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Ending the Tobacco Problem: A Blueprint for the Nation (2007)

Chapter: Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs

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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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D
The Long-Term Promise of Effective School-Based Smoking Prevention Programs

Brian R. Flay

Department of Public Health

Oregon State University


Researchers and others have developed many school-based tobacco prevention programs over the past 30 years. Several reviews (Best et al. 1988; Burns 1992; DHHS 2000; Flay 1985; Glasgow and McCaul 1985; Goldstein et al. 1997; IOM 1994; Lantz et al. 2000; Skara and Sussman 2003) and meta-analyses (Black et al. 1998; Bruvold 1993; Rooney and Murray 1996; Rundall and Bruvold 1988; Tingle et al. 2003; Tobler 1986; Tobler 1992; Tobler et al. 2000; Tobler and Stratton 1997) have established that some programs and strategies, particularly those based on the social influences approach (educating youth about social norms and influences and providing skills for resisting such influences) were effective, although for some programs effects were often limited or did not last (Ellickson and Bell 1990; Flay et al. 1989; Murray et al. 1989).

Meta-analyses of school-based prevention programs have used various criteria and so have varied in scope, from including 74 smoking prevention studies among 207 substance prevention studies (Tobler et al. 2000) to including only 8 studies with grade 12 (or age 18) outcome data (Wiehe et al. 2005). The result has been a confusing array of findings, ranging from precise effect sizes for some type of programs to a conclusion that most school-based prevention programs do not work (Glantz and Mandel 2005; Wiehe et al. 2005).

Several studies (Black et al. 1998; Tobler 1986; Tobler 1992; Tobler and Stratton 1997) suggest that programs that use interactive learning strategies and involve same- or similar-age peers as leaders or facilitators are most effective. Consistent with earlier meta-analyses, Tobler and colleagues (2000) found that smoking prevention programs produced an average effect size of 0.16, with “interactive” programs producing a significantly larger effect size than noninteractive programs (0.17 versus 0.05) (Tobler et al. 2000). Even after adjusting for intraclass correlations (which many earlier analyses had not done), Rooney and Murray (1996) found that social influence programs produced reductions in smoking of between 5 and 30 percent (Rooney and Murray 1996). Tobler and colleagues (2000) found that programs that address multiple substances were not significantly less effective at reducing tobacco use than programs that targeted only tobacco—and they had the added benefit of reducing alcohol and other substance use as well (Tobler et al. 2000). Tobler (1986) also found program effects to be larger in schools with predominantly special or high-risk populations (minorities, high levels of absenteeism or dropouts, poor academic records) (Tobler 1986).

The purpose of this review is to determine what long-term (by age 25) effects the nation might expect if the best school-based smoking prevention programs were to be adopted nationwide. Recent findings have raised questions about the medium-term (high school) effects of school-based smoking prevention programs. Wiehe and colleagues (2005) conducted a meta-analysis of eight studies with results reported at grade 12 or age 18 (Wiehe et al. 2005). These included evaluations of programs of known ineffectiveness from prior studies and even from

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

multiple prior studies and a meta-analysis (e.g., Drug Awareness and Resistance Education), which are discussed further below.

The Hutchinson project (conducted at the Fred Hutchinson Cancer Center, University of Washington) was designed to be a multiyear (grades 3–10) social influences tobacco prevention program. A large randomized trial (20 school groups per condition) produced no significant effects at the end of grade 12 or 2 years later (Peterson et al. 2000). These findings are impossible to interpret, because the investigators have not reported what effects there were or were not at any other time, including prior to entering high school (when most other programs report short-term results) or at the end of the program (grade 10). Certainly, one cannot use these results to conclude that the social influences approach to smoking prevention is ineffective in the long-term deterrence of smoking among youth (Peterson et al. 2000). These results must be interpreted in the context of many other studies on the social influences approach in the literature (Botvin et al. 2001; Botvin et al. 2001; Sussman et al. 2001).

The DARE (Drug Awareness and Resistance Education) Program was developed by the Los Angeles Police Department (LAPD) and the Los Angeles Unified School District (LAUSD) in the early 1980s. They essentially took the two variants of Project SMART (Self Management and Resistance Training) that were being tested with 7th grade students in LAUSD schools at the time (Graham et al. 1990), combined them, and added a great deal of information about drugs for police officers to deliver to 5th and 6th grade students. The results of a randomized trial of the two SMART variants found that the resistance skills program was effective, albeit with small effects, and that the self-management program actually led to increased drug use relative to control group students (Graham et al. 1990; Hansen et al. 1988a). These results, combined with our knowledge that information does not often greatly influence behavior and that the police officers who used are not usually highly skilled teachers, make it no great surprise that DARE was not be effective. Although early nonrandomized studies suggested that DARE sometimes had small effects for elementary school students, multiple randomized trials have shown that DARE has little or no impact on drug use in the short term and no impact in the long term (Clayton et al. 1925; Dukes et al. 1996; Ennett et al. 1994a; Lynam et al. 1999; Rosenbaum et al. 1994; Rosenbaum and Hanson 1998). For a summary, see the meta-analysis by Ennett and colleagues (1994b). In response, DARE has developed programs for junior and senior high school students; the junior high program also has been shown not to be effective (Perry et al. 2003).

Another program that has been promoted as being an effective prevention program, but that has no medium-term effects on smoking is the Michigan Health Education Model. It consists of 30 lessons taught during grades 5–8, some of which include resistance skills training. Although it produced an 82 percent relative reduction (RR) in ever smoking at the end of the program (Shope et al. 1996), no significant effects on smoking behavior remained by the end of grade 12—indeed, boys became more likely to smoke (Shope et al. 1998). It seems that the prevention content of this program was not intensive or long enough to produce permanent effects, that additional programming might have been needed when the students were adolescents, or that some content may even have had a negative effect as some older informational programs did (Goodstadt 1978).

Other studies included in the Wiehe and colleagues (2005) meta-analysis were early studies of the social influences approach (Flay et al. 1989; Shean et al. 1994)1 that, in retrospect, one should never have expected to have long-term—or even medium-term—effects (Wiehe et al.

1

A similar study that reported 12th grade data, but was not included by Wiehe and colleagues (2005), was the early Minnesota smoking prevention program that many others were modeled after (Murray et al. 1989).

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

2005). These programs were initial small-scale experimental tests of the social influences approach that included only 5 to 10 sessions in one or two grades without any boosters or programming in high school. Another was Project ALERT, which consisted of only eight sessions in 7th grade and three booster sessions in 8th grade (Ellickson et al. 1993). Clearly, programs need to include more sessions, preferably with some in high school, in order to be effective in the long-term.

Of the studies reviewed by Wiehe and colleagues (2005), only the Life Skills Program, which is an interactive program of 15 sessions in 7th grade, 10 in 9th grade, and 5 in 10th grade that incorporates the social influences approach as well as other general personal and social skills, was effective at medium-term follow-up, concluded that “there is little evidence to suggest that existing programs produce medium-term decreases in smoking prevalence” (Wiehe et al. 2005, p. 168). In an editorial comment, Glantz and Mandel (2005) misleadingly stated that the Wiehe and colleagues (2005) review of medium-term trials “convincingly shows that they are not effective” (Glantz and Mandel 2005, p. 157). They then discount the Life Skills Program evaluation because of the use of one-tailed t-tests and the failure to take multiple comparisons into account. However, it is perfectly appropriate to use one-tailed t-tests when a clear hypothesis is stated, and adjusting for multiple comparisons would not have eliminated the significant effects. In addition, the short-term effects of Life Skills Training (LST) have been replicated in multiple studies (see below). Glantz and Mandel (2005) suggest that all aspects of smoking education should be integrated into regular core curriculum classes. However, this approach has not been shown to be effective. Furthermore, it is not likely to happen in the near future because of the current demands on schools, nor is it likely to be effective because one would expect much less adherence to the program components if the program was delivered by multiple teachers (Glantz and Mandel 2005).

