second phase, the covariates along with Aad and respondents' usage status predicted intentions and actual usage 1 year after initial measurement. The lagged analysis disclosed negative associations between Aad and usage intentions and between Aad and actual marijuana use (both ps < .05); however, this association held only for users (p < .01), not vulnerable or resolute nonusers. Users who reported more positive attitudes toward the ads were less likely to report intention to use marijuana and to continue marijuana use at 1-year follow-up. These findings may inform designers of persuasion-based prevention campaigns, guiding preimplementation efforts in the design of ads that targeted groups find appealing and thus, influential.

Should we ask our Children about Sex, Drugs and Rock & Roll?: Potentially Harmful Effects of Asking Questions About Risky Behaviors

Research shows that asking questions can fundamentally change behavior. We review literature on this question-behavior effect, which demonstrates that asking questions changes both normal and risky behaviors. We discuss potential explanations for the effect and review recent findings that reveal interesting moderators of the influence of questions on behavior. We then highlight the potential impact of the question-behavior effect in an important public health context: screening adolescents for risky behavior. While medical guidelines emphasize the importance of asking adolescents questions about substance (drug, alcohol) use and sexual behaviors, research on the question-behavior effect suggests that asking adolescents about risky behaviors has the potential to increase the frequency with which they engage in these behaviors. We argue that the act of screening or measuring risky behavior is potentially counterproductive. We emphasize the importance of interventions beyond screening, and suggest ways in which screening can be carried out to minimize its impact. In short, asking questions about behaviors can change behavior, and asking questions about risky behaviors may itself be a risky undertaking.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomized controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomized controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomized to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomized controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we computed pooled estimates only for those trials that could be analyzed together and for which statistical data were available. We predominantly synthesized the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence; multi-modal programmes). Within each group, we placed them into three categories (low, medium and high risk of bias) according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 94 randomized controlled trials identified, we classified 23 as category one (most valid). There was one category one study of information-giving and two of teaching social comeptence. There were thirteen category one studies of social influences interventions. Of these, nine found some positive effect of intervention on smoking prevalence, and four failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive eight-year programme on smoking behaviour. There were three category one RCTs of combined social influences and social competence interventions: one provided significant results and one only for instruction by health educators compared to self-instruction. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was one category one study providing data on social influences compared with information giving. There were four category one studies of multi-modal approaches but they provided limited evidence about the effectiveness of multi-modal approaches including community initiatives.

AUTHORS' CONCLUSIONS

There is one rigorous test of the effects of information-giving about smoking. There are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies failed to detect an effect of the intervention. There are only three high quality RCTs which test the effectiveness of combinations of social influences and social competence interventions, and four which test multi-modal interventions; half showed significant positive results.

Identifying principal risk factors for the initiation of adolescent smoking behaviors: the significance of psychological reactance

An in-school youth survey for a major state anti-tobacco media campaign was conducted with 1,831 students (Grades 6-12) from 70 randomly selected classrooms throughout the state. Tobacco users accounted for nearly 25% of the sample. Pretest questionnaires assessed demographic variables, tobacco use, and various other risk factors. Several predictors of adolescents' susceptibility to tobacco use, including prior experimentation with tobacco, school performance, parental smoking status, parents' level of education, parental communication, parental relationship satisfaction, best friend's smoking status, prevalence of smokers in social environment, self-perceived potential to smoke related to peer pressure, and psychological reactance, were examined using discriminant analysis and logistic regression to identify the factors most useful in classifying adolescents as either high-risk or low-risk for smoking uptake. Results corroborate findings in the prevention literature indicating that age, prior experimentation, and having friends who smoke are among the principal predictors of smoking risk. New evidence is presented indicating that psychological reactance also should be considered as an important predictor of adolescent smoking initiation. The utility of producing antismoking messages informed by an awareness of the key risk factors-particularly psychological reactance-is discussed both in terms of the targeting and design of anti-tobacco campaigns.

Does measurement dependence explain the effects of the Life Skills Training program on smoking outcomes?

BACKGROUND

The Life Skills Training (LST) program is the most prominent school-based smoking prevention program in terms of its consistency in being named on lists of best practices. This study assessed whether the results pertaining to cigarette smoking reported in evaluations of the LST program are measurement dependent.

METHODS

Seventeen reports published between 1980 and 2003 that included at least one outcome measure pertaining to cigarette smoking were identified. Data pertaining to the cigarette smoking measures used in the analysis and whether the results showed a statistically significant difference between experimental and control groups at follow-up were extracted from the reports.

