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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



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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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).

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Ending the Tobacco Problem: A Blueprint for the Nation 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-

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Ending the Tobacco Problem: A Blueprint for the Nation 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).

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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).

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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-

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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).

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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