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Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths (1994)

Chapter: 5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS

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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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. 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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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. 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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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.

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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not going on to regular smoking, about 6.4%;56 nevertheless, prevention of even moderate (monthly or weekly) use of cigarettes during adolescence may translate to a substantial effect in terms of the long-term health care and social cost savings. An assessment of potential cost savings and maintenance of preventive effects is needed to determine the economic basis for integrating school-based prevention with a community effort to reduce tobacco use.

Summary Points

Most reviews of the smoking-prevention research consistently have come to the same conclusions, summarized as follows:

1. School-based prevention programs that identify the social influences prompting youths to smoke and that teach skills to resist such influences have demonstrated consistent and significant reductions or delays in adolescent smoking. These programs usually target youths in the seventh to ninth grades, when smoking experimentation and initiation is foremost. The effects of these prevention programs dissipate with time, but can be enhanced with booster sessions or further application of the program. The difference in smoking rates or initiation between treatment and nontreatment student groups ranges from 25% to 60% and persists from 1 to 4 years (although few studies include more than a 1-year follow-up).

2. The effectiveness of school-based programs appears to be strengthened by community-wide programs involving parents, school policies, mass media and youth access, and mobilizing community organizations. The tendency for positive intervention effects to dissipate over time has been particularly evident in school-based intervention studies that included little or no emphasis on booster sessions, few (if any) community-wide activities or policy interventions, or few (if any) mass-media-based components.

3. A school-based prevention program alone has inherent limitations in impact and scope. Any effort to prevent adolescent tobacco initiation or dependence must address the social context for tobacco use. Initial studies suggest that the combination of school and community tobacco use prevention programs can enhance the short-term impact of the school-based programs by providing a longer-term, multi-pronged approach that complements or is synergistic with school-based programs. Given the number of studies, the variability in program format and scope, the various communities and subcultures in which these studies were implemented, and the potential threats to internal and external validity in school-based research, the consistency in overall reductions in smoking prevalence across all these studies is all the more remarkable. Still, while current studies have demonstrated that adolescents from different environments and cultural backgrounds are generally responsive to social influence programs, an as-

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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sessment is needed of programs tailored to ethnic groups, particularly for African-American, Hispanic, and Asian youths.

PREVENTION OF SMOKELESS TOBACCO USE

During the past several years, approximately 11% of high school seniors have reported using smokeless tobacco (SLT) within the past 30 days and about 4% have reported daily use.57 The publication of the surgeon general's report in 1986 on the health consequences of using smokeless tobacco and subsequent reports of widespread smokeless tobacco use by children and adolescents58 resulted in the publication of a wide range of written and media materials on the risks of using SLT.59 The objective of these materials, which have been made available to school personnel and parents, is to counter the perception of SLT as ''a safe alternative to smoking." Materials and programs have been produced and widely distributed by federal agencies, such as the National Cancer Institute and the National Institute of Dental Research; voluntary nonprofit groups, such as the American Cancer Society; and professional organizations, such as the American Dental Association and the American Academy of Otolaryngology. However, their impact on SLT use by youths aged 12-18 has not been evaluated. Unique aspects of SLT use and a review of prevention programs are presented below.

Unique Aspects of Smokeless Tobacco Use

Five unique aspects of smokeless tobacco use should be considered in the development and evaluation of prevention and cessation programs. First, children or youths can use moist snuff without other people being aware of it (this is also true for chewing tobacco, though less so). This potential for surreptitious use of snuff provides some difficulty in monitoring its use and allows for use in situations where use is not permitted, for example, in school classrooms or during sports activities. Second, smokeless tobacco causes oral lesions, which are direct physical evidence of detrimental health effects from using snuff or chewing tobacco. Third, up to 30% of regular users of chewing/spitting tobacco also report use of cigarettes.60 Fourth, smokeless tobacco is perceived as a safe product to use: 81% of youths regard smokeless tobacco to be "much safer than cigarettes."61 One study reports that only 40% of junior and senior high students believe that SLT is "very harmful."62  This inaccurate perception of SLT as "safe" may lead adolescents to start using tobacco products and parents to allow this behavior. Furthermore, adolescents perceive SLT to be more socially acceptable to adults than smoking.63 Parents' acceptance of their child's chewing or dipping contributes, in turn, to the perception that this behavior is safe and encourages continued use. And fifth, unlike cigarettes, chewing tobacco products are generally not packaged in individual doses; therefore, self-monitoring of use and accurate measurement of use are difficult.64

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Evaluation of SLT Prevention Programs

Use of smokeless tobacco by youths is a relatively recent phenomenon; therefore, evaluation of prevention efforts is in a developmental phase, and few SLT prevention programs have been evaluated for either short- or long-term efficacy. Those that have been evaluated are either single components embedded in broad tobacco prevention programs, or single programs whose impact is evaluated on both cigarette smoking and smokeless tobacco use. Seldom have SLT prevention programs been implemented independently of other substance use prevention efforts or more general tobacco use prevention efforts. The rationale for this integration is that smokeless tobacco products are used primarily by males, prevalence may be lower for SLT than for cigarette use, and concern about use of snuff or chewing tobacco is often less than for hard drugs and cigarette smoking. Although logical, inclusion of smokeless tobacco prevention in other prevention efforts renders the evaluation of the smokeless tobacco component problematic.