RESULTS

Fourteen different outcome measures were used across 17 reports. Only three pairs of reports presented the same set of outcomes. Recent reports showed the most consistent set of findings in support of the LST program, but there was little consistency in the outcome measures used in these analyses.

CONCLUSIONS

The use of so many smoking outcomes in the LST program evaluations raises concern as to whether the positive program effects reported are measurement dependent.

Determinants of Smoking Habit among Medical Students

A cross sectional study of smoking habits among medical students was carried out to find out the prevalence of smoking and its association with certain factors such as parental smoking, peer pressure, use of alcohol and other drugs. Prevalence of smoking was 46%. There was significant association of smoking with parental smoking habit, peer pressure, use of alcohol and other drugs. Strategies to counter these social determinants have been discussed.

Adolescent reactance and anti-smoking campaigns: a theoretical approach

Children between the ages of 9 and 15 are a high-risk group for tobacco use. The Centers for Disease Control estimates that first use of cigarettes among adolescents has risen 30% over the past decade, and that more than 1.2 million people age < 18 became daily smokers in 1996 alone. Moreover, research indicating that awareness and liking of cigarette advertisements is higher among adolescents than adults underscores the need to devote more effort to understanding reactions to tobacco-related messages. Adding to this problem is the fact that the early gains of some successful anti-tobacco interventions disappear as adolescents age. Drawing on the theory of psychological reactance, a number of hypotheses were tested that addressed the impact of pro- and anti-smoking messages on a variety of outcomes, including participants' intended behaviors, evaluation of message sources, and seeking of disconfirming information. All the messages were created and delivered to 4th-, 7th-, and 10th-grade students via personal computers. The pattern of results supports the theoretically derived hypotheses, indicating that grade level and message type had a significant impact on the processing of tobacco-related messages. Implications and suggestions for future tobacco prevention campaigns are discussed.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomised controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials and Tobacco Review group registers, MEDLINE, EMBASE, Psyclnfo, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomised controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomised to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow-up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomised controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we did not perform a meta-analysis. We synthesised the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence and multi-modal programmes). Within each category, we placed them into three groups according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 76 randomised controlled trials identified, we classified 16 as category one (most valid). There were no category one studies of information giving alone. There were fifteen category one studies of social influences interventions. Of these, eight showed some positive effect of intervention on smoking prevalence, and seven failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive 8-year programme on smoking behaviour. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was limited evidence about the effectiveness of multi-modal approaches including community initiatives.

REVIEWER'S CONCLUSIONS

There is no rigorous test of the effects of information giving about smoking. There are well-conducted randomised controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies showed no effect of the intervention. There is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programmes that include community interventions.

Ethnic and gender differences in psychosocial risk, protection, and adolescent alcohol use

Theoretical models suggest that many diverse psychosocial factors contribute to the etiology of substance use among youth. It has been suggested that substance use is a function of the total number of etiologic factors, rather than a specific type or set of factors. This study examined whether cumulative psychosocial risk and protection measured in the 7th grade predicted alcohol use in the 9th grade across ethnically diverse samples of adolescents. Participants consisted of black (n = 775) and Hispanic (n = 467) inner-city youth and white suburban youth (n = 708). Prevalence rates for alcohol use and risk/protection varied more widely based on ethnic group compared to gender. Black youth reported the fewest risk factors and lowest levels of alcohol use, white youth reported the most risk factors and highest levels of alcohol use, and Hispanic youth reported the fewest protective factors and intermediate levels of alcohol use. Despite these differences, structural equation modeling indicated that a latent factor consisting of cumulative risk, protection, and their interaction significantly predicted later alcohol use for the combined sample as well as for each ethnic/ gender subgroup. However, the proportion of variance explained in alcohol use varied across subgroups, and moderator analyses indicated that protection significantly buffered the effects of risk differentially across subgroups. The strongest protective effects were observed among black inner-city youth. Findings suggest that prevention approaches should focus on enhancing protection in addition to reducing risk, particularly among youth with lower levels of psychosocial protection.

