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PREVENTION OF SMOKING

School-Based Smoking Prevention Research

In the absence of a comprehensive national children's health policy, the responsibility for preventing adolescent tobacco use has fallen primarily on individual school districts, often guided by their state legislatures or departments of education, which may mandate general health education goals. Schools are the only place where virtually all young people can be reached. This universal access enables health promotion programs to address variations in ethnicity, age, socioeconomic status, and cultural factors, all of which may contribute to tobacco use within the structure of the schools. School settings afford easy access to youth peer groups, access that is critical for affecting peer social interactions related to initiation and use of tobacco. Moreover, the purpose of schooling-to prepare young people for future productive adult roles-is compatible with the goal of health promotion.

However, many schools are ill-equipped to conduct effective smoking prevention programs and unmotivated to do so, and only a few preventive efforts have been mounted by the schools themselves. The major impetus for prevention of tobacco use has been largely external to school systems, driven by federally funded research and voluntary health agencies concerned with the magnitude of health problems caused by tobacco use and the continued high prevalence of adolescent smoking. These programs have worked under severe constraints within the school system, including time restrictions (hours available of class time and for training sessions), limited qualified personnel, and lack of material



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Page 143 PREVENTION OF SMOKING School-Based Smoking Prevention Research In the absence of a comprehensive national children's health policy, the responsibility for preventing adolescent tobacco use has fallen primarily on individual school districts, often guided by their state legislatures or departments of education, which may mandate general health education goals. Schools are the only place where virtually all young people can be reached. This universal access enables health promotion programs to address variations in ethnicity, age, socioeconomic status, and cultural factors, all of which may contribute to tobacco use within the structure of the schools. School settings afford easy access to youth peer groups, access that is critical for affecting peer social interactions related to initiation and use of tobacco. Moreover, the purpose of schooling-to prepare young people for future productive adult roles-is compatible with the goal of health promotion. However, many schools are ill-equipped to conduct effective smoking prevention programs and unmotivated to do so, and only a few preventive efforts have been mounted by the schools themselves. The major impetus for prevention of tobacco use has been largely external to school systems, driven by federally funded research and voluntary health agencies concerned with the magnitude of health problems caused by tobacco use and the continued high prevalence of adolescent smoking. These programs have worked under severe constraints within the school system, including time restrictions (hours available of class time and for training sessions), limited qualified personnel, and lack of material

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Page 144 resources. Because health promotion may not be seen as central to the school's mission, the development and implementation of smoking prevention programs have had to contend with many obstacles. Despite these impediments, significant knowledge of how to prevent young people's tobacco use has been gained over the past two decades. School-based research programs have explored a variety of approaches, which have helped identify the most useful program elements. School-based smoking prevention efforts have also been made more effective when reinforced by broad-based community programs. Moreover, these methods are now being applied with success to preventing smokeless tobacco use. Recent publication of the Centers for Disease Control and Prevention's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction1 and reviews calling for a national agenda for school health promotion2 give further impetus to supporting schools as the locus for tobacco prevention efforts. Comprehensive prevention and health promotion programs that prevent the initiation and use of tobacco products can assist in attaining Healthy People 2000 objectives.3  A review of school-based tobacco prevention programs and programs that integrate prevention into the context of a community effort to reduce tobacco use is a useful basis for developing the model for a comprehensive policy to prevent addiction to tobacco among children and youths. Approaches to School-Based Prevention Research Following the publication of the surgeon general's report in 1964, development of school-based programs to prevent tobacco use by youths grew incrementally, theoretical approach by theoretical approach, program concept by program concept, for two reasons. First, the limitations of behavioral research techniques made it difficult to measure the effect of more than one intervention component at a time. Second, prevention as a lifestyle behavioral concept was a new approach to public health. During this time, however, the most successful components were identified and, as the capacity to conduct multicomponent research among large populations advanced with experience and technology, the best behavioral approaches and program components were combined into more effective interventions. The following section highlights the promising approaches and their components for school-based prevention programs that are reinforced by community-based programs. Information-Deficit Model. The 1964 surgeon general's report provided evidence to the public health community and to the general public that smoking contributes to mortal diseases. A significant percentage of adults acted on that information by quitting smoking. The information, however, had not been designed to reach children and youths. Public health professionals and educators assumed that youths who smoked would quit using tobacco if they were exposed