NIH has funded eight research grants to develop interventions to prevent the initiation or regular use of smokeless tobacco by youths and to help youths quit using SLT. Most of these projects have been school-based activities, with the primary focus on middle school students and students in grades six, seven, and eight. A few SLT programs have been implemented in non-school settings, for example, in 4-H clubs, Little League baseball clubs, and Native-American community centers. Smokeless tobacco prevention has also been included in more comprehensive drug use prevention curricula such as the Comprehensive Health Education Foundation's "Here's Looking at You, 2000," and in community-based interventions to reduce drug use.

School-Based Programs

Studies of two curricula in which adolescents received a preventive curriculum targeting both smoking and smokeless tobacco use report positive outcomes. A multicomponent social influence intervention program of seven class periods was delivered by regular classroom teachers and same-age peer leaders to classes in randomly assigned middle and high schools in Oregon. The intervention focused on sensitizing students to overt and covert pressures to use tobacco, and on developing effective skills to respond to these pressures (refusal skills), especially through role playing. The physical and social consequences of SLT use were highlighted in a video. Big Dipper. An effort to involve parents included mailing of three brochures with "parent messages" designed to reinforce refusal skills and encourage parents to discuss their standards and expectations on tobacco use. Follow-up of 1,768 students 1 year later confirmed that there was less of an increase in the use of SLT by middle school boys in the intervention than by control students and a reduction in smokeless tobacco use by high school

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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boys. Parallel analysis of the intervention did not show any positive effect of the intervention on cigarette smoking. The results are encouraging, since only two of the seven class periods of the intervention were devoted to SLT information and activities.65

The Toward No Tobacco Use (TNT) project has had a positive effect in reducing SLT use. The TNT project implements four different prevention curricula independent of one another. The curricula address: (1) peer norms for using tobacco (normative social influence); (2) incorrect social information about tobacco use (informational social influence aid); (3) misperceptions and lack of knowledge about physical consequences resulting from tobacco use; and (4) the effects of combined social and physical consequences. In each curriculum, trained health educators deliver ten lessons to seventh grade students. The evaluation of TNT included a control, or usual care, group that offered health education by school personnel. Seventh-grade classes in 48 schools in southern California were randomized to the four curricula and the control group. The outcome variables were changes in reported tobacco use, smokeless tobacco, and cigarettes, at 1-year follow-up (eighth grade). All program curricula except for the informational social influence approach resulted in a significant reduction in smokeless tobacco use and experimentation. The curriculum on combined consequences was superior to all other program curricula for reducing initial and weekly use of smokeless tobacco and cigarettes. The results indicate that learning about the physical consequences of SLT use can be as successful as a social influence program (refusal skills) and that a combination of both is probably best for deterring use of SLT.66

The Southern California and Oregon studies suggest that a tobacco prevention program can be successful in reducing SLT use by embedding the smokeless program in a school-based tobacco prevention intervention provided to seventh and ninth grade students. Other school-based interventions, however, have not been as successful in deterring adolescents' use of SLT. Project SHOUT (Students Helping Others Understand Tobacco) was evaluated in 22 junior high schools in San Diego County (California). Trained undergraduate group leaders delivered ten intervention sessions to seventh, eighth, and ninth graders. The curriculum focused on health consequences of tobacco use, celebrity endorsements of non-use, social consequences of use, rehearsal of methods to resist peer pressure, and decision making. The eighth grade curriculum also included community action projects designed to mobilize the students as anti-tobacco activists. The intervention had a significant effect on cigarette use, smokeless tobacco use, and combined use of cigarettes and smokeless tobacco at the 3-year follow-up. The low prevalence of smokeless tobacco use in the sample (5.2% in control subjects and 2.7% for intervention subjects in the ninth grade) made it difficult to assess the impact of the program on SLT use.67

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Non-School-Based Programs

Non-school-based SLT prevention programs implemented at 4-H clubs, to Little League teams, and on American-Indian reservations may reach subgroups of children and adolescents who are most likely to use smokeless tobacco products. Chewing tobacco and snuff have long been used by baseball players,68 and several gum products provide youths with look-alike products (for example, "Big League Chew"). The focus of a prevention program on youngsters who play organized baseball in Little League provides a unique early opportunity to provide information on health roles of SLT use and counter or negate some of the positive image youngsters may hold for using SLT "like the pros do." Observations of televised broadcasts of the World Series in 1987 documented 24 minutes of viewing time of professional sports heroes chewing.69 Later observations, in 1989, reported a decrease in televised spitting tobacco use by these sports idols during the broadcast of the World Series; however, the World Series still represents significant visibility of tobacco use by sports stars.70 The results of a recent large-scale prevention intervention with youngsters playing organized Little League baseball are not yet available.