Skara and Sussman (2003) reviewed medium-term studies (at least 24 months) of 25 tobacco and other drug prevention programs. They found that 18 of the 25 studies reported significant short-term effects and that 15 of the 25 reported significant medium-term effects. Of 17 studies with pretest and posttest data, 11 (65 percent) reported significant medium-term effects, with an average reduction in the percentage of baseline nonusers who initiated smoking in the program condition relative to control conditions of 11.4 percent (range 9 to 14.2 percent). Of the studies with significant short-term effects, 72 percent (13 of 18) were found to have significant medium-term effects. Results also indicated that program effects were less likely to decay for programs with extended programming or booster sessions (Skara and Sussman 2003).

In summary, findings from various reviews and meta-analyses suggest that school-based smoking prevention programs can have significant long-term effects if they: (1) are interactive social influences or social skills programs; (2) involve 15 or more sessions, including some up to at least ninth grade; (3) produce substantial short-term effects. These findings also suggest that many more programs that have reported short-term effects might also have medium- and long-term effects if they were evaluated. Unfortunately, long-term studies are relatively rare, mostly due to lack of funding.

METHODS

For the purposes of this report, the Institute of Medicine’s Committee on Reducing Tobacco Use: Strategies, Barriers, and Opportunities wanted to develop an estimate of the size of the effect that the best programs could produce if widely implemented. This required a focus on studies of programs that both were successful in reducing smoking in the short term and also in-

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

cluded follow-up data into high school (grades 10–12). Few studies have included follow-up beyond high school, but for those that did, the reported effects are of interest. Since the purpose was to determine the size of the effects that could be obtained by the best programs that have been tested, the decision was made, based on past reviews, to limit this review to programs that included 15 or more sessions (preferably including some in high school) and that had demonstrated effects at both short term and medium term. Only three school-based programs and four school-plus-community programs fulfilled these criteria.2 For each of these programs, Table D-1 shows the research design, the number of sessions, the duration, the grade levels of the program, the grade of the last follow-up, and the short- and medium-term program effects. These two sets of studies are labeled Category I studies of school-based and school-plus-community or mass media programs, respectively.3

Given the small number of Category I studies, evaluations of other programs with the promise of medium- and long-term effectiveness are also reviewed. Category II studies consist of school-based and school-plus-community or mass media programs that had large effects and were of a large enough scope and sequence to suggest likely medium- and long-term effects. Four school-based programs and one school-plus-community program met these criteria.

Percent relative reduction (RR) is used as the indicator of effect size for two reasons. First, it is readily available for all programs, whereas the detailed statistics needed to calculate an effect size are sometimes incompletely reported. Second, RR is readily understood and utilized in cost and benefit calculations. For randomized trials, pretest levels of smoking should be the same in both program and control groups, and RR would be the difference between posttest control (C) and program (P) groups divided by the control group level [i.e., (C - P)/C]. However, pretest levels were not always the same, and these should be adjusted for; thus, in cases where pretest data were reported, RR is the posttest difference between groups minus the pretest difference between groups, divided by the control group posttest level, that is [(Post C – Post P) – (Pre C – Pre P)] / Post C, expressed as a percentage.

Another complication in determining effect sizes is that different studies report different levels of smoking as their outcome variable. For both short- and medium-term effects, the most commonly used outcomes were ever (lifetime) use, use in the past month, or use in the past week. When studies report more than one of these, all are reported. While relatively few studies reported more than one outcome measure, the RRs were remarkably consistent across outcomes when they were reported. On the assumption that investigators reporting only one outcome may have chosen to report the outcome with the largest effect size, the estimates are likely to be on the generous side.

REVIEW OF CATEGORY I
STUDIES AND FINDINGS

Category I
School-Based Programs

2

This review is not limited to randomized trials.

3

All seven Category I programs were included in the 25 studies with at least 2 years of follow-up reviewed by Skara and Sussman (2003) (Skara and Sussman 2003). The other studies in their review did not meet one or more of the criteria for inclusion. For many, the last follow-up was earlier than grade 10 (and some of these are in my Category II). For some, there were no demonstrable short-term program effects (e.g., Peterson et al. 2003).

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×
The Tobacco and Alcohol Prevention Project

The Tobacco and Alcohol Prevention Project (TAPP) (Hansen et al. 1988b) was a 15-session social influences-oriented program developed at the University of California, Los Angelos, in the early 1980s. The core components of the social influences approach have been employed in many evaluated programs, including those reviewed here. Hansen (1988) provides a good description of the theory and content of this approach. It has two main core elements: (1) resistance skills training to teach skills to resist the specific and general social pressures to smoke and (2) normative education to correct student misperceptions of prevalence and acceptability of use. Programs using this approach also often involve active learning or the use of the Socratic or dialectic teaching approaches, open discussion, the use of peers or older admired youth as instructors, and behavioral rehearsals to ensure that skills are learned well (Hansen 1988a). TAPP included the above core elements plus inoculation against mass media messages, information about parental influences, information about the consequences of use, and the making of a public commitment not to smoke. Peer opinion leaders were used to assist teachers with program delivery.

TAPP was evaluated in two cohorts of 7th grade classes in a nonrandomized study in Los Angeles County. Only cohort 1, conducted in two moderately-sized school districts, was followed into grade 10. Health education and social studies teachers received 2 days of training prior to delivering the program. As shown in Table D-1, by the end of 7th grade the RR in past-month smoking was 26.2 percent. By the end of 10th grade there was a 19.1 percent RR in past-month smoking and an 18.3 percent RR in ever smoking. In a secondary analysis of only those students present at all waves of the study, the RR in past-month smoking was 43 percent.

This was an early study of the social influences approach, and it demonstrated that the approach can be very effective. The use of peer leaders probably enhanced what program effects would have occurred with teacher-only delivery (Klepp et al. 1986; Tobler 1992). The whole-sample result is preferred as the initial estimate of program effects because it provides a more realistic assessment of what would happen under real-world conditions; however, note that the larger effect obtained for students present throughout the study could be obtained if all schools were to implement the program.

Life Skills Training

Life Skills Training (LST) is one of the most researched school-based smoking prevention or any other kind of substance use prevention program. Developed by Botvin and Eng (1982), originally at the American Health Foundation and then at Cornell University, LST consists of 30 classroom sessions with 15 delivered in 7th grade, 10 in 8th grade and 5 in 9th grade (usually the first year of high school)4 (Botvin and Eng 1982). The program was designed to teach students a wide array of personal and social skills. These include content similar to other smoking prevention programs that focus on social influences (Glynn 1989; Hansen 1988b) , including learning and practicing refusal and other assertion skills, information about the short- and long-term consequences of smoking, correction of misperceptions of the prevalence of use by same-age peers, and information about the decreasing acceptability of smoking in society. Other generic program content addresses the development of communication skills and ways to develop personal relationships.