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Page 145 to information about the health risks of smoking. Behavioral scientists tested ''information-deficit models" to determine whether providing students with information about the health risks of smoking would get them to stop smoking or never initiate smoking. Informational programs were designed and implemented using most forms of educational media available: books, pamphlets, posters, films, and lectures. The images and messages were explicit: smoking increases the risk for numerous serious physical consequences throughout life, including premature death from heart disease or cancer. The message often was presented in a manner intended to arouse fear. Comprehensive reviews of the programs conducted in the 1970s based on the information-deficit model showed that the model had not deterred the adoption of cigarette smoking by youths.4 Providing knowledge of the health consequences of smoking is a basic and necessary step, but it is not sufficient to change the behavior of most youths, for three reasons. First, the information-deficit model does not address the complex relationship between knowledge acquisition and subsequent behavior. Second, the model does not consider the addictive nature of tobacco use. Third, the model does not address risk factors such as peer use and approval of tobacco and perceived prevalence of peer tobacco use. Affective Education Model. When the shortcomings of the information-deficit model became apparent, behavioral scientists turned their attention to personal factors that mediate cognitive factors, for example, beliefs, attitudes, intentions, and perceived norms. Another approach, known as affective education or motivational education, was developed during the 1970s to change smoking behavior among youths. The approach was based on the assumption that adolescents use tobacco because their self-perceptions are somehow compatible with that health-compromising behavior.5 The affective education approach focused on increasing the students' sense of self-worth or self-esteem by helping them learn general skills such as assertiveness, communication, and problem solving. Educators and counselors hypothesized that since smoking and other problem behaviors, such as low motivation to achieve, school absenteeism, and antisocial behavior, were often related, a focus on increasing self-worth could positively affect all of these behaviors. The questions asked, therefore, by researchers were (1) If adolescents' sense of self-worth were increased, would they establish a health-related value system that would preclude tobacco use? and (2) If an adolescent were helped to change his or her attitudes about school, family, or community, would various problem behaviors, including tobacco use, be prevented? Research on the affective education model reported that this approach was no more successful than the information-deficit model at preventing youths from smoking. In fact, an unintended effect of the programs, suggested but not conclusively proven by several studies, might be the elicitation of interest in the very behaviors that are being discouraged.6

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Page 146 Social Influences Resistance Model. A third approach to prevention of tobacco use was developed after evaluations of the earlier interventions demonstrated two critical deficiencies. First, interventions had largely been used among high school and college students. Although smoking is heavier and more prevalent among these students than among younger students, the development of smoking behavior actually begins early, when students are in the sixth or seventh grade.7  Therefore, prevention of smoking initiation and early use necessarily must target students at an age when most initiation occurs. Second, the programs were designed on a universal basis of intervention. It became apparent that tobacco use typically develops in a series of phases, progressing gradually to more addicted behavior. Children progress from experimental, to occasional, to regular tobacco use.8  The time span and the progression through phases of smoking behavior imply that influences beyond just information or affective factors must be considered as determinants of adolescent tobacco use. By the early 1980s, researchers understood those factors to be socio-demographic, environmental, behavioral, personal, and pharmacologic.9 Essentially, the earlier programs had not taken into account the extent to which social environmental factors influence adolescent tobacco use. The third approach, resisting social influences, recognized the importance of the social environment as an influence of tobacco use, and researchers posed the question: If adolescents were to develop skills that allow them to identify and resist social influences, would they refrain from using tobacco? The assumption was that adolescents who smoke lack the skills to counteract (a) the misperception that most people smoke, (b) the appeal of image advertising and promotional activities, and (c) the desire to behave as their tobacco-using role models, peers, or family members behave. Therefore, most programs based on the resisting-social-influences model include training components that foster general assertiveness, decision making, and communication skills that are clearly linked with smoking.10 The skills-based interventions avoided the earlier scare tactics of the information-deficit model and instead focused on the detrimental short-term social consequences of smoking, on understanding the techniques of tobacco advertising, and on the social advantages of being a nonsmoker. Although the theory underlying the skills approach derives from the knowledge that multiple factors influence tobacco use, the knowledge is limited to broad understandings of these factors. There are major gaps in the knowledge about factors influencing tobacco use. These factors are multidimensional by nature, and current theories conflict on the psychological routing of those factors. A theory that attempts to describe that complexity is the theory of "triadic influence," which considers three types of influence that flow through three levels or tiers from ultimate to distal to proximal. Flay and Petraitis review 13 theories to account for the initiation and use of tobacco by youth, and identify gaps in each of them. 11 Their approach considers distal causes, such as behavior of family members and genetic inheritance of traits, as indirect influences on