A program to reduce SLT use by children ages 10-14 was developed and implemented in 72 4-H clubs in 24 California counties. Five tobacco-related outcome variables were evaluated: knowledge, attitudes, perceived social influences, intentions, and behaviors. In the program, five sessions of tobacco education were provided at the monthly club meetings by volunteers (41 adults and 26 teens) trained to deliver the program in their locales. The 1-year follow-up showed that the program had a significant effect on knowledge of harmful effects of SLT use and intentions to smoke, but no effect on actual use of SLT. The 2-year follow-up showed no difference between program and control 4-H clubs. The authors concluded that, despite the difficulty of managing a tobacco prevention program through 4-H clubs because of time constraints on club meetings, the program is a useful complement to school-based programs to change social norms.71

Smokeless tobacco use by American-Indian youths on reservations is higher than by other groups. American-Indian and Native-Alaskan children use snuff and chewing tobacco early, frequently, and heavily. Girls use these products at levels almost equal to boys.72 Programs being implemented on reservations are characterized by sensitivity to the unique aspects of tobacco use by Native Americans, especially its role in sacred rites. Native Americans present these programs, which adapt materials to specific tribal groups. These programs have not yet been evaluated.

Summary Points

1. Smokeless tobacco prevention programs have modest effects on reducing SLT initiation and use by middle school and high school boys.

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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2. Smokeless tobacco prevention programs have been modeled after cigarette smoking interventions and have similar components. Most SLT programs focus on social influence components and include information about the detrimental health effects of regular SLT use.

3. Children and adolescents perceive smokeless tobacco as a safe alternative to cigarette smoking, and this belief should be countered in any prevention program. Adolescents erroneously believe that they can easily quit using smokeless tobacco; thus, the addictive potential of snuff and chewing tobacco should be emphasized in any program.

4. Preventive interventions targeting high-risk youth or special populations require tailored interventions and alternative channels of community delivery. These programs have not been evaluated.

ADOLESCENT CESSATION OF SMOKING

Data on Smoking Cessation

Few studies have been conducted on adolescent cessation of tobacco use, and those vary considerably in scientific quality; many are anecdotal. Therefore, at this time, no effective means are known for helping youths to quit using tobacco or to remain abstinent once they have attempted to quit.

Four sources of data on adolescent smoking cessation are available: (1) national probability surveys on patterns of adolescent attempts to quit, (2) convenience sample surveys on self-initiated quit attempts by adolescents, (3) reports from adolescent prevention projects on treatment effects on youth who were smokers at baseline, and (4) programs that explicitly try to recruit adolescent smokers into cessation programs. The data available show that adolescent smokers do make repeated attempts to quit smoking, but usually fail. Two large national population surveys provide data on a few aspects of adolescent smoking cessation: the High School Seniors Survey (sponsored by the National Institute on Drug Abuse) and the Youth Risk Behavior Survey. Both surveys sample high school classrooms, and therefore do not include school dropouts (who have much higher smoking rates).73 Data from the High School Seniors Survey since 1976 show that 42-47% of smokers want to stop smoking (They answer yes to the question, "Do you want to stop now?") In the more recent (1985-1989) surveys, in response to the question "Have you ever tried to quit and found that you could not?", 27.8% of those smoking at all and 39.4% of those smoking more than 1 cigarette in the past month answered affirmatively.74 In the 1989 Teenage Attitudes and Practices Survey, 74% of 12- through 18-year-old smokers reported that they had seriously thought about quitting, 64% that they had tried to quit smoking, and 49% that they had tried to quit during the previous 6 months.75

The strength of chemical dependency, or addiction, to nicotine is evident in

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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that over half of adolescents who try to quit smoking experience withdrawal symptoms, the same symptoms reported by adult smokers. (See chapter 2.) The use of nicotine replacement therapy has not been evaluated with adolescent smokers, but has been consistently efficacious with adult smokers.76 Some older adolescent smokers might be appropriate candidates for nicotine reduction therapy, although this is currently contraindicated and does not have FDA approval. In a survey of adolescents going to primary care facilities, 29% of adolescent smokers (mean age = 16.4) checked "medication to make quitting easier" as a suggestion for smoking cessation, whereas only 8% checked "stop smoking class or program."77

Cessation Intervention Programs

Although the primary goal of smoking prevention programs, reviewed earlier in this chapter, is to prevent smoking initiation and the progression from experimentation to regular smoking, occasionally an added effect is that some smokers participating in these programs reduce the amount of cigarettes they smoke.78 Nevertheless, the impact of prevention programs on students who are experimental or regular smokers is small and inconsistent.79 Furthermore, smoking prevention programs typically are implemented for middle-school children, and the small number of regular smokers in this population tends to preclude meaningful cessation analyses.80

Cessation Interventions in Schools

A number of smoking cessation programs and materials have been developed and implemented in schools, but evaluation has typically been anecdotal or descriptive. Two school-based cessation programs evaluated in 1983, one using trained peer leaders81 and one using a cognitive behavioral group approach,82 reported no quits. The largest and most systematic school-based cessation study recruited students in 16 rural and suburban high schools in two states. At the 3-month follow-up, there was no effect from the intervention; 6.8% of clinic participants and 7.9% of controls were abstinent. Attrition was high: 48.4% from session one to session five, and an additional 60.8% from session five to the 3-month follow-up. The negative results in the study are especially noteworthy because the investigators used input from 31 focus groups with adolescents to develop the recruitment strategies and the content of the intervention.83 (This study also treated smokeless tobacco users.)