4

This is the number of lessons for the version tested in the studies reported here. Different versions of the program have different numbers of lessons per grade.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Multiple studies over 25 years have demonstrated the effectiveness of the program when delivered by different providers, in different kinds of schools, and for different kinds of students (see Botvin 2000 and Botvin and Griffin 2002 for reviews). Only one study has included medium-term follow-up through high school (Botvin et al. 1995). This was a follow-up of the largest single trial, conducted in 56 suburban and rural schools serving largely white students (91 percent) in three geographical regions of New York State (Botvin et al. 1990). Schools were assigned randomly to two experimental conditions (one day or video-taped teacher training) or a control condition. Level of implementation ranged from 27 to 97 percent by teacher reports, with about 75 percent of the students receiving 60 percent or more of the intervention. Six program schools and 18 percent of the students were excluded from the analysis of program effects because of poor implementation.

As shown in Table D-1, at the end of 9th grade the RR was a relatively small 8.9 percent (1.63 percent vs. 1.48 percent) for weekly smoking, reflecting the low prevalence of weekly smoking at this age. At the end of 12th grade, the RRs were 19.7 percent (33 percent versus 26.5 percent) and 20.4 percent (27 percent versus 22 percent) for monthly and weekly smoking, respectively.5 For the high-implementation group, the medium-term RRs were both 28 percent. However, the RRs for the (almost) complete sample provide the most appropriate estimate of what effects could be obtained under real-world conditions—indeed, they may still be an overestimate of the effects that might be obtained when the program developer is not involved—although larger effects might be obtained with full, high-quality implementation.

Independent evaluations of LST have found similar or larger short-term effects. In a nonrandomized trial in Spain, where the program was delivered by teachers to 9th grade students, a 21 percent RR in average monthly smoking at the end of grade 10 reduced to 11 percent by the end of grade 12 (Fraguela et al. 2003). Independent evaluations of LST in Midwestern states found a short-term RR of 22 percent in a randomized trial in rural Iowa (Spoth et al. 2002; Trudeau et al. 2003) and short-term RRs of 43 percent in current smoking and 9 percent in ever-use in Indianapolis (Zollinger et al. 2003). Another small-scale (three schools per condition) randomized evaluation in Pennsylvania found small immediate effects for girls only, and these had decayed by the end of grade 7 and were no longer apparent by the end of grades 8–10 (Smith et al. 2004). In a nonrandomized trial of a German adaptation of the life skills approach in 106 German-speaking elementary schools in Austria, Denmark, Luxembourg, and Germany, a 10 percent RR in ever smoking and less than 1 percent RR in past-month smoking were reported (Hanewinkel and Asshauer 2004).

Project SHOUT

Project SHOUT (Students Understanding Others Understand Tobacco) (Eckhardt et al. 1997; Elder et al. 1993) used trained college undergraduates to teach 18 sessions to 7th and 8th graders that included information on the health consequences of smoking, celebrity endorsements on nonuse, the antecedents and social consequences of tobacco use, decision making, resistance skills advocacy (writing letters to tobacco companies, magazines, and film producers; participating in community action projects designed to mobilize them as antitobacco activists), a public commitment to not use tobacco, and positive approaches to encouraging others to avoid tobacco or quit. In 9th grade, five newsletters were mailed to students and two to their parents, and each

5

Note that the RR of 21 percent [(33 - 27)/33] reported by Skara and Sussman was based on the method that used only posttest results. Our RR is based on the method that includes pretest results (Skara and Sussman 2003).

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

student received four phone calls from trained undergraduate counselors that were individually tailored to their tobacco use status at the end of 8th grade or the prior phone call. During 11th grade, approximately half of the students received two more newsletters that focused on tobacco company tactics to recruit new smokers; information on recent city, state, or national legislation regarding tobacco; cessation advice and information on second-hand smoke; and one phone call that focused on eliminating smoking in restaurants and other public places as well as information concerning the rights of customers and employees in those places affected by the potential ban.

The program was evaluated in 22 schools with ethnically diverse populations in the San Diego area, some suburban and some rural. Schools were assigned randomly to program and control conditions after matching on pretest levels of tobacco use. Effects observed at the end of 8th grade (14.6 percent versus 10.8 percent, RR = 22 percent) were not statistically significant. However, as shown in Table D-1, by the end of 9th grade the intervention produced a relative reduction in tobacco use in the past month of 30.3 percent (19.8 percent versus 13.2 percent). By the 11th grade, the average RR was 44.1 percent (12.6 percent versus 7 percent). For the group that did not receive the 11th grade intervention, the RR decayed to only 9.5 percent.

The pattern of effects observed for this study suggest that much of the medium-term effect was due to personal attention via newsletters and phone calls in grades 9 and 11. Indeed, one has to wonder if the personal attention set up a response bias among respondents such that those who received personalized newsletters and phone calls were motivated to tell the researchers what they wanted to hear. Lack of a differential response rate to the surveys by condition speaks against this, however, at least in part. Considerable research suggests that the power of similarage peers and the power of college-age counselors for high school students should not be underestimated. Although the cost of the intervention as studied was kept down by the use of volunteer students, it is not clear how easily this model can be disseminated. The results also strongly suggest, however, that even a brief intervention during high school was enough to actually increase the effect observed at the end of grade 9.

Summary of Findings From Category I School-Based Programs

Results from three social influence and social competence programs with 15 or more sessions over 2–4 years, preferably with some content in high school, had significant medium-term effects (i.e., at grades 10–12): an average of a 27.6 percent (range 18.7–44.1) RR in smoking. The extraordinary effects of Project SHOUT may have been due to the added content on tobacco industry activities, the teaching and encouragement of advocacy skills, and the personal attention. These results need to be replicated. The medium-term effects suggest that a minimal personal contact intervention of this kind in high school could increase the effects of any other program delivered in middle school.

Category I
School-Plus-Community Programs

The North Karelia Project

Vartiainen and colleagues (Vartiainen et al. 1983; Vartiainen et al. 1986; Vartiainen et al. 1990; Vartiainen et al. 1998) tested a 10-session social influences program delivered by trained health education teachers and peer leaders in the province of North Karelia, Finland. A community-wide heart disease prevention program and mass media campaign modeled on the Stanford three-cities project (Farquhar et al. 1977) was going on throughout North Karelia at the same

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

time. Two schools received the 10-session program from the project health educator and trained peer leaders and two schools received a 5-session version from regular teachers. Two schools from another province, where there was no prevention program, were used as controls. As shown in Table D-1, at the end of grade 9 the RR (average of lifetime, monthly, and weekly) was 44.6 percent for both program conditions, which decayed to 38.7 percent by grade 11. By 3 years beyond the end of high school, the RR had decayed to 22.9 percent in the health educator condition and 37.3 percent in the teacher condition. By 10 years beyond high school, the average RR was 20 percent with the two conditions not significantly different.

The results reported here can only be interpreted as the joint effects of the school-based smoking prevention program and the community-wide heart disease prevention campaign (which had a reduction of smoking as one of its targets). Thus, these results suggest effects that are larger than those of the school-based programs reviewed above. The larger effects obtained by regular teachers suggests that programs might be more effective when delivered by regular classroom teachers than when delivered by visitors to classrooms, possibly because of the ongoing relationships that teachers establish with students. However, the long-term effects were no different.