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Page 147 behavior, through their effects on more proximal or direct predictors (such as social skills, motivations, and expectancies). Causes at one level could be said to be "mediated" by causes at another level. Factors of one type of influence could also "moderate" or affect the influence at another level. In analysis of research studies of multiple factors, this is known as the statistical interaction effect, and it is difficult to interpret how this combination of factors works to affect smoking behavior. To date, no single theory comprehensively encompasses all of the factors or accounts for a large proportion of the variance in smoking behavior. Prevention programs have targeted social influences that are most proximal to smoking behavior, but these interventions have not affected more distal factors. The following section describes several structural and content components in current skills programs, and highlights programs that have most successfully applied those components. Most programs based on a skills-resisting model incorporate several components: · information about the short-term negative consequences of tobacco use (for example, bad breath, yellow teeth, reduced blood circulation, or vasoconstriction); · an exploration of inaccurate beliefs about tobacco use (for example, that students usually overestimate the percentage of peers who smoke); · an examination of the many reasons students smoke (for example, peer acceptance and image seeking); and · practice of strategies for resisting the influences of tobacco use (for example, refusal skills). An example of a large-scale randomized trial that incorporates all of the above components is the Waterloo Smoking-Prevention Program, implemented with sixth graders in six 1-hour weekly sessions. The program was effective in preventing the onset of experimental smoking through the end of the eighth grade.12 Format variations are, in most cases, minor among the numerous approaches to developing skills to resist social influences to smoke.13 Most programs rely on classroom teachers to implement these programs, although variations include using trained health teachers and science teachers.14 Some intervention variations have used a combination of trained teachers with same-age student peer leaders. 15 Peer leaders from high school have helped junior high school students develop the skills needed to resist social pressures to smoke by identifying social pressures and then rehearsing and modeling the strategies for coping with the pressures.16 A prototypical peer-led social influences intervention reduced the incidence of daily and weekly smoking 35-50% more than an adult-led program emphasizing health consequences. These effects had dissipated at the 5- and 6year follow-ups.17 College undergraduate students have also served as leaders to young adolescents, both in the classroom and over the telephone, in booster calls, when students left middle schools.18

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Page 148 Other interventions have used media supplements and have involved the students' parents. For example, five different 5-minute video segments were aired on a local television station and coordinated with a classroom program in Los Angeles, and a significant number of youths got their parents to view the segments.19 Another program used homework activities to involve parents and other family members in role playing in order to reinforce a social influences program taught by health, science, and social studies teachers.20 A slightly different approach to enlist parental support was mailing to parents a set of four messages designed to reinforce classroom activities and urging parents to establish family policies regarding smoking.21 The media and parent interventions have attempted to broaden the social context for components on peer pressure and resistance skills training. Videotapes of nonsmoking peers were used to impart information and to teach skills needed to resist social influences in a program described as "social inoculation" developed in the mid-1970s.22 Another variation of the social-skills training approach adds components on self-control, decision making, problem solving, and self-reward. By this problem-solving approach, students learn self-control skills for smoking prevention coupled with self-reward for personal successes.23 Numerous programs implementing an approach of personal and social skills training based on various aspects of cognitive-behavioral theory have been successful in reducing experimental smoking and initiation of smoking, and in reducing regular smoking. The general goal of the program is to enhance students' self-esteem, self-mastery, and self-confidence in order to decrease their susceptibility to indirect social pressures to smoke and to prepare students to cope with anxiety induced by social situations. The life skills approach focuses on knowledge, capabilities, and skills to enact pertinent behaviors, such as not smoking around peers. The approach, which may involve up to twenty classroom  sessions, includes resistance skills, behavioral research, role playing, self-control, decision making, problem solving, and self-reward, as well as components devoted to increasing selfesteem, self-confidence, autonomy, and assertiveness.24 Effectiveness of School-Based Smoking Prevention Programs Research on smoking prevention has by its nature had to contend with various threats to validity posed by methodologic issues of mixed units of analysis (individual student versus school or classroom), attrition of the subject (student) population, quality of implementation, and homogeneity of the subject population.25 To a large extent, most recent research studies have been designed to deal with these methodologic obstacles and have consistently found moderately strong prevention effects. These factors have been assessed in four important meta-analytic studies published since 1980.