One program did have some success: four sessions on immediate physiological effects of smoking and social cues influencing adoption of the habit implemented in tenth grade health classes in three California high schools (n = 477) resulted in a significantly greater percentage of subjects reporting abstinence than in the control group.84 A follow-up study that evaluated the efficacy of individual components of the program found no significant differences.85

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Adolescent smokers are reluctant to participate in multisession quit programs. Several factors may underlie the pervasive difficulty in recruiting adolescent smokers to school-based quit programs. Adolescents may worry that parents or teachers will learn that they smoke (since parental consent would be required for participation). Adolescents may not be highly motivated to quit, because long-term health consequences are less salient for them. Possibly, the population of smokers at schools, and therefore the recruitment base, is small. Or, the methods of recruitment might not be effective. Participants are usually recruited through school channels such as newsletters and class and public address announcements. One study found that intensive, face-to-face recruitment is better than public address and other announcements and posters.86 When the participants are referred by school authorities for infractions of school smoking policies, quit rates are likely not to be high. For example, in one program, in which over half the participants enrolled because they had been caught smoking on school property, only 13.5% (n = 30) were abstinent (by self-report) at the end of the program. Though minimally successful, programs for rule-breaking smokers are likely to be more in demand, as some states such as Oregon have made smoking (or possession of tobacco products) a misdemeanor for persons under age 18 and thereby force school authorities to take action against students caught smoking on school grounds.

Non-School-Based Interventions

Although recruitment was more successful in an HMO-based smoking cessation program, the outcome was not.87 Adolescents between 14 and 17 years of age who were members of a large health maintenance organization (HMO) were screened and recruited by mail and phone; 325 girls (46%) and 168 boys (37.2%) agreed to participate and were randomly assigned to either an intervention or a no-treatment control group. The intervention consisted of a counseling session with a nurse practitioner at a convenient HMO clinic, encouragement for the adolescent to set a quit date, provision of strategies for successful quitting, and telephone follow-up. At the 1-year follow-up, there were no significant effects of the intervention. The intervention was modeled on interventions for adult smokers that usually yield positive results, but this was clearly not the case for adolescent smokers.

Some success was obtained with boys but not girls in a program that awarded money for achieving target carbon monoxide levels in expired air samples. Eleven "hard core" smokers, ages 13 to 18, in an alternative school participated. Five of the six boys successfully reduced smoking and carbon monoxide levels during the reduction and quit phases with four maintaining abstinence during a 5-month fading, follow-up phase. In contrast, all five girls dropped out during the program and were unsuccessful. The authors speculate that the girls were

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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less responsive than the boys to monetary rewards, and possibly would be more influenced by social consequences.88

Intervention Program Concepts

Clearly, there is a need for cessation programs for adolescent smokers. More than half of adolescent smokers want to quit, try to quit, and fail to quit. A survey by the Gallup Organization reported that 38% of youths ages 12 to 17 had some interest in youth-targeted smoking cessation programs.89 Research is needed to discover from youths the kinds of assistance they will respond to and some of the barriers that keep them from seeking assistance in quitting tobacco use. For example, since youths spend much time with computers, watching television and or movies, and talking on the telephone, might these media, singly or in combination, be effective vehicles for cessation interventions? Interactive computer programs for adolescents are already developed for health education and health promotion and could be adopted for smoking cessation.90 There are numerous videos on smoking and health, and even on smoking cessation, but these have not been specifically developed for youths; specially developed videos informed by focus groups might be a useful way of reaching adolescents, especially the high-risk smokers who are not comfortable with written materials. Finally, telephone counseling has been shown to be a useful and effective treatment channel for adult smokers and might be a useful way of reaching adolescents as well.91 Telephone counseling can be a cost-effective way to provide personalized assistance that complements written or video materials.92

Summary Points

Because the addictive quality of nicotine is powerful, there is a strong need to evaluate whether the use of techniques for quitting tobacco use by adults can be beneficial to adolescents. It is reasonable to assume that if adolescent tobacco users are addicted at adult levels (for example, if they smoke a pack a day), the use of nicotine replacement should prove to be an effective adjunct to behavioral treatment in cessation.

The following conclusions are supported by the research base:

1. Adolescent smoking cessation has been the subject of very little systematic research. Adolescents who are regular smokers experience the same withdrawal symptoms as adults when they attempt to quit.

2. Adolescents frequently express interest in quitting and report making numerous, usually unsuccessful quit attempts, but they tend not to participate or remain in formal cessation programs.

3. Cessation programs for adolescents have not resulted in significant quit rates.

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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4. Once a person becomes a regular smoker, he or she finds it difficult to quit; few adolescents succeed in quitting.

CESSATION OF SMOKELESS TOBACCO USE

Desire to Quit Using Smokeless Tobacco

Three types of evidence indicate that snuff and chewing tobacco users are interested in quitting their use of SLT products. First, users respond to ads for cessation programs. In recruiting adults for a study, Boyle reported that he received 675 phone calls in 11 weeks in response to newspaper and radio ads for a cessation program.93 It is less clear that adolescent SLT users will readily volunteer for cessation programs: only modest success has been reported in soliciting adolescent male volunteers for school-based SLT clinic programs.94 A program in Tennessee reported poor response to flyers and ads in papers, but was able to recruit 130 subjects from 11 post-secondary schools in Tennessee by having coaches and health educators contact SLT users directly.95 Second, users report interest in quitting or their intention to quit. In a survey, 68% of SLT users reported that they had tried to quit, with an average of four attempts each, and 54% reported that they would make a quit attempt in the subsequent year.96 Third, users report prior quit attempts. In one study, more than one-third of current male adolescent SLT users reported unsuccessful quit attempts.97 In a national probability sample, 39% of adult SLT users reported having made unsuccessful attempts to quit.98 Given the addictive nature of nicotine, reversing the trend of SLT use requires the development of interventions to first motivate youths to quit using snuff and chewing tobacco, then to help them stop using tobacco.