The Class of 1989 Study

This project was another in which a school-based prevention curriculum was tested in the context of a community-wide heart disease prevention program (Perry et al. 1989). The community program consisted of community education, including mass media and organization activities as well as screening, cessation clinics, and workplace education designed to reduce three cardiovascular risk factors: smoking, cholesterol levels, and blood pressure (Luepker et al. 1994; Mittelmark et al. 1986). The school-based smoking prevention program (Perry et al. 1992; Perry et al. 1994) was based on the Minnesota Smoking Prevention Program (Arkin et al. 1981; Murray et al. 1994), one of the early social influences programs, and included material on diet and exercise as well as tobacco. Seven sessions on smoking prevention were delivered by peer leaders assisted by teachers in 7th grade. In 8th and 9th grades an additional 10 sessions concerning tobacco use were delivered by teachers. The classroom components were supplemented by the development of health councils through which students participated in other cardiovascular risk reduction projects.

The smoking prevention program was evaluated with a design in which students in all of the schools in one community received both the community-wide cardiovascular intervention and the school-based smoking prevention program and students in all the schools in another community did not. All students in one cohort were surveyed every year from 6th to 12th grade. As in all school-based studies, attrition occurred continuously over the 6 years, and by 12th grade only 45 percent of the original participants were surveyed. There were no differences in smoking rates at 6th grade. By the end of 7th grade, after the core smoking prevention content had been delivered, weekly smoking prevalence was about 40 percent lower in the program condition, and this effect was maintained through 12th grade, 3 years after the end of direct smoking prevention instruction and a year after the end of general community education (Table D-1).

Like the North Karelia project, this study demonstrates that school-plus-community programming can have substantial effects that are maintained to a large extent through the end of high school.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×
Midwestern Prevention Project

The Midwestern Prevention Project (MPP; also known as Project STAR [Students Taught Awareness and Resistance]) tested a school-plus-community (and mass media) version of the social influences approach in eight communities in the Kansas City metropolitan area. The school-based component consisted of 10 sessions delivered by classroom teachers to 6th or 7th grade students (depending on the year of transition to middle school) and 5 sessions delivered the following year (when a parent involvement component was also implemented). Of these schools, 8 were assigned randomly to conditions, 24 other schools elected to deliver the program, and 18 others elected to wait till after the project. Mass media programming was available to all communities every year. Other community-based programming started in the third year and likewise was available in all communities.

At the 2-year follow-up, the RR was 37.5 percent (Table D-1) (Pentz et al. 1989). By grades 9–10, it was 18 percent (Table D-1) (Johnson et al. 1990). These results are difficult to interpret because all students were exposed to the mass media and community components. The mass media programming, in particular, would be expected to reduce the difference between groups because the control group would no longer be a real control and it might have reduced students’ rate of onset relative to if they had not been exposed to the community program. This might explain the relatively fast decay.

Vermont Mass Media Project

The Vermont project tested the effectiveness of a mass media social influences smoking prevention program when delivered in the context of a school-based program. Worden and colleagues (1988) undertook a careful development process to develop television and radio spots that would discourage cigarette smoking by adolescents. They randomly assigned two communities to the program condition (mass media plus school) and two matched communities to a school-only condition. There was no true control group. In the program communities, they purchased the time for airing the spots (734 TV spots in year 1 decreasing to 348 by year 4, and 248 radio spots in year 1 increasing to 450 by year 4) and provided schools with the school-based program (four sessions in each of 5th through 8th grades and three sessions in both 9th and 10th grades—each student in the study cohort was exposed to 4 years of program during 5th through 8th grades, 6th through 9th grades, or 7th through 10th grades) and teacher training to deliver them. Neither schools nor students were told about the media programming, and the mass media programming never mentioned the school program. Thus, as far as students were concerned, there was no linkage between the two programs (Worden et al. 1988).

As shown in Table D-1, the RRs in weekly smoking among the school plus mass media program group compared to the school-only program group were 36.6 percent (14.8 percent versus 9.1 percent) at the end of the program (grades 9–11) and 28.8 percent 2 years later at grades 10–12 (Flynn et al. 1992; Flynn et al. 1994; Flynn et al. 1995). Larger effects were observed for daily smoking—44 percent RR at the end of the program and 36 percent a year later. It is difficult to estimate what the effects of the school-only program might have been and therefore it was diffucult to estimate the relative contributions of the school and mass media programming. Nevertheless, this study demonstrates that well-designed media programming can produce large effects above those of the school-only program, about 80 percent of which are maintained for at least 2 years.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×
Summary of Findings from Category I School-Plus-Community Programs

The school-plus-community studies produced short-term RRs of about 40 percent, almost twice as good as the school-only programs. These effects decayed an average of 22 percent to about 31 percent. Because the effects of school-only programs tended to increase rather than decay over time, the medium-term effects of school-plus–community or mass media programs were only about 12 percent better than school-only programs. Note, however, that program effects were maintained at a higher level (almost 40 percent, or 31 percent better than school-only programs) for those programs that included a high school component (North Karelia and Class of 1989 Studes), reinforcing the conclusion above that high school programming reduces the decay of effects. Despite this latter result, we conclude conservatively that ongoing school plus mass media or community programs can produce a medium-term RR of between 31 and 40 percent.

The use of multiple delivery modalities increases effectiveness over those obtained from school-only programs (Flay 2000). This is consistent with theories about the influences on behavior existing across multiple domains of life (Bronfenbrenner 1979; Bronfenbrenner 1986; Flay and Petraitis 1994; Flay et al. 1995). It helps if students receive consistent messages across community contexts and over time.

CATEGORY II
PROGRAMS

This section provides a brief review of several programs that show exceptional promise or provide other important insights to help estimate the potential and likely relative reduction in smoking onset if prevention programs were widely implemented. These programs are summarized in Table D-2.

Category II
School-Only Programs

The Adolescent Alcohol Prevention Trial

Hansen and Graham (1991) tested two variants of early social influences program (nine sessions delivered to 7th grade students) targeted to alcohol use (Hansen and Graham 1991). They contrasted information plus resistance skill training, information plus normative education alone, or both of these combined. Schools were assigned randomly to one of these three conditions or to a control. Although the program focused mostly on alcohol, it did produce effects on cigarette smoking. The normative education and combined programs produced the largest effects. As shown in Table D-2, the RRs at the end of the program were 21.4 percent for lifetime smoking and 26.2 percent for monthly smoking. At 11th grade follow-up, the RR in lifetime smoking was 13.9 percent (Taylor et al. 2000). Although this program focused mostly on alcohol, it also produced effects for cigarette smoking. These effects were not too different in magnitude from those reported earlier from TAPP (developed by the same principal investigator), although, as might be expected because the program was not focused on smoking, these effects were not maintained as well.

Towards No Tobacco

Sussman and colleagues (1993a; 1993b; 1996) developed the Towards No Tobacco (TNT) program as a more intensive approach to tobacco prevention that incorporated the social influ-

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

ences approach and new approaches to altering normative beliefs and social skills training. In a large randomized trial, they found RRs in ever smoking of 34 percent at the end of the program (grade 8) and 30 percent at grade 9, and RRs in weekly smoking of 64 percent at the end of the program and 56 percent at the end of grade 9. These effects are larger than those found in other programs, so one would expect that the medium-term effects might also be larger (Dent et al. 1995; Sussman et al. 1993a; Sussman et al. 1993b; Sussman et al. 1995).

Know Your Body

Investigators at the American Health Foundation developed the Know Your Body (KYB) program in the early 1980s as a comprehensive health education program that included social influences and competence prevention components. It consisted of 384 lessons delivered during 4th through 9th grades. In a randomized trial, Walter and colleagues (Walter et al. 1988; Walter and Wynder 1989) found an 11.5 percent RR in thiocyanate (a biological marker of smoking) at grade 8 and a 73.3 percent RR in lifetime smoking at the end of grade 9. This is an exceptionally large effect. Without long-term follow-up data we cannot be sure how well it would have been maintained, but this study shows that strong prevention effects can be obtained by comprehensive health education programs that also include proven approaches to prevention.