Preventing illicit drug use in adolescents: long-term follow-up data from a randomized control trial of a school population

National survey data indicate that illicit drug use has steadily increased among American adolescents since 1992. This upward trend underscores the need for identifying effective prevention approaches capable of reducing the use of both licit and illicit drugs. The present study examined long-term follow-up data from a large-scale randomized prevention trial to determine the extent to which participation in a cognitive-behavioral skills-training prevention program led to less illicit drug use than for untreated controls. Data were collected by mail from 447 individuals who were contacted after the end of the 12th grade, 6.5 years after the initial pretest. Results indicated that students who received the prevention program (Life Skills Training) during junior high school reported less use of illicit drugs than controls. These results also support the hypothesis that illicit drug use can be prevented by targeting the use of gateway drugs such as tobacco and alcohol.

Competence skills help deter smoking among inner city adolescents

OBJECTIVE

To test whether higher levels of general competence are linked to more frequent use of refusal assertiveness that is in turn related to less subsequent smoking among inner city adolescents.

METHODS

Longitudinal study conducted during three year middle school or junior high school period. A sample of 1459 students attending 22 middle (ages 11-14 years) and junior high (ages 12-15 years) schools in New York City participated. Students completed surveys at baseline, one year follow up, and two year follow up. The students self reported smoking, decision making skills, personal efficacy, and refusal assertiveness. Teams of three to five data collectors administered the questionnaire following a standardised protocol. These data were collected in school during a regular 40 minute class period.

RESULTS

Based on the tested structural equation model, decision making and personal efficacy (that is, general competence) predicted higher refusal assertiveness and this greater assertiveness predicted less smoking at the two year follow up. The tested model had a good fit and was parsimonious and consistent with theory.

CONCLUSIONS

Adolescent smoking prevention programmes often teach refusal skills in order to help youth resist peer pressure to smoke. The present findings suggest that teaching general competence skills as well may help to reduce smoking because youth with better personal efficacy and decision making skills are better able to implement smoking refusal strategies.

Toward a new paradigm in substance abuse and other problem behavior prevention for youth: youth development and empowerment approach

The purpose of this article is to 1) address a paradigm shift taking place in the field of substance abuse prevention directed for youth and 2) to introduce an innovative approach to substance abuse and other problem behavior prevention that reflects this shift in prevention paradigm. The new path introduced is youth development and empowerment (YD&E) approach. In order to establish a conceptual foundation for this approach, this article 3) reviews the theoretical advances made in the field of substance abuse prevention during the last three decades. This is followed by a conceptualization of the processes of implementing the YD&E program by 4) specifying the mechanism used for the empowering processes and by 5) identifying the structural components of the youth empowerment model that serve the empowering processes. It is hoped that this article serves as a conduit for an improved approach to adolescent substance abuse prevention and youth development that goes beyond, rather than against, the traditional risk-factor approach. In this new approach, youths are viewed as assets and resources to our community rather than social problems or community liabilities. The organizing concept of this new paradigm is: social, economic, and public opportunity denied to youth is equal to social problems imposed on youth by adults.

Adolescent drinking and driving: etiology and interpretation

In the adolescent population, drinking and driving is an important cause of injury, disability and premature death. A literature review of the demographics and etiology of drinking and drinking/driving reveals: 1) which subgroups of the adolescent population are more likely to drink and drink/drive; 2) where and why adolescents drink and drink/drive; 3) peer and family issues associated with adolescent drinking and drinking/driving; and 4) adolescent expectancies and perceived efficacies associated with drinking and drinking/driving. A discussion of the role of theory and the use of etiologic data in intervention research precedes an overview of several types of school-based alcohol-prevention programs and recommendations for more theory based interventions.

Determinants of intentions of Junior High School students to become sexually active and use condoms: implications for reduction and prevention of AIDS risk

The purpose of this study was to examine factors associated with young adolescents' increased risk for AIDS. A multiethnic sample of 303 seventh-grade students in three schools in the greater New York area completed questionnaires assessing their basic demographic characteristics (gender and ethnicity), AIDS knowledge, substance use (cigarette smoking, alcohol use), and decision-making skills. AIDS knowledge, substance use, decision-making skills, gender, and ethnicity predicted intentions to engage in sexual behavior in the future. Relevant knowledge of AIDS was associated with lower intentions to engage in sexual behavior in the future. More frequent substance use, less frequent use of decision-making skills, and being male increased intentions to engage in sexual behavior in the future. Our findings are discussed in terms of their implications for education and prevention of adolescent sexual activity and AIDS-risk reduction.