Studies of Cessation of Smokeless Tobacco Use

Despite the evidence of negative health consequences from use of SLT, research on cessation of smokeless tobacco use has been minimal; to date, only a few studies have been reported in the scientific literature. One of the barriers to conducting research on cessation of SLT use is the lack of standardized methods for assessing levels of SLT use (as discussed in chapter 2). Furthermore, just as interventions for smoking cessation have not been transferred successfully to youths, neither are interventions for cessation of SLT use likely to be transferable. For example, the American Cancer Society's Fresh Start Adult Smoking Cessation Program was adapted for youths 18 to 22 years of age using SLT, but the program was ineffective.99 An intervention that has not been adapted for youths but was successful with adult men involved four components: cue extinction, setting a target date for quitting, the use of a buddy system, and relapse prevention. Cue extinction involved identifying two or three situations most

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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.

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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:

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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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.

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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5. Durell, Jack, and W. Bukoski. "Preventing Substance Abuse: The State of the Art." Public Health Reports 99:1 (1984): 23-31.

6. Kinder, Bill N., N. E. Pape, and S. Walfish. "Drug and Alcohol Education Programs: A Review of Outcome Studies." The International Journal of the Addictions 15:7 (1980): 1035-1054; Schaps, Eric, R. DiBartolo, J. Moskowitz, C. S. Palley, and S. Churgin. "A Review of 127 Drug Abuse Prevention Program Evaluations." Journal of Drug Issues (Winter 1981): 17-43: Hansen, William B., C. A. Johnson, B. R. Flay, J. W. Graham, and J. Sobel. "Affective and Social Influences Approaches to the Prevention of Multiple Substance Abuse Among Seventh Grade Students: Results from Project SMART." Preventive Medicine 17 (1988): 135-154.

7. Leventhal, Howard, and Paul D. Cleary. "The Smoking Problem: A Review of the Research and Theory in Behavioral Risk Modification." Psychological Bulletin 88:2 (1980): 370-405; Stern, Robert A., J. O. Prochaska, W. F. Velicer, and J. P. Elders. "Stages of Adolescent Cigarette Smoking Acquisition: Measurement and Sample Profiles." Addictive Behaviors 12 (1987): 319-329.

8. Chassin, Laurie A., C. C. Presson, and S. J. Sherman. "Stepping Backward in Order to Step Forward: An Acquisition-Oriented Approach to Primary Prevention." Journal of Consulting and Clinical Psychology 53:5 (1985): 612-622.

9. Evans, Richard I. "A Social Inoculation Strategy to Deter Smoking in Adolescents." In Matarazzi, J. D., S. M. Weiss, J. A. Herd, N. E. Miller, and S. M. Weiss, eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: John Wiley, 1984; McAlister, Alfred L., J. A. Krosnick, and M. A. Milburn. "Causes of Adolescent Cigarette Smoking: Test of a Structural Equation Model." Social Psychology Quarterly 47:1 (1984): 24-36; and Chassin, Laurie, C. Presson, and S. J. Sherman. "Cigarette Smoking and Adolescent Psychosocial Development." Basic and Applied Social Psychology 5:4 (1984): 295-315.

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13. Ibid.

14. Biglan, Anthony, R. Glasgow, D. W. Ary, R. Thompson, H. H. Severson, E. Lichtenstein, et al. "How Generalizable Are the Effects of Smoking Prevention Programs? Refusal Skills Training and Parent Messages in a Teacher-Administered Program." Journal of Behavioral Medicine 10:6 (1987): 613-628.

15. Perry, Cheryl L., K.-I. Klepp, and C. Sillers. "Community-wide Strategies for Cardiovascular Health: The Minnesota Heart Health Program Youth Program." Health Education Research 4:1 (1989): 87-101; and Arkin, Rise M., H. F. Roemhild, C. A. Johnson, R. V. Luepker, and D. M. Murray. "The Minnesota Smoking Prevention Program: A Seventh-Grade Health Curriculum Supplement." The Journal of School Health (November 1981): 611-616.

16. McAlister, Alfred L., C. Perry, J. Killen, L. A. Slinkard, and N. Maccoby. "Pilot Study of Smoking, Alcohol and Drug Abuse Prevention." American Journal of Public Health 70:7 (1980): 719-721.

17. Murray, David M., M. Davis-Hearn, A. I. Goldman, P. Pirie, and R. V. Luepker. "Five- and Six-Year Follow-Up Results from Four Seventh-Grade Smoking Prevention Strategies." Journal of Behavioral Medicine 12:2 (1989): 207-218.