The Good Behavior Game

Kellam and and Anthony (1998) applied the Good Behavior Game (GBG) (Barrish et al. 1969) to improving elementary student behavior in the expectation that it would prevent subsequent adolescent problem behavior (Kellam and Anthony 1998; Storr et al. 2002). In a trial where 1st grade students were assigned randomly to control classrooms and classrooms or teachers were assigned randomly to the GBG, another intervention, or control conditions, students received three 10-minute sessions per day at the beginning of 1st grade, increasing in frequency and duration during 1st through 2nd grades. Ialongo and colleagues (1999) found a 24 percent RR in problem behavior at the end of grade 2 (Ialongo et al. 1999) while Fur-Holden and colleagues (2004) reported a 26.3 percent RR in lifetime smoking 8th grade (Furr-Holden et al. 2004). These studies demonstrates that important changes in life course trajectories of behavior brought about early in life can lead to important changes in adolescent behavior, including smoking.

Other school-based programs that improve elementary school children’s behavior also have this kind of potential, for example, the Fast Track (Conduct Problems Prevention Research Group 2002) and Positive Action programs (Flay et al. 2001; Flay and Allred 2003). Some non-school interventions that improve the behavioral trajectory of young children—for example, preschool maternal counseling (Cullen and Cullen 1996) and home nursing visitation (Olds 2002)—also have this potential.

Summary of Findings from Category II School-Based Programs

Although these programs are not strictly comparable, the average effect size of these four projects was 27.2 percent for short-term effects and 39.1 percent for medium-term effects (usually 8th or 9th grades), but with large variation (12 to 49 percent for short term and 26 to 73 percent for medium term). Given that Category I programs actually had increased effects over time, these results suggest that it may be possible to have medium-term effects considerably higher

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

than the estimates derived from Category I programs with more comprehensive or newer school-based programs.

The results of the GBG and other elementary school and preschool programs are particularly intriguing because they demonstrate the power of changing the trajectories of behavior early in life. A relatively nonintensive prevention program provided to these students in middle and high school might have much larger medium- and long-term effects on smoking and other health-related behaviors.

Category II
School-Plus-Community Program

Project 16

Project 16 (Biglan and Ary 2000) was a randomized, multiple cross-sectional design to test the effects of a comprehensive community-based intervention designed to reduce smoking by 7th and 9th graders. Sixteen communities were assigned randomly to two conditions: a five-session social influences school-based program and the school plus the community program. The community program included media advocacy, youth antitobacco activities, family communications about tobacco use, and reduction of youth access to tobacco. At the end of 2 years of intervention, the covariate adjusted prevalence of smoking among 7th and 9th graders in the community program communities had increased 0.9 percent (from 10.7 percent to 11.6 percent) while prevalence had increased 3.3 percent (from 8.1 percent to 11.4 percent) in the school-based only communities—an RR of 21.1 percent (Table D-2). One year later, the parallel rates were 5.9 percent (from 7.9 percent to 13.8 percent) and 2.1 percent (from 10.3 to 12.4 percent), respectively, or a RR of 27.5 percent (Table D-2). The RRs obtained by this intervention suggest that well-designed community-based interventions can have effects that seem likely to be maintained at substantial levels. The lack of a true control group makes estimating the true effect difficult. However, the results of this study suggests that significant medium- and long-term effects can be expected from well-designed and implemented school-plus-community programs.

Summary of Category II Programs

The findings from both the school-only and the school-plus-community programs in this section suggest that programs can be developed and implemented that will be as effective or more so in the medium- or long-term as the Category I programs reviewed above.

Summary of Findings and Conclusions

School-Only Programs

This review suggests that interactive social influences or social competence smoking prevention programs that provide 15 or more lessons, start in upper elementary or middle school, and continue into high school can produce solid medium-term effects. Other conditions that appear to improve the effectiveness of school-only programs relate to content (social influences and general social competence are of critical importance), how well they are delivered (related to how well teachers are motivated and trained), and the involvement of older peers (see Tobler et al. 2000 for elaboration of the 13 components of effective programs).

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Results from three social influence and social competence programs with 15 or more sessions over 2–4 years, preferably with some content in high school, had significant short-term effects of about 22 percent RR in monthly or weekly smoking that increased during high school in two of the studies to an estimated average of 28 percent RR. Some other programs (Category II) provided further evidence that: (1) the social influence approach can affect tobacco use even when alcohol use was the main focus; (2) comprehensive health education programs that include strong social influence content can be effective, possibly even more effective than stand-alone social influence programs; and (3) programs early in life can alter developmental pathways for the better, including less tobacco use in adolescence.

Based on an average of the medium-term effects of Category I studies and supported by the estimated medium-term effects of Category II studies, the possible medium-term effects of a national program of well-implemented, school-based smoking prevention programs of proven effectiveness are estimated to be 28 percent.

School-Plus-Community and/or Mass Media Programs

The four Category I school-plus-community studies produced short-term RRs of about 42 percent, decaying to medium-term effects of about 31 percent. Findings from one Category II community-based program implemented with a school-based program support this estimate of effect size. Thus, the possible medium-term effects of a national program of well-implemented school-plus-community and/or mass media smoking prevention programs of proven effectiveness are estimated to be 31 percent.

Expected Effects into Young Adulthood

Program effects are likely to decay beyond high school. Unfortunately, few studies are available to guide us in how large or small this decay might be. However, national U.S. data may allow for an estimate. A U.S. National Household survey on Drug Abuse data suggests that about 3.012 percent (average for 1989–1999, range = 2.63–3.46) of 18 year-olds who are not smoking daily become daily smokers by the time they are 25 (Giovino 2004). The Monitoring the Future 2003 data provide a national estimate of the percentage of 12th grade students that smoke daily at 15.8 percent, meaning that 84.2 percent of 12th graders were not smoking daily. For school-only programs, this would represent a 23.3 percent RR in daily smoking by age 25 (see Table D-3 for calculations) or a decay in RR of (28 − 23.3)/28 = 17 percent. The decay of school-only programs might be greater than this estimate, maybe 20 percent, and the decay of school plus ongoing community or mass media programs might be less, maybe 15 percent because the messages remain in the larger environment to influence or reinforce behavior.

Expected Effects Under Real-World Conditions

There are at least two other factors that could reduce the effects of even the best programs in real-world implementations: (1) rate of adoption by schools and communities and (2) level and quality of implementation or delivery.

Less-than-complete adoption clearly would reduce the expected national-level effect size. Getting effective prevention programs adopted by schools is not easy (DHHS 2000; Ennett et al. 2003; Ringwalt et al. 2002). Estimates of effects often come from efficacy trials where adoption is not as large an issue because only those schools or communities willing to adopt the program have been entered into the study, and also where implementation quantity and quality may not be

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

major issues because the implementers are trained and monitored by the researchers. Nevertheless, it would be helpful to have an estimate of the proportion of schools that would be willing to implement an effective tobacco prevention program; however, we know of few such estimates. The Conduct Problems Prevention Research Group (2002) reported that seven of eight school districts that were offered the fast track program accepted, and 52 of the 54 schools asked agreed to participate.