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Page 149 Program Content Components. Tobler examined 143 studies of drug-use prevention programs for sixth- through twelfth-grade students and found that these programs do have an effect on behavior, skills, and knowledge. Peer-led programs and programs dealing with social influences were more effective than other models.26 Tobler later confirmed these findings with more rigorous analytic methods.27 The Rundall and Bruvold meta-analysis of 47 studies of school-based smoking intervention programs examined knowledge, attitude, and behavioral outcomes of social influence programs versus traditional programs; the social influence programs were more likely to affect attitudes and behavior.28 Rooney examined 90 school-based tobacco use prevention programs conducted from 1974 through 1989 that sought to develop skills to resist social influences. The meta-analysis took into account the clustering of students in schools and used the school as the unit of analysis. Results indicated that smoking prevalence was 4.5% lower among students in the social influence programs than among students in control conditions. The social influence programs that were most effective at 1-year follow-up had the following components: they were delivered to sixth-grade students, used booster sessions, concentrated the program in a short time period, and used an untrained peer to present the program. Under these more optimal conditions, long-term smoking prevalence was about 25% lower.29 Bruvold's meta-analysis included 94 separate interventions from the 1970s and 1980s. The intervention programs were categorized as rational (providing factual information), developmental (increasing self-esteem and decision-making skills), social-norms-oriented (providing alternatives and reducing alienation), and social-reinforcement-oriented (developing skills to deal with social pressures to smoke). The meta-analysis showed that the rational approach had very little impact on smoking behavior, that the developmental and social norms approaches had equivalent and intermediate effects on smoking behavior, and that the social reinforcement approach had the greatest effect on smoking behavior.30 The results of several individual studies suggest that the initial positive impacts of school-based interventions may dissipate over time,31 particularly if intervention activities and booster sessions do not extend throughout middle school, junior high, and high school.32 School-based programs may also be strengthened by supplementary intervention activities that extend beyond the school context into the community.33 (See section below on community interventions.) Efforts have been made to test the generalizability of the social influence model of prevention program with ethnic groups and special populations. Some studies have yielded comparable results with African-American and Hispanic-American adolescents.34 A specific program has been suggested for American Indians.35 However, reports with ethnic populations are relatively few, and more research is clearly warranted. These studies must address the group-specific

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Page 150 social factors that affect smoking onset that research has begun to identify36 and the cultural norms and values that are an essential part of culturally appropriate interventions.37 The meta-analyses described above do not distinguish between smoking prevention programs implemented in the context of wider drug use prevention programs and those that focus on tobacco alone. Most research on smoking prevention has been conducted on programs that focus solely on tobacco use. Programs that are multi-behavioral and target several drug use behaviors (such as life skills programs) can be effective if adequate time is allocated to social reinforcement components such as resistance skills specific to tobacco use. Program Structural Elements. Eight structural elements are considered both necessary and sufficient for effective school-based smoking prevention programs. These features were identified by a National Cancer Institute (NCI) panel of experts who analyzed 15 intervention trials conducted by NCI.38 These essential elements, listed below, were confirmed in Rooney's meta-analysis of research studies 1974-1989.39 1. Classroom sessions should be delivered at least five times per year in each of two years in the sixth through eighth grades. 2. The program should emphasize the social factors that influence smoking onset, short-term consequences, and refusal skills. 3. The program should be incorporated into the existing school curricula. 4. The program should be introduced during the transition from elementary school to junior high or middle school (sixth or seventh grades). 5. Students should be involved in the presentation and delivery of the program. 6. Parental involvement should be encouraged. 7. Teachers should be adequately trained. 8. The program should be socially and culturally acceptable to each community. Of critical importance is the integrity of implementation and the fidelity of instruction.40 The programs should be adopted by schools and used in a manner that is close to the way they were evaluated. In addition to the above eight elements, an effective component is the establishment of school policies restricting tobacco use and compliance with the policy by students. States such as Minnesota and California report widespread support and adoption of tobacco-free policies; enforcement of these policies can have a significant impact on reducing tobacco use. A study of the impact of smoking policies on over 5,000 adolescents in 23 schools in 2 California counties found that schools with comprehensive policies (restricting smoking on and near school grounds and including educational programs) had significantly lower smoking rates than schools with less comprehensive policies.41