18. Young, Russell L., C. de Moor, M. B. Wildey, S. Gully, M. F. Hovell, and J. P. Elder. "Correlates of Health Facilitator Performance in a Tobacco Use Prevention Program: Implications for Recruitment." Journal of School Health 60:9 (November 1990): 463-467; and Elder, John P., M. Wildey, C. de Moor, J. F. Sallis, Jr., L. Eckhardt, C. Edwards, et al. "The Long-Term Prevention of

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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20. Pentz, Mary A., J. H. Dwyer, D. P. MacKinnon, B. R. Flay, W. B. Hansen, E. Y. I. Wang, and C. A. Johnson. "A Multicommunity Trial for Primary Prevention of Adolescent Drug Abuse." Journal of the American Medical Association 261:22 (1989): 3259-3266.

21. Biglan, Glasgow, et al.

22. Evans, Richard I., B. E. Raines, and J. G. Getz. "Applying the Social Inoculation Model to a Smokeless Tobacco Use Prevention Program with Little Leaguers." In National Cancer Institute. Smokeless Tobacco or Health: An International Perspective. NIH Pub. No. 92-3461. Washington, DC: NCI, 1992. 260-276.

23. Schinke, Steven P., L. D. Gilchrist, R. F. Schilling II, W. H. Snow, and J. K. Bobo. "Skills Methods to Prevent Smoking." Health Education Quarterly 13:1 (1986): 23-27.

24. Botvin, Gilbert J. "Substance Abuse Prevention Research: Recent Developments and Future Directions." Journal of School Health 56:9 (November 1986): 369-374.

25. Flay, Brian R. "Psychosocial Approaches to Smoking Prevention: A Review of Findings." Health Psychology 4:5 (1985): 449-488; Biglan, Anthony, H. Severson, D. Ary, C. Faller, C. Gallison, R. Thompson, R. Glasgow, and E. Lichtenstein. "Do Smoking Prevention Programs Really Work? Attrition and the Internal and External Validity of an Evaluation of a Refusal Skills Training Program." Journal of Behavioral Medicine 10:2 (1987): 159-171; and Murray, David M., and P. J. Hannan. "Planning for the Appropriate Analysis in School-Based Drug-Use Prevention Studies." Journal of Consulting and Clinical Psychology 58:4 (1990): 458-468.

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27. Tobler, Nancy S. "Drug Prevention Programs Can Work: Research Findings." Journal of Addictive Diseases 11:3 (1992): 1-28.

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29. Rooney, Brenda. A Meta-analysis of Smoking-Prevention Programs After Adjustment for Study Design. Minneapolis-St. Paul: University of Minnesota, 1992. (Dissertation).

30. Bruvold, William H. "A Meta-analysis of Adolescent Smoking Prevention Programs." American Journal of Public Health 83:6 (1993): 872-880.

31. Kozlowski, Lynn T., R. B. Coambs, R. G. Ferrence, and E. M. Adlaf. "Preventing Smoking and Other Drug Use: Let the Buyers Beware and the Interventions Be Apt." Canadian Journal of Public Health 80 (1989): 452-456; and Flay, Brian R., D. Koepke, S. J. Thomson, S. Santi, J. A. Best, and K. S. Brown. "Six-Year Follow-Up of the First Waterloo School Smoking Prevention Trial." American Journal of Public Health 79:10 (1989): 1371-1376.

32. Botvin and Botvin. "Adolescent Tobacco," 1992.

33. Perry, Cheryl L., K.-I. Klepp, and J. M. Shultz. "Primary Prevention of Cardiovascular Disease: Communitywide Strategies for Youth." Journal of Consulting and Clinical Psychology 56:3 (1988): 358-364; and Perry, Cheryl L., S. H. Kelder, D. M. Murray, and K.-I. Klepp. "Communitywide Smoking Prevention: Long-Term Outcomes of the Minnesota Heart Health Program and the Class of 1989 Study." American Journal of Public Health 82:9 (1992): 1210-1216.

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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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35. Schinke, Steven P., M. A. Orlandi, R. F. Schilling II, G. J. Botvin, L. D. Gilchrist, and C. Landers. "Tobacco Use by American Indian and Alaska Native People: Risks, Psychosocial Factors, and Preventive Intervention." Journal of Alcohol and Drug Education 35:2 (1990): 1-12.

36. Sussman, Steve, C. W. Dent, B. R. Flay, W. B. Hansen, and C. A. Johnson. "Psychosocial Predictors of Cigarette Smoking Onset by White, Black, Hispanic, and Asian Adolescents in Southern California." Morbidity and Mortality Weekly Report 36:4S (1987): 11 S-16S.

37. Marin, Gerardo. "Defining Culturally Appropriate Community Interventions: Hispanics as a Case Study." Journal of Community Psychology 21 (April 1993): 149-161.

38. Glynn, Thomas J. "Essential Elements of School-Based Smoking Prevention Programs." Journal of School Health 59:5 (May 1989): 181-188.

39. Rooney.

40. Flay, Brian R. "Social Psychological Approaches to Smoking Prevention: Review and Recommendations." Advances in Health and Education Promotion 2 (1987): 121-180.

41. Pentz, Mary A., B. R. Brannon, V. L. Charlin, E. J. Barrett, D. P. MacKinnon, and B. R. Flay. "The Power of Policy: The Relationship of Smoking Policy to Adolescent Smoking." American Journal of Public Health 79:7 (1989): 857-862.