In actuality, not even all schools entered into studies always carry through with their willingness to implement the program. For example, Battistich and colleagues (2000) reported that only 5 of 12 schools recruited into the program arm of a nonrandomized project based on faculty interest and perceived likelihood of being able to implement the program actually implemented the program moderately well to very well during the 3-year study (Battistich et al. 2000).

In these days of high demands on schools, they are not going to address prevention unless they have to (or unless it can be shown to improve achievement) and they are not going to adopt a program unless they have the funding for it. Adoption probably would not be 100 percent even with a clear mandate and earmarked funding, although it might increase over time following the S-shaped adoption curve, as successes are publicized. A clear mandate to include tobacco prevention in the curriculum, together with earmarked funding and monitoring of adoption, should help obtain rates of adoption of evidence-based school-based programs of 75 percent or more.

Getting comprehensive programs implemented fully and with integrity, even when they are adopted with full information and commitments, is also no small task, and the level and quality of implementation are clearly related to program effectiveness (Kam et al. 2003). Factors believed to influence program implementation have been identified and they are related not only to the program itself (e.g., program complexity, provision of technical assistance, user-friendly materials) but also to the environment in which the program is implemented (i.e., district, school, teacher, and participant characteristics) (Durlak 1998).

For some programs with high levels of monitoring, levels of implementation might be high. For example, the Conduct Problems Prevention Research Group (2002) reported that participating teachers taught an average of 85 percent of the lessons in the first year of the program, 91 percent of parents participated in the program, and 79 percent of them attended at least 50 percent of the parent sessions.

Without ongoing monitoring, implementation might be much more uneven. Uneven implementation of a national program could reduce the effect size substantially—but by how much? The effect sizes reported for LST already took incomplete implementation into account. The authors reported that about 76 percent of the students received 60 percent or more of the program from trained teachers in schools who had signed onto the study (Botvin et al. 1995). The 20 percent medium-term RR reported was for the whole sample (for the high-fidelity sample, the medium-term RR was 28 percent). Independent evaluations of the LST program have reported a wide range of effects. None of these studies provided data on levels or integrity of implementation.

The tobacco industry has sponsored adoption, implementation, and evaluation of LST (Interactive Inc. 2000; Interactive Inc. 2001).6 During the first 2 years, teachers who provided implementation data (73 percent) taught 80 percent of the units, met 75 percent of the objectives, and covered at least 69 percent of the activities. If one assumes that the 27 percent who did not provide implementation reports did not teach LST, then the average implementation level would

6

Unfortunately, the design of this evaluation (unmatched control group, for which date are not reported) does not allow for any interpretation regarding program effectiveness.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

be between 50 and 60 percent. Some teachers noted that the only reason they implemented LST at all, especially in year 2, was because it was being monitored or evaluated. Thus, one could conclude that under conditions of ongoing monitoring or evaluation a high level of implementation (60 percent or more) could be achieved.

There may be less compromise in the delivery of a mass media campaign than of school programs because they are of larger scale. As long as campaigns are well designed and fully funded (including purchase of time on television and radio), a 75 percent implementation might be a reasonable expectation.

DISCUSSION

There are a number of limitations to the studies that met the criteria for this review. First, the most appropriate design is the school-based randomized trial, where schools are assigned to conditions and data are analyzed taking into account the nesting of students in schools (Flay and Collins 2005; Murray 1998). Many prevention studies—including some of those reviewed here—did not use randomization, but instead used matched controls or other designs. Some so-called quasi-experimental designs (Shadish et al. 2002) may be acceptable under certain conditions (Flay et al. 2005; Flay et al. in press). Second, although more than one program has reported significant medium-term effects, none of the individual programs has more than one evaluation of medium-term effects. Thus, although we can conclude that comprehensive, interactive programs with 15 or more sessions, including in high school, can have medium-term effects, we do not yet know whether the medium-term effects of any one of the programs meeting these criteria can be replicated.

Third, there is a reliance on self-report measures of tobacco use. For many years, the validity of self-reports of sensitive behaviors was questioned. After a series of studies of the use of biochemical validation or the collection of biochemical samples for use in a “bogus pipeline” procedure (Aguinis et al. 1993; Presti et al. 1992; Roese and Jamieson 1993), methods for surveying adolescents that ensure confidentiality were developed that seem to ensure the validity of self-reports of sensitive behaviors (Graham et al. 1984; Murray and Perry 1987; Patrick et al. 1994; Stacy et al. 1990). Although multiple studies suggest that students do report their substance use honestly when asked under conditions of confidentiality, these studies were limited to middle school students, so it would be wise to have some studies use biochemical verification with high school students and young adults.

Fourth, the available long-term evaluations do not allow determination of the relative effectiveness of these programs for different populations. However, indications from meta-analyses that these types of programs have larger effects in schools with a predominantly special or high-risk (minority, high absenteeism or dropout, poor academic records) populations are promising.

Fifth, the last time of data collection in most of these studies was while youth were still in high schools (hence, “medium-term”). We need many more truly long-term studies of the ongoing effects of smoking prevention programs, preferably up to age 25.

Sixth, there is great variability in the way researchers and evaluators assess outcomes. Researchers have used ever smoking, smoking in the past month or week, and other indicators of youth smoking. Fortunately, there was reasonable consistency in estimates of prevention effectiveness across measures in most of the reviewed studies. Nevertheless, it would help future reviewers if researchers could settle on consistent measures. In addition, however, future research needs to include assessment of multiple short-term effects (or mediating variables) in addition to tobacco use. For example, programs are designed to improve knowledge of the influences on be-

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

havior (including tobacco industry promotions); knowledge of the physical, economic, environmental and social consequences of tobacco use; perceptions of risk; normative estimates or beliefs; decision-making, peer pressure resistance, and coping skills; and possibly student’s activism against smoking in their environment. All of these need to be measured in future research, and their mediating effects on tobacco use behavior demonstrated.

Seventh, there was large variation across studies in program content, which affects the validity of some prior reviews of this literature. Conducting meta-analyses of these studies seems like comparing apples with oranges, or even with yams (instead of comparing multiple crops of Gala apples or even different breeds of apples). The variation makes it difficult to compare programs. In other disciplines, one would not conduct a meta-analysis or review of such different kinds of programs and draw a conclusion for all programs as a group. One would not, for example, conduct a meta-analysis of all treatments for breast cancer and conclude that breast cancer treatment does not work. Rather, one would attempt to determine which kinds of treatments work the best (and for whom and under what conditions), and then adopt the best treatment as the standard of practice. Unfortunately, some meta-analysts of various smoking prevention programs have treated them as a homogeneous group and concluded that they do not have medium- or long-term effects. It would be more appropriate to try to find which kinds of programs produce significant effects, or the largest effects (as well as for which kinds of people and under what conditions), as Tobler and colleagues as well as this author have attempted.

Finally, program developers were involved in all of the evaluations reported. It is quite probable that the effect sizes reported by program developers are larger that those that will be obtained under other conditions. The field is urgently in need of independent replications of the findings summarized in this paper (Flay et al. in press).

Despite, or maybe because of, the above limitations, there are multiple reasons to suspect that estimates of effect sizes derived from the small number of studies reviewed here might be conservative (underestimates). First, some of the effect sizes reported were derived from studies that already included less than optimal implementation. Second, if a program was implemented nationwide for multiple years, there might be increasing effects over time as new generations of students passed through the program. For example, as fewer young adults become smokers, there will be less social support for smoking and fewer adolescents will be tempted to try smoking. Third, the possibility of larger effect sizes were suggested by the larger short-term effects of the TNT and KYB projects, the promising effects of general behavior improvement programs such as the GBG and the Positive Action program, and the extraordinarily large effects of Project SHOUT with minimal high school boosters.