Cultural diversity in the predictors of adolescent cigarette smoking: the relative influence of peers

A culturally diverse sample of 4375 adolescents completed a self-report inventory assessing their current amount of smoking, and several psychosocial predictors of smoking (e.g., depression, anger, stress, smoking among peers, etc). Results revealed that Whites smoke more than Blacks, Asians, and less acculturated Latinos but not more than highly acculturated Latinos. Stepwise regression analyses of the predictors of smoking found significant ethnic and acculturation differences in the relative predictive power of 18 well-known risk factors. Smoking among peers was the best predictor of smoking for White adolescents (accounting for 23.5% of the variance) but accounted for only 15% of the variance for Latino youth, 9.6% of the variance for Asian youth, and none of the variance for Black youth. Results are discussed in terms of their implications for smoking prevention programs that focus on resisting peer influences.

A comprehensive multi-media program to prevent smoking among black students

Much research has been done in developing and implementing smoking prevention programs; however, few studies have focused on urban Black populations. In November of 1989, a comprehensive prevention program was implemented to decrease the incidence of new smokers within the adolescent population in a Black community. The program combined a school-based curriculum with a comprehensive media intervention. All components of the program were financed by business leaders from the targeted community. There were two experimental conditions: one group participated in a school-based intervention and were prompted to participate in a multi-media intervention and the other group had access to the multi-media intervention; however, they were not prompted to participate. A key finding was that the rate of smoking decreased for all children involved in the intervention. The authors present a model that can be employed to prevent other high-risk behaviors within the Black population.

Assessment of adolescent refusal skills in an alcohol misuse prevention study

Although many substance abuse prevention programs seek to enhance the ability of adolescents to refuse offers of alcohol and other drugs, few report assessments of refusal skill ability or its relationship to substance use. This report describes a procedure to assess the ability of adolescents to refuse the offer of a beer, and presents the findings of those assessments as well as their relationships to alcohol misuse prevention knowledge, susceptibility to peer pressure, internal health locus of control, self-esteem, and alcohol use and misuse. A one-third random sample (n = 1012) of 10th graders participating in a longitudinal evaluation of an alcohol misuse prevention curriculum was assessed individually. Students rated their own refusals, which were also rated by trained female and male raters. The results indicated that adolescents refuse the offer of a beer only somewhat convincingly. Those adolescents with better refusal skills had higher levels of alcohol misuse prevention knowledge, especially regarding resisting pressures to use alcohol and the application of knowledge of typical alcohol-related situations. They also reported less susceptibility to peer pressure, greater internal health locus of control and self-esteem, and less alcohol use and misuse. The results provide support for teaching refusal skills in substance abuse prevention programs and for assessing refusal skills in the evaluation of such programs.

Assertiveness in Hispanic adolescents: relationship to alcohol use and abuse

An investigation was carried out on the relation of assertiveness to use of alcohol among 3129 Hispanic junior high school students. Data were obtained through questionnaires administered in 47 public and parochial schools in New York City to 5501 students. An 18-item modified version of the Gambrill-Richey Assertiveness Inventory was used to assess assertiveness. Factor analysis of the inventory identified five assertiveness factors of substance awareness, mastery of cognitive skills, individual rights, dating, and social skills. Significant gender differences were observed. Multiple regression analysis showed that substance awareness was negatively associated with alcohol use while dating, social skills, and individual rights factors were positively associated with alcohol use. Acculturation with peers was also a significant predictor of alcohol use or abuse. The findings provide a basis for design of alcohol prevention programs that specifically focus on Hispanic youth.

A meta-analysis of adolescent smoking prevention programs

OBJECTIVES

A large number of studies evaluating adolescent smoking prevention programs have been published. Systematic quantitative reviews of this literature are needed to learn what does and does not work. The present meta-analysis focuses on the efficacy of school-based programs.

METHODS

Evaluations of 94 separate interventions were included in the meta-analysis. Studies were screened for methodological rigor and those with weaker methodology were segregated from those with more defensible methodology; major analyses focused on the latter.

RESULTS

Behavioral effect sizes were found to be largest for interventions with a social reinforcement orientation, moderate for interventions with either a developmental or a social norms orientation, and small for interventions with the traditional rational orientation. Attitude effect sizes followed the same pattern, but knowledge effect sizes were similar across all four orientation categories.

CONCLUSIONS

Because behavioral effect represents the fundamental objective of programs for prevention of adolescent tobacco use, the present results indicate that school-based programs should consider adopting interventions with a social reinforcement, social norms, or developmental orientation.

Underestimates of student substance use by school personnel: a cause for concern?