42. Centers for Disease Control and Prevention, "Guidelines," 1994.

43. Perry, Cheryl L., D. M. Murray, and G. Griffin. "Evaluating the Statewide Dissemination of Smoking Prevention Curricula: Factors in Teacher Compliance." Journal of School Health 60:10 (1990): 501-504.

44. Botvin, Gilbert J., 1986.

45. Bandura, Albert. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall, 1986.

46. Flay, Brian R. "What We Know About the Social Influences Approach to Smoking Prevention: Review and Recommendations." In Bell, Catherine S. and R. Gatjes, eds. Prevention Research: Deterring Drug Abuse Among Children and Adolescents.  NIDA Research Monographs 63. Rockville, MD: National Institute on Drug Abuse, 1985.

47. Biglan, Severson, et al.; Pirie, Phyllis L., D. M. Murray, and R. V. Luepker. "Smoking Prevalence in a Cohort of Adolescents, Including Absentees, Dropouts, and Transfers." American Journal of Public Health 78:2 (1988): 176-178.; Johnson, C. Anderson, M.A. Pentz, M.D. Weber, et al. "Relative Effectiveness of Comprehensive Community Programming for Drug Abuse Prevention with High-Risk and Low-Risk Adolescents." Journal of Consulting and Clinical Psychology 58:4 (1990):447-456.

48. Mittelmark, Maurice B., R. V. Luepker, D. R. Jacobs, N. F. Bracht, R. W. Carlaw, R. S. Crow, et al. "Community-wide Prevention of Cardiovascular Disease: Education Strategies of the Minnesota Heart Health Program." Preventive Medicine 15 (1986): 1-17.

49. Perry, Klepp, and Sillers, 1989; Pentz, Dwyer et al., 1989; and Vartianen, Erkki, U. Fallonen, A. L. McAlister, and P. Puska. "Eight-Year Follow-Up Results of an Adolescent Smoking Prevention Program: The North Karelia Youth Project." American Journal of Public Health 80:1 (1990): 78-79.

50. Perry, Kelder et al., 1992.

51. Vartianen et al.

52. Pentz, Mary, D. P. MacKinnon, J. H. Dwyer, E. Y. I. Wang, W. B. Hansen, B. R. Flay, and C. A. Johnson. "Longitudinal Effects of the Midwestern Prevention Project on Regular and Experimental Smoking in Adolescents." Preventive Medicine 18 (1989): 304-321.

53. Pentz, Mary A., J. H. Dwyer, D. P. MacKinnon, et al. "A Multicommunity Trial for Primary Prevention of Adolescent Drug Abuse." Journal of the American Medical Association 261:22 (1989): 3259-3266; and Errecart, Michael T., H. J. Walberg, J. G. Ross, R. S. Gold. J. L. Fiedler, and L. J. Kolbe. "Effectiveness of Teenage Health Teaching Modules." Journal of School Health 61:1 (1991 ): 26-30.

Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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54. Ellickson, Phyllis L., R. M. Bell, and K. McGuigan. "Preventing Adolescent Drug Use: Long-Term Results of a Junior High Program." American Journal of Public Health 83:6 (June 1993): 856-861.

55. Clayton, R. R., A. Cattarello, L. E. Day, and K. P. Walden. "Persuasive Communication and Drug Prevention: An Evaluation of the DARE Program." In Donhew, L., H. E. Sypher, and W. J. Bukoski, eds. Persuasive Communication and Drug Abuse Prevention. Hillsdale, NJ: Lawrence Erlbaum Associates, 1991.

56. Pentz, MacKinnon, Dwyer, et al., 1989.

57. Johnston, Lloyd, J. Bachman, P. O'Malley. "Monitoring the Future Study." Press release. The University of Michigan, Ann Arbor. (27 January 1994.)

58. Boyd, Gayle, et al. "Use of Smokeless Tobacco Among Children and Adolescents in the United States."  Preventive Medicine 16 (1987): 402-421; and Office of the Inspector General. Youth Use of Smokeless Tobacco: More Than a Pinch of Trouble. Washington. DC: OIG, Office of Analysis and Inspections, 1986.

59. Wilson, Mark G., and K. M. Wilson. "Strategies and Materials for Smokeless Tobacco Education." Journal of School Health 57:2 (1987): 74-76; and Laflin, Molly, E. D. Glover, and J. F. McKenzie. "Resources for Smokeless Tobacco Education." Journal of School Health 57:5 (1987): 191-194.

60. Severson, Herbert H. "Enough Snuff: ST Cessation from the Behavioral, Clinical, and Public Health Perspectives." Smoking and Tobacco Control Monograph 2. NIH Publication No. 92-3461. Bethesda, MD: National Cancer Institute, 1992. 279-290; and Chassin et al., 1985.

61. Office of the Inspector General.

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63. Chassin et al., 1985.

64. Severson, Herbert H. "Smokeless Tobacco: Risks, Epidemiology, and Cessation." In Orleans, C. Tracy, and John Slade, eds. Nicotine Addiction: Principles and Management. New York: Oxford University Press, 1993. 262-278.