Summary Statements and Recommendations

The summary statements and recommendations derived from this review apply only to the specific programs reviewed and cannot be extended to other programs, even programs similar to those reviewed. The specific programs are those developed by Hansen (TAPP and AAPT), Botvin (Life Skills Training), and others who have demonstrated that their adaptation and/or extension of similar strategies was effective (Project SHOUT, TNT). Even the community or mass media programs reviewed here used adaptations of the social influences approach (North Karelia, Class of 1989 Studies, Midwestern Prevention Project, Vermont, Project 16). However, one cannot assume that every adaptation or extension of this approach will be effective. Examples of the ineffectiveness of the DARE and Hutchinson programs provide vivid examples of the danger of such extrapolation.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Summary Statement Regarding Effects of School-Based Programs

Based on the studies reviewed, decay post high-school will erode the medium-term effect sizes of school-based programs by about 20 percent relative to the literature's evaluations through the end of high school. Thus, with complete adoption and implementation, the nation’s schools could produce a long-term (by age 25) reduction in smoking initiation of more than 22 percent [0.28 × (1 − 0.2)]. However, scaled-up replication of model school-based prevention programs might yield effect sizes less than half as large (45 percent) as those reported in the research literature because of incomplete adoption (75 percent) and less than optimal fidelity (quantity and quality) of delivery (60 percent). Hence, a suggested effect size for realistic long-term effects of school-based programs might be about 10 percent [0.28 × (1 − 0.2) × 0.75 × 0.60].

Summary Statement Regarding Effects of School-plus-Community and/or Mass Media Programs

Based on the studies reviewed, decay post-high school will erode the medium-term effect sizes of school-plus-community or media programs by about 15 percent. Thus, with full implementation, comprehensive school-plus-community and mass media programming might reduce smoking initiation by age 25 by as much as 26 percent [0.31 × (1 − 0.15)]. However, scaled-up replication of model school-plus-community or mass media programs might yield effect sizes only about 75 percent as large as those reported in the literature. Hence, a suggested effect size for realistic long-term (by age 25) effects of school-plus-community and/or mass media programs is about 20 percent [0.31 × (1 − 0.15) × 0.75].

Given that school-based prevention could produce significant and practical reductions in youth and young adult smoking levels, the following recommendations seem appropriate.

Recommendation 1: Every middle and high school should implement an evidence-based smoking prevention program (or a similar substance abuse prevention program that has been shown to reduce smoking) at all grade levels. As a corollary, they should be discouraged from using programs for which there is evidence of ineffectiveness (e.g., DARE)

Effective prevention programs might cost up to $50 per student for the first year and as much as $10 per student thereafter for program materials and training. However, the savings due to the benefits of preventing significant numbers of students from starting to smoke and delaying the start date (and therefore the lifetime consumption) for others are significant. Caulkins and colleagues (2004), for example, estimate the social benefits of smoking prevention alone to be about $300 per student and the social benefits of substance abuse prevention to be about $840 per student (Caulkins et al. 2004). The social benefits of even broader behavior improvement programs could be considerably greater (Aos et al. 2004). Clearly, from a societal perspective, the costs of effective prevention are well worth it both to the individual students and to society as a whole.

We still lack consistency and continuity across developmental stages (preschool through college), and this clearly is an area where continued research is desirable. At the preschool and elementary school levels, implementation of more general and promising approaches such as the GBG or the Positive Action program should be used to prepare students to adopt tobacco-free lifestyles. Increasing evidence suggests that behavior improvement or positive youth development programs can have pervasive effects on behavior, including reducing tobacco use, and also can improve school performance. However, the lack of replicated findings regarding specific ef-

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

fects on tobacco use to date suggests that they should be accompanied by rigorous evaluations. Such evaluations will contribute to the knowledge base of prevention and positive youth development.

Recommendation 2: Governments, communities, or school districts should provide funding for evidence-based programs for every school in their jurisdiction.

The current environment, with such a high focus on student achievement, is not very conducive to implementation of this recommendation. However, there is increasing evidence that effective behavior improvement programs also improve student achievement. This likely occurs because better behaved classrooms give teachers more time to teach and well-behaved students are more likely to learn.

The current climate might be more supportive of general substance abuse prevention programs or more general behavior improvement programs than tobacco-specific programs. However, smoking prevention programs can also lead to lower levels of initiation of alcohol and other drugs. Accordingly, they are eligible for Safe and Drug Free Schools and Communities (SDFS) funding. Given the availability of evidence-based smoking and substance abuse prevention programs, SDFS funds should be maintained, or even increased, to support comprehensive school-based prevention programming.

Increasing evidence suggests that more general behavior improvement programs not only have more effects, but have larger effects on each of the behaviors and these effects are more likely to be maintained because they support each other. More general programs also are more likely to include elements that change the climate of entire schools (or other locations in which they are implemented), thus providing more generalized support for the positive behaviors encouraged by the programs (Catalano et al. 2004; Eccles and Gootman 2002; Flay 2002).

Recommendation 3: Governments, communities, or schools also should provide funding to develop and deliver comprehensive community or mass media programs that complement school-based programs.

School-plus-community or mass media programs have been shown to have effects that are 10–20 percent larger than school-only programs. Conversely, school-based programs can provide the normative change that is needed to support community programs or policy changes regarding smoking in public places or the pricing of tobacco in the community.

Recommendation 4: Schools and communities must take steps to ensure that adopted programs are implemented with high fidelity.

Programs implemented with higher fidelity produce larger effects, and larger effects are more likely to be maintained through high school and into adulthood. Schools will need to provide the resources and support for every teacher and staff person to be trained in proper implementation. This also requires ongoing monitoring of implementation as well as ultimate effects on student behavior.

Recommendation 5: Prevention programs must be sustained over time.

It is not sufficient to deliver a prevention program, whether school only, community only, mass media only, or school plus mass media or community, for only a few years. Any program must be sustained for a meaningful length of time (a generation) to be effective at the population

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

level in the long term. Sustained programs may have greater effects in the long term; however, effects over an extended period are hard to estimate. Rather than just reducing young adult smoking by 10–20 percent for the first cohort, a sustained program could potentially cut the population prevalence of smoking in half in about two decades.

Recommendation 6: The nation should find the funding to make the above recommendations a reality.

SDFS funds are one source of funding ($437 million in 2005). Others might include excise taxes on tobacco, extension of the Master Settlement Agreement, and penalizing the tobacco industry for every new smoker under the age of 21. The maximum costs of the above recommendations would be $2.5 billion for the first year of implementation (based on approximately 50 million pre-K through12th grade students [NCES 2003] at $50 per student). This represents about 13.2 cents per pack of cigarettes sold in the United States (more than 19 billion packs in 2001 [FTC 2003]). Subsequent years would cost as little as one-fifth of these amounts, about $500 million, only a little more than current SDFS funding, or about 2.6 cents per pack of cigarettes sold. An alternative approach might be to amortize the costs over 5–10 years at about $600 million per year.