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Page 151 The CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction recommend that the above-mentioned essential elements be implemented in the context of broader policy support. 1. Develop and enforce a school tobacco-free policy. 2. Provide instruction about the short- and long-term negative physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills. 3. Provide intensive tobacco-use prevention education during early adolescence (sixth grade), in junior high or middle school, and reinforce the program in high school. 4. Provide program-specific training for teachers. 5. Involve parents or families in support of school-based programs to prevent tobacco use. 6. Support cessation efforts among students and all school staff who use tobacco. 7. Assess the tobacco-use prevention program at regular intervals.42 Dissemination. To date, the dissemination and diffusion of prevention programs have been documented, but there are no data on their impact on smoking rates. In Minnesota, 81 schools were invited to receive one of four recommended smoking prevention programs and to participate in a study. Seventy percent of contacted schools agreed to participate in the study, and 96% of all schools applied for and received tobacco use prevention funds from the State of Minnesota.43 The study demonstrates the feasibility of a large-scale adoption of a smoking prevention program by schools. Community-wide Programs to Prevent Smoking Although schools offer a number of pragmatic and practical advantages for launching a preventive effort, there are limitations to what they can accomplish. Schools have limited time and resources for meeting routine educational demands. In addition, they are only one of the settings in which social influences on smoking operate. In fact, while the results of more than 20 research studies have shown that school-based prevention programs alone have consistently delayed onset of smoking, lasting effects have only been demonstrated at 2-year follow-up.44 The concept of reciprocal determinism would argue that successful interventions should target the major elements of the dynamic person-environment interaction that school-based interventions may not be capable of reaching, much less influencing.45 These more wide-ranging determinants include community influences, environmental regulations, legislative initiatives concerning the pricing and promotion of tobacco products, and other types of societal interventions described elsewhere in this report. Recent research has begun to add community intervention components that explicitly target the social environment

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Page 152 to help adolescents remain nonsmokers. The term "community interventions" has been used in a variety of ways. These efforts vary and include using print and electronic media to reach a broad community, using specific targeted programs (smoking cessation), and targeting community leaders and organizations to change community practices in specific ways to reduce tobacco use (for example, enforcing age restrictions on sale of tobacco in local stores). All community programs share a focus on altering the social environment or social context in which tobacco products are obtained or consumed. The components all share the goal of making the social environment supportive of non-use or cessation, and therefore could increase the effects of a school-based program by creating a social context for the program that enhances the effects of its messages.46 Also, community programs can reach adolescents who are missed by school-based programs, either because they have dropped out of school, are absent during the intervention, or are not influenced by the school program. School-based prevention programs report a higher attrition rate among smokers (at pretest) and a much higher smoking prevalence among absentees and dropouts (over 70%); thus, students most at risk may be missing either from the intervention or the follow-up. Community programs, however, report equivalent reductions in tobacco use for youths at different levels of risk.47 Community interventions can also help change community norms or practices that are relevant to adolescent tobacco use (for example, enforcement of age restrictions on the sale of tobacco) and that make repeated interventions necessary.48 Evidence for the efficacy of community interventions comes from both large-scale multicommunity studies of heart disease prevention and large-scale studies that focus explicitly on smoking and drug use. Three studies have shown consistent effects on reducing tobacco use by teens, each using experimental designs that have overcome some, but not all, of the methodologic problems of school-based prevention programs. In fact, because the community is the unit of assignment, the small number of communities in each of the studies precludes a true experiment. The Class of 1989 Study, a part of the Minnesota Heart Health Program, tested the efficacy of a smoking prevention intervention within the larger program to reduce heart disease in entire communities. The study used cohort and cross-sectional analyses to compare two matched communities over a 7-year period. One community received a school-based smoking prevention program for 3 years. In addition to the school intervention, this community participated in a population-wide intervention that included risk-factor screening, adult smoking cessation, and consideration of new smoking ordinances at school and other community components. At the follow-up assessment, the smoking rates for adolescents in the intervention (educated) community were 40% lower than in the reference community, which did not receive the intervention.49 A significant reduction in smoking rates was maintained over a 6-year period, even with the school, not the individual student, as the unit of analysis. At the end of high