65. Severson, Herbert H., R. Glasgow, R. Wirt, P. Brozovsky, L. Zoref, C. Black, et al. "Preventing the Use of Smokeless Tobacco and Cigarettes by Teens: Results of a Classroom Intervention." Health Education Research 6:1 (1991): 109-120.

66. Sussman, Steve, C. W. Dent, A. W. Stacy, et al. "Project Towards No Tobacco Use: 1-Year Behavior Outcomes." Journal of Public Health 83:9 (1993): 1245-1250.

67. Elder et al.

68. Connolly, Gregory N., C. T. Orleans, and M. Kogan. "Use of Smokeless Tobacco in Major-League Baseball." New England Journal of Medicine 318:9 (1988): 1281-1285; and Ernster, Virginia L., D. G. Grady, J. C. Greene, et al. "Smokeless Tobacco Use and Health Effects Among Baseball Players." Journal of the American Medical Association 264:2 (1990): 218-224.

69. Jones, Rhys B. "Use of Smokeless Tobacco in the 1986 World Series." New England Journal of Medicine 316:15 (1987): 952.

70. Sussman, Steve, and M. Barovich. "Smokeless Tobacco: Less Seen at 1988 World Series." American Journal of Public Health 79 (1989): 521-522. (Letter.)

71. D'Onofrio, C., J. Moskowitz, and M. Braverman. Unpublished data cited in Centers for Disease Control. Preventing Tobacco Use Among Young People. A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services, 1994. 237.

72. Schinke, Steven P., R. F. Schilling II, L. D. Gilchrist, M. R. Ashby, and E. Kitajima. "Native Youth and Smokeless Tobacco: Prevalence Rates, Gender Differences, and Descriptive Characteristics." Smokeless Tobacco Use in the United States. Monographs No. 8. Bethesda, MD: National Cancer Institute, 1989. 39-42.

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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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74. Centers for Disease Control and Prevention. Preventing Tobacco Use, 1994. 78.

75. Allen, Karen, A. J. Moss., G. A. Giovino, D. R. Shopland, and J. P. Pierce. "Teenage Tobacco Use: Data Estimates From the Teenage Attitudes and Practices Survey, United States, 1989." Advance Data 224 (1 Feb. 1993): 1-20.

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77. Tuakli, Nadu, M. A. Smith, and C. Heaton. "Smoking in Adolescence: Methods for Health Education and Smoking Cessation. A MIRNET Study." Journal of Family Practice 31:4 (1990): 369-374.

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80. Best et al., 1984.

81. St. Pierre, Richard W., R. E. Shute, and S. Jaycox. "Youth Helping Youth: A Behavioral Approach to the Self-Control of Smoking." Health Education (Jan./Feb. 1983): 28-31.

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83. Sussman, Steve, D. Burton, A. W. Stacy, and B. R. Flay. School-Based Adolescent Tobacco Use Prevention and Cessation Research. Newbury Park, CA: Sage Publications. (In press.)

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86. Peltier, Bruce, M. J. Telch, and T. J. Coates. "Smoking Cessation with Adolescents: A Comparison of Recruitment Strategies." Addictive Behaviors 7 (1982): 71-73.

87. Hollis, Jack F., T. M. Vogt, V. Stevens, A. Biglan, H. Severson, and E. Lichtenstein. "The Tobacco Reduction and Cancer Control (TRACC) Program: Team Approaches to Counseling in Medical and Dental Settings." In National Cancer Institute, Tobacco and the Clinician: Interventions for Medical and Dental Practice. Smoking and Tobacco Control Monograph No. 5. NIH Pub. No. 94-3693. USDHHS, 1994. 143-185.

88. Weissman, Wendy, R. Glasgow, A. Biglan, and E. Lichtenstein. "Development and Preliminary Evaluation of a Cessation Program for Adolescent Smokers." Psychology of Addictive Behaviors 1:2 (1987): 84-91.

89. Gallup International Institute. Teen-Age Attitudes and Behavior Concerning Tobacco. Princeton, NJ: The George H. Gallup International Institute, Sept. 1992.

90. Hawkins, Robert P., D. H. Gustafson, B. Chewning, K. Bosworth, and P. M. Day. "Reaching Hard-To-Reach Populations: Interactive Computer Programs as Public Information Campaigns for Adolescents." Journal of Communication 37:2 (1987): 8-28.

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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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93. Boyle, Raymond. Smokeless Tobacco Cessation with Nicotine Replacement: A Randomized Clinical Trial. Eugene, OR: University of Oregon, 1992. (Dissertation.)

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95. Williams, Nancy J. A Smokeless Tobacco Cessation Program for Postsecondary) Students. Memphis State University, May 1992. (Thesis.)

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97. Ary, Dennis V., E. Lichtenstein, and H. H. Severson. "An In-Depth Analysis of Male Adolescent Smokeless Tobacco Users: Interviews with Users and Their Fathers." Journal of Behavioral Medicine 12:5 (1989): 449.

98. Novotny, Thomas E., J. P. Pierce, M. C. Fiore, and R. M. Davis. "Smokeless Tobacco Use in the United States: The Adult Use of Tobacco Surveys." National Cancer Institute Monographs 8 (1989): 25-28.

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102. Sussman, Burton, et al., in press.

103. Chakravorty.

104. Williams.

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106. Ockene, Judith K. "Clinical