CONCLUSION

It is time for the nation to face up to the fact that preventing as many children and youth as possible from starting to smoke cigarettes is feasible and worthwhile, both economically for the nation and in terms of improved health of the population.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Table D-1 Short- and Medium-Term Effects of Seven Selected Social Influence Programs with Follow-up into High School

Investigator

Project Name

Designa

Number of Classes

Time (years)

Modalityb

Grade(s)

Grade at Last Follow-up

Short-Term Effect Size (%)c

Medium-Term Effect Size (%)c

Ever

Month

Week

Average ES

Ever

Month

Week

Average ES

School-only programs

Hansend

TAPP (Cohort 1)

NR-S

15

1

S

7

10

 

26.2

 

26.2

18.3

19.1

 

18.7

Botvine

Life Skills Training

R-S

30

3

S

7–9

12

 

 

8.9

8.9

 

19.7

20.4

20.0

Elderf

Project SHOUT

R-S

18+

3

S+

7–9+

11

 

30.3

 

30.3

 

44.1

 

44.1

MEANS for school programs

 

 

 

 

 

 

28.2

8.9

21.8

18.3

27.6

20.4

27.6

School-plus-community or mass media programs

Vartiaineng

North Karelia

NR-C

10+

2 yrs

S+C

7–8

12

44.8

43.7

45.3

44.6

40.3

39.2

36.7

38.7

Perry

Minnesota Class of 89

NR-C

17+

 

S+C

6–10

12

 

 

40.0

40.0

 

 

39.4

39.4

Pentz

MPP

PR-S

15+

2 yrs

S+C

6–7/7–8

9–10

 

40.9

34.1

37.5

 

18.0

 

18.0

Flynnh

Vermont Mass Media

R-C

22+

3 yrs

S+M

5–8, 6–9 or 7–10

10–12

 

 

36.6

36.6

 

 

28.8

28.8

MEANS for School + Community or Media Programs

 

 

 

44.8

42.3

39.0

39.7

40.3

28.6

35.0

31.2

OVERALL MEANS for all programs

 

 

 

 

44.8

35.3

33.0

32.0

29.3

28.0

31.3

29.7

MPP = The Midwestern Prevention Project

SHOUT = Project SHOUT (Students Understanding Others Understand Tobacco)

TAPP = The Tobacco and Alcohol Prevention Project

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

a R = random, NR = nonrandom, PR = partial random, S = school, C = community.

b S = school only, S+ = school plus small media or family outreach, M = mass media, C = community.

c As either (% change in C – %change in P)/%C or (%C – %P)/%C, where P = program condition and C = control. Short-term effects are generally at the end of grade 8 or 9.

d The medium-term effect for smoking in the past month is larger (42.9%) for students present at all waves of the study.

e Randomization was originally complete, but six program schools were dropped from the analysis because of low implementation. The RR for high-implementation students at grade 12 was 37%.

f Reported effect is with half the high school students receiving a high school booster (two newsletters and one phone call during grade 1); effect size decreases to 9.5% when no students receive the booster.

g At 3 years post–high school the effect was 23% for the health educator (HE) condition and 37% for the teacher condition; at 10 years post–high school the effect was 20% for both the HE and the teacher conditions.

h This study tested the difference between school plus mass media and school-only (there was no control group).

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Table D-2 Short- and Medium-Term Effects of Seven Category II Programs

Investigator

Project Name

Designa

N classes

Time (years)

Modalityb

Grade(s)

Grade at Last Follow-up

Short-Term Effect Size (%)c

Medium-Term Effect Size(%)c

Life

Month

Week

Average ES

Life

Week

Average ES

School-only programs

Graham and Hansend

AAPT

NR-S

9

 

S

7

11

21.4

26.2

 

23.8

13.9

 

13.9

Sussmane

TNT

R-S

12

2

S

7–8

9

34.4

 

64.3

49.3

30.4

55.5

43.0

Walterf

KYB

R-S

384

6

S+

4–9

9

 

 

 

11.5

73.3

 

73.3

Kellamg

GBG

R-K

120a

2

S

1–2

8

 

 

 

24.4

26.3

 

26.3

MEANS for school programs

 

 

 

 

 

27.9

26.2

64.3

27.2

36.0

55.6

39.1

Schoo-plus-community programs

Biglanh

Project 16

R-C

5+

2 yrs

S+C

7-9

7-9

21.1

 

 

21.1

27.5

 

27.5

OVERALL MEANS

 

 

 

 

 

 

25.6

26.2

64.3

26.0

34.3

55.6

36.8

a R = random, NR = nonrandom, PR = partial random, S = school, C = community.

b S = school only, S+ = school plus small media or family outreach, M = mass media, C = community.

c As either (% change in C – %change in P)/%C or (%C – %P)/%C, where P = program condition and C = control. Short-term effects are generally at the end of grade 8 or 9.

d Adolescent Alcohol Prevention Trial.

e Towards No Tobacco Use.

f Know Your Body Included parent communications. Short-term effects are for thiocyanate, an biological indicator of tobacco use.

g Good Behavior Game Initially three 10-minute classes per week in grade 1, increasing in duration and frequency during grades 1 and 2. Short-term effects are for "problem behavior" at the end of grade 2.

h Multiple cross-sectional design, where successive cohorts of seventh and ninth grade students were surveyed.

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

TABLE D-3 Calculation of Decay in Prevention Effects by Age 25

Type

Decay (%)

Average school-only RR

28.00

Average school + community or media RR

31.00

Without the prevention

 

Average proportion not smoking in high school who will start by age 25 (SAMHSA Household Survey 1989-99)

3.12

Average high school daily smoking without intervention (Monitoring the Future)

15.80

Therefore, proportion of new smokers by age 25

2.63

Therefore, total proportion smoking by age 25

18.43

With school-based prevention

 

Proportion smoking after school-based prevention

11.38

Therefore, proportion not smoking

88.62

Therefore, proportion new smokers by age 25

2.77

Therefore, total proportion smoking by age 25

14.14

Therefore, new RR

23.62

Decay in RR

16.93

With school + community or media prevention

 

Proportion smoking after school-based prevention

10.90

Therefore, proportion not smoking

89.10

Therefore, proportion new smokers by age 25

2.78

Therefore, total proportion smoking by age 25

13.68

Therefore, new RR

25.75

Decay in RR

16.93

Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Appendix D: The Long-Term Promise of Effective School-Based Smoking Prevention Programs." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Next: Appendix E: Adolescents' and Young Adults' Perceptions of Tobacco Use: A Review and Critique of the Current Literature »
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The nation has made tremendous progress in reducing tobacco use during the past 40 years. Despite extensive knowledge about successful interventions, however, approximately one-quarter of American adults still smoke. Tobacco-related illnesses and death place a huge burden on our society.

Ending the Tobacco Problem generates a blueprint for the nation in the struggle to reduce tobacco use. The report reviews effective prevention and treatment interventions and considers a set of new tobacco control policies for adoption by federal and state governments. Carefully constructed with two distinct parts, the book first provides background information on the history and nature of tobacco use, developing the context for the policy blueprint proposed in the second half of the report. The report documents the extraordinary growth of tobacco use during the first half of the 20th century as well as its subsequent reversal in the mid-1960s (in the wake of findings from the Surgeon General). It also reviews the addictive properties of nicotine, delving into the factors that make it so difficult for people to quit and examines recent trends in tobacco use. In addition, an overview of the development of governmental and nongovernmental tobacco control efforts is provided.

After reviewing the ethical grounding of tobacco control, the second half of the book sets forth to present a blueprint for ending the tobacco problem. The book offers broad-reaching recommendations targeting federal, state, local, nonprofit and for-profit entities. This book also identifies the benefits to society when fully implementing effective tobacco control interventions and policies.

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