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Page 153 school, the smoking rates for students in the intervention community remained 40% lower than in the reference community.50 The North Karelia Youth Project in Finland, a comprehensive community program to reduce cardiovascular risk factors, also reports lower smoking rates immediately after, 2 years after, and 8 years after classroom interventions taught to 13- to 15-year-old students. The difference is attributed to the context of the community program in which specific school interventions were implemented.51 The Midwestern Prevention Project is a 6-year longitudinal intervention study that varied the interventions and grade levels (grades six and seven). The project was implemented in 50 middle/junior high schools in the Kansas City and Indianapolis areas. The project included schools, media, parent and community organizations, and health policy programs that focused on resistance skills training and environmental support for nonsmoking and non-drug use. The program first targeted the most proximal influences on youth initiation of smoking (school and parents) and subsequently the more distal influences (community organization and policy changes). Media were used in all years to promote and reinforce other components. Results, adjusted for race and grade, showed a significant effect of the program on reducing cigarette smoking. A pattern maintained (though not as strongly) at 2-year follow-up. At 2 years, the rate of increase of smoking in control schools was 1.5 times the rate in program schools.52 The results of the Midwestern Prevention Project, the North Karelia Youth Project, and Class of 1989 Study demonstrate the potential impact of a broad community prevention program. In all cases a strong school-based prevention intervention was embedded in a community-wide program. These programs appear to have enhanced the effects of school-based interventions, and the positive effects endured; however, experimental designs examining the effects of school-based and community-based programs administered separately and jointly are needed to verify these suggestive findings. Current randomized community interventions will provide further evaluation of the degree to which community-wide programs enhance or extend the effects of school-based programs on adolescent smoking. Researchers have debated whether smoking prevention programs should be integrated into drug prevention programs or stand alone as independent interventions. Evaluations of smoking prevention programs that were integrated into comprehensive drug use prevention programs have been inconclusive. Some researchers have reported positive results,53 whereas others have reported only short-term effects on smoking54 or no effects.55 The results may have to do with the amount of time provided for exposure to smoking and to creating a clear norm about nonsmoking. Preventive programs targeting multiple drugs may not provide adequate instruction on how to manage social influences to use tobacco products. Community-based prevention studies have not included economic analyses in their reports. Overall effects are modest in terms of the percentage of students

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Page 164 strongly associated with SLT use and breaking the associations by refraining from taking a dip for 30 minutes or more. Eight men (with a mean age of 32 years and who had used SLT on average for 9 years) participated in 8 1-hour behavioral treatment sessions over a period of 7 weeks in small groups of 3 subjects each. Of the 7 men completing the program, 6 remained abstinent at the 9-month follow-up.100 Studies of Users Recruited from Schools Three recent studies are informative about school-based interventions for cessation of SLT use. An intervention in high schools in Eugene, Oregon, had modest success with daily SLT users. The study recruited 25 boys, ages 14-18, 11 of whom constituted a comparison group by receiving delayed treatment. This behavioral treatment consisted of three 1-hour small-group meetings with counselors, for example, focusing on coping skills for cessation (e.g., "The 4-As": Avoid, Alter, Alternatives, and Activities). Of the 21 boys completing the program, 9 were successful in quitting their SLT use at the end of treatment. At 6-month follow-up only 3 (12%) were still abstinent. However, participants not achieving abstinence reported reduction of 45% in their daily use of SLT from baseline levels. The participants reported that in addition to the group sessions, the telephone calls and support by the counselor were key elements in their quitting. 101 The study, conducted in 16 high schools in Illinois and California, described above in the smoking cessation section, also included a component for cessation of SLT use. The attrition rate was high, about half. Of the 16 SLT users who participated in the 5 sessions, 7 (43.8%) reported quitting at the end of treatment, whereas none of the 5 SLT subjects in the wait-group reported quitting. At 3-month follow-up, 3 (15.2%) of the subjects randomized to treatment were confirmed as still abstinent. It appears that a school-based multi-session clinic can result in modest cessation rates for volunteering adolescents; however, attrition is high. 102 Non-nicotine substitutes for snuff were used as a cessation intervention for 83 boys recruited from 6 high schools in rural Illinois. Two schools each were randomized to either the mint snuff substitute, chewing gum, or a lecture only. Of the 70 boys in the program, 30 were in the mint snuff groups, 15 in the gum groups, and 25 in the lecture-only groups. At the end of treatment (session two was 30 days later), there was no difference in quit rates for the 3 groups, but the self-reported reductions of SLT use by those using the mint snuff substitute were significantly higher than for the other 2 groups. There were no follow-up data provided about maintenance or relapse.103 Self-Help Program A self-help guide produced by the American Cancer Society combined with modest counselor assistance was effective in getting 12% of participating young