The present study was designed to compare school personnel's (i.e., principals, counselors, teachers) estimates of student substance use with student self-reported data. Comparisons were made in 78 schools between 5431 student self-reports of tobacco, alcohol, and drug use and 170 school personnel's estimates of student substance use. The results indicated that a significant number of school personnel were unable to estimate student substance use. Personnel who did provide estimates typically underestimated the degree of substance use, in comparison to student self-reported substance use. School personnel did not significantly overestimate use in comparison to student self-reported substance use for any substance in any grade or geographic area. It is suggested that school personnel may resist the adoption of prevention programs because of a perceived lack of need due to underestimation of the substance use problem.

[Prevention beginning at school of tobacco use and other addictive substances]

We review the literature on school programs of prevention of consumption of tobacco and other addictive substances among adolescents. We describe the keys of these programs. The programs enforcing the abilities to resist the social pressure to the consumption of addictive substances report better results and they achieve significant reduction in the initiation of tobacco consumption. They also report promising results for alcohol and other addictive substances, but they are not so clearly supported. Average duration of the programs is between 8 and 12 ours a year, generally in 6th and 8th course. Other purposes of similar duration based on: self-esteem, the development of activities other than drug consumption, or the simple information on drugs, have not shown significant positive results for these ages.

A cognitive-behavioral approach to substance abuse prevention: one-year follow-up

This study presents one-year follow-up data from an evaluation study testing the effectiveness of a cognitive-behavioral substance abuse prevention approach which emphasizes the teaching of social resistance skills within the larger context of an intervention designed to enhance general social and personal competence. The follow-up study involved 998 eighth graders from 10 suburban New York junior high schools. Two schools were assigned to each of the following conditions (a) peer-led intervention, (b) peer-led intervention with booster sessions, (c) teacher-led intervention, (d) teacher-led intervention with booster sessions, and (e) control. The original intervention was implemented in the seventh grade; the booster intervention was implemented during the eighth grade. Results indicate that this type of prevention strategy, when implemented by peer leaders in the seventh grade and when additional booster sessions are provided during the eighth grade, can reduce tobacco, alcohol, and marijuana use. Similar effects are evident for females when the prevention program is implemented with fidelity by classroom teachers. Moreover, the prevention program is also capable of producing a significant impact on several hypothesized mediating variables.

Social influences approach to smoking prevention: the effects of videotape delivery with and without same-age peer leader participation

This study tested the hypothesis that cigarette smoking adoption among adolescents could be suppressed by providing school-based videotape instruction for resisting social influences to smoke. The utilization of same-age peer leaders was also varied to test whether their participation in the classroom would enhance program effects. Seventh grade students (N = 540) from one junior high school in Southern California were randomly assigned by classrooms (N = 15) to: (a) videotape instruction, (b) videotape instruction plus peer leader involvement, or (c) survey-only. Seventh grade students (N = 234) in a second junior high school served as a measurement-only control. Assessments were conducted at the beginning and end of the academic year. Results revealed a marked suppression in the onset of both experimental and regular smoking among those students exposed to the pressure resistance training with peer leader involvement. Pressure resistance training without peer leader involvement produced a more variable and less powerful effect on students' smoking behavior. Data collected on students' use of alcohol and marijuana revealed a generalized suppression effect, albeit weaker than for tobacco, among those students exposed to the social resistance training with peer leader involvement. Results provide further encouraging support for the use of peer-led pressure resistance training in preventing adolescent drug use.

The Stanford Adolescent Heart Health Program

This study was designed to create, implement, and test a school-based multiple risk factor reduction program for high school students. All tenth graders in four senior high schools (N = 1447) from two school districts participated in the study. Within each district, one school was assigned at random to receive a special 20-session CVD risk reduction intervention and one school served as a control. The schools were matched for size and distribution of racial groups before randomization. At a two-month follow-up, knowledge gains were significantly greater for students in the treatment group on each of the risk factor domains tested: nutrition/diet (p less than 0.0001), physical activity (p less than 0.0001), and cigarette smoking (p less than 0.0001). Compared to controls, a higher proportion of those in the treatment group who were not exercising regularly at baseline, reported regular exercise at follow-up (p less than 0.0003). Almost twice as many baseline experimental smokers in the treatment group reported quitting at follow-up while only 5.6% of baseline experimental smokers in the treatment group graduated to regular smoking compared to 10.3% in the control group (p = 0.009). Students in the treatment group were more likely to report that they would choose heart healthy snack items (p less than 0.0001). Beneficial treatment effects were observed for resting heart rate (p less than 0.0001), BMI (p = 0.05), triceps skinfold thickness (p = 0.003), and subscapular skinfold thickness (p = 0.01). The results suggest that it is feasible to provide CVD risk reduction training to a large segment of the population through school-based primary prevention approaches.