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Page 165 adult SLT users to quit. One hundred thirty participants, ages 18 to 27, were recruited from 11 postsecondary schools in the Memphis, Tennessee, area. Subjects were randomized into 2 groups; one group met for 2 sessions, the other met for 4 sessions. There was a 15.4% attrition rate, with 110 subjects completing treatment. At 90-day follow-up, the cessation rate was 10.6% for the 2-session group and 14.1% for the 4-session group, for an overall quit rate of 12.3%.104 The modest quit rate is consistent with other self-help minimal interventions for tobacco use. To date, no other self-help programs for smokeless users have been evaluated. Nicotine Replacement Therapy The use of nicotine replacement therapy for SLT users has been studied in adults only. One hundred smokeless users were randomized to receive active (2 mg) nicotine gum or placebo (0 mg) nicotine gum as an adjunctive aid in a five-session group counseling program. Fifty percent of the subjects in the active nicotine gum condition were verified abstinent at the end of treatment, and 40% of the subjects receiving placebo were abstinent; the differences were not statistically significant. Nevertheless, the study demonstrates that adult SLT users, even those on placebo, can be successful in quitting SLT use. At 6- and 12-month follow-up the biochemically confirmed quit rates were 16% and 14% with no difference between groups.105 There are no published reports to date on the use of nicotine skin patches as an adjunct to behavioral treatment for users of smokeless tobacco. Clinic-Based Interventions Given that most smokers do not go to cessation programs to quit but many respond to a prompt from a health care provider,106 health care settings might be an attractive avenue for promoting cessation of SLT use. One example is a low-cost intervention conducted at seven prepaid dental clinics in the Portland, Oregon, area. Men who use moist snuff and/or chewing tobacco (n = 576) were identified by a questionnaire in clinic waiting rooms; participants were randomized to either usual care or an intervention. The intervention consisted of a routine oral exam; an explanation of the health risks of using SLT, including pointing out any lesions or other effects of SLT identified during the exam; advice to stop using tobacco; a 9-minute videotape; and a self-help manual. The differences between the groups in self-reported abstinence at 3 months were statistically significant, furthermore, the quit rates were significant for subjects reporting abstinence from SLT at both 3 and 12 months (18.4% for the intervention group and 12.5% for the usual care group).107 The results are modest in terms of overall quit rate, but the impact of having dentists, hygienists, nurses, and physicians counseling patients to quit their use of smokeless tobacco could

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Page 166 have significant impact on prevalence in the longer term. Programs for adolescents conducted in the context of regular visits to dentists or to other health care providers have not been studied. The identification of oral lesions could be a natural entry to raise the issue of SLT use, since many daily users have an identifiable lesion—one study reported that 79% of SLT users had observable lesions. 108 Co-use of SLT and Cigarettes The Monitoring the Future Project, 1985-1989, reports that 43% of high school seniors who use SLT also smoke cigarettes, and 32.5% of smokers use SLT. Studies report co-use of SLT and cigarettes at prevalences between 12% and 30% for all regular SLT users. 109 Since the addictive element in tobacco is nicotine, individuals who quit using snuff or chewing tobacco might increase their use of cigarettes, and vice versa. For adolescents who use both substances, a decrease in the use of one tobacco product may lead to a direct increase in their use of the other tobacco product. 110 There is no net gain in the health risk status of those individuals. Tobacco cessation rates among men who use both cigarettes and SLT are significantly lower than those who use SLT exclusively.111 Summary Points Little is known about cessation of smokeless tobacco use, and the evidence available must be considered cautiously. Additionally, research is needed on the psychosocial factors that may affect both cessation and relapse. The small sample sizes, self-selective nature of subjects, lack of control groups, and lack of longterm follow-up render the few studies reported inconclusive. Research is needed to (1) describe the factors that accompany cessation, for example, use levels and patterns and relapse rates, and (2) test the effectiveness of various kinds of interventions, for example, nicotine replacement, self-help quitting, physician or health professional's advice, environmental restrictions, and increased product cost. The following conclusions are supported by the research base: 1. Smoking cessation materials can be adapted and used to help people quit their use of smokeless tobacco. Preliminary evidence from clinical studies with adults shows modest quit rates that are comparable to smoking cessation (15% quit rates at 1-year follow-up). 2. There have been few studies with adolescents of cessation of smokeless tobacco use. The results have been both negative and positive. The cessation rates at follow-up are modest: 12% to 16% confirmed at 3- to 6-month follow-up. Response by adolescents to school-based cessation programs is modest; dropout rates are high.