Adolescent smoking. A review of prevalence and prevention

This review critically evaluates the extensive literature on the epidemiology and prevention of adolescent smoking. Trends in adolescent smoking attitudes and behavior as well as the immediate and long-term health consequences of adolescent smoking are discussed. The factors associated with adolescent smoking and several smoking interventions are analyzed. Suggestions are made for improving the evaluation of future programs designed to prevent adolescent smoking.

A meta-analysis of school-based smoking and alcohol use prevention programs

Tobacco and alcohol use among adolescents continue at historically high rates, and school-based interventions designed to deter students from smoking and drinking are increasingly being implemented. This study reports a meta-analysis of 47 smoking and 29 alcohol school-based intervention programs published after 1970. Results indicate that, in general, smoking and alcohol interventions have equally modest effects on immediate behavioral outcomes. Smoking interventions, however, have been more successful than alcohol interventions at altering students' long term behavior. All of the alcohol programs and all but one of the smoking programs reviewed successfully increased knowledge regarding the risks of these behaviors. Attitude change appears to be more difficult to achieve. Twenty-nine of 33 smoking studies and only 19 of 31 alcohol studies successfully changed students' attitudes. Finally, the data indicate that for immediate smoking outcomes and long-term alcohol outcomes innovative interventions relying upon social reinforcement, social norms, and developmental behavioral models are more effective than traditional "awareness" programs designed to inform adolescents about the health risks associated with tobacco and alcohol use. The implications of these findings for future of school-based health promotion programs are discussed.

Evaluation of a tobacco and alcohol abuse prevention curriculum for adolescents

This study examined the effectiveness of a tobacco and alcohol prevention program that was delivered to sixth and seventh grade students by minimally trained classroom teachers. The program focused on (a) teaching students to identify and resist peer influences, (b) information about short- and long-term consequences of tobacco and alcohol use, (c) the correction of normative expectations, and (d) the establishment of conservative intentions regarding tobacco and alcohol use. Two cohorts of students were pretested, and subsequent to delivery of the program, they were tracked longitudinally. The first cohort was followed for four years, the second was followed for three years. Results indicate that the program reduced the onset and prevalence of tobacco use but not alcohol use. The effects for tobacco were differentially related to the school district in which the program was delivered, the sex of student, and ethnicity, suggesting that prevention program content is only one variable that may affect the effectiveness of prevention interventions.

Affective and social influences approaches to the prevention of multiple substance abuse among seventh grade students: results from project SMART

Two drug abuse prevention curricula were tested to determine their efficacy in preventing the onset of tobacco, alcohol, and marijuana use among adolescents. The first program focused on prevention through social pressure resistance training. The second featured affective education approaches to prevention. Curricula were tested on seventh grade students. Subjects were pretested just prior to the program and were post-tested at 12 and 24 months. Post-test analyses indicated that the social program delivered to seventh grade subjects was effective in delaying the onset of tobacco, alcohol, and marijuana use. No preventive effect of the affective education program was observed. By the final post-test, classrooms that had received the affective program had significantly more drug use than controls.

The prevention of cigarette smoking in children: two- and three-year follow-up comparisons of four prevention strategies

Recent studies have suggested that a prevention program that addresses the social influences that encourage smoking can be effective in deterring cigarette use by adolescents. This study presents 1-, 2-, and 3-year follow-up results from two studies which evaluated three variations of the social influences curriculum and compared them to a health consequences program and a usual-care comparison group. These results suggest that a peer-led, social influences program can restrain smoking among both baseline nonsmokers and baseline experimental smokers at 2 years postintervention. Analyses of attrition data suggest no evidence to threaten the internal validity of these findings, although their generalizability to baseline smokers may be limited.

The changing smoking environment for middle and high school students: 1980-1983

Cultural-historical changes in smoking prevalence and in smoking-related attitudes and beliefs were examined as part of a cohort-sequential study of 6th- to 12th-grade midwestern adolescents (N = 8681) between 1980 and 1983. Smoking prevalence decreased over the 4 years for the younger cohorts and remained unchanged for high school students. Paradoxically, however, some specific beliefs and attitudes about smoking (including health beliefs) became less negative with time. It is suggested that continuing negative social beliefs about smoking are supporting declines in smoking prevalence among younger cohorts. Implications of these cultural-historical changes for smoking behavior and smoking control are discussed.