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Page 167 3. There is a need to provide cessation aids to SLT users, as a significant number of users have made unsuccessful quit attempts or report interest in quitting. 4. Smokeless tobacco users are as addicted to nicotine as regular smokers and experience the same withdrawal symptoms. Nicotine replacement therapy (use of gum or patches) may be appropriate as an adjunct to behavioral therapy, as it has consistently proven beneficial with adult smokers. RECOMMENDATIONS Over the past 20 years, school-based prevention programs have evolved a focus on the social influences that are most proximal to a young person's decision to initiate and use tobacco products. Research has consistently demonstrated that a brief school intervention that focuses on social influences and teaches refusal skills can have a modest but significant effect in reducing onset and level of tobacco use. Multiple-grade interventions and more intensive interventions can increase this effect. Community programs that include parent involvement, school rules and regulations with regard to tobacco use, community organizations, and use of media can increase the effectiveness of school-based programs. Some community components have also focused on reducing youth access to tobacco by educating store clerks or conducting sting operations at convenience stores known to be lax in checking the age of purchasers (see chapter 7). To be most effective, school-based programs must target youths before they initiate tobacco use or drop out of school. School programs offer the opportunity to prevent the initiation of regular tobacco use and help persons avoid the difficulties of trying to stop after they are addicted. School-based programs to prevent tobacco use can also contribute to preventing the use of illicit drugs such as marijuana and cocaine, especially if the programs are designed to prevent the use of these substances. The Centers for Disease Control and Prevention's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction offer specific program recommendations for meeting the tobacco use prevention objectives of the nation for the year 2000. Although the Committee concludes that prevention of tobacco use is the better public health approach to the health consequences of tobacco use, it also recognizes that many adolescents have already become regular users, and in some cases heavy daily users, of tobacco products. Many of these youths want to quit using tobacco and need help with their addiction problem. There is a paucity of research on how to reach, motivate, and treat adolescents addicted to cigarettes or smokeless tobacco products. To prevent the addiction of children and youths to tobacco products, and thereby to prevent the associated health consequences, the Committee recommends:

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Page 168 1. Under federal leadership, the United States should develop a national child health policy that gives high priority to the prevention of tobacco use by youths. This policy should provide the mechanisms to guide and support multifaceted health promotion programs for children and youths. 2. All schools should adopt and implement the CDC guidelines to prevent tobacco use and addiction. To ensure the greatest impact, schools should implement all seven recommendations. 3. Already proven models of school-based prevention programs should be systematically implemented into a comprehensive approach to reducing tobacco use by children and youths. The comprehensive approach should embrace prevention programs that include broader social networks of influences (that is, parents, community, and media) set in the context of a community effort. A comprehensive program to reduce tobacco use is not a new idea. The Committee recognizes that most schools and communities do not have comprehensive tobacco prevention programs in place. Without significant resources it is unlikely that schools would be in a position to implement the CDC guidelines listed above. School prevention programs without the support of community efforts are less successful in reducing adolescent tobacco use. 4. Tobacco prevention should be integrated into any drug prevention program aimed at youth. 5. Systematic research should be conducted on the optimal way to disseminate and implement tobacco use prevention programs on a large scale. 6. Research should be conducted on the development and evaluation of programs to help children and youths who are regular tobacco users to quit their habitual use of cigarettes, snuff, or chew. Research is needed to determine whether or not nicotine replacement therapies as an adjunct to behavior therapies contribute to achievement of enduring cessation. 7. Research should be conducted to identify the need for, and to develop and evaluate, prevention programs aimed at reducing tobacco use among specific ethnic groups. REFERENCES 1. Centers for Disease Control and Prevention. ''Guidelines for School Health Programs to Prevent Tobacco Use and Addiction." Morbidity and Mortality Weekly Report 43:RR-2 (25 Feb. 1994): 1-18. 2. Lavin, Alison T., G. R. Shapiro, and K. S. Weill. "Creating an Agenda for School-Based Health Promotion: A Review of Selected Reports." Journal of School Health 62:6 (1992): 212-228. 3. U.S. Department of Health and Human Services. Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. USDHHS Publication No. (PHS)91-50212, 1990. 4. Thompson, Eva L. "Smoking Education Programs 1960-1976." American Journal of Public Health 68:3 (1978): 250-257; and Goodstadt, Michael S. "Alcohol and Drug Education: Models and Outcomes." Health Education Monographs 6:3 (1978): 263-279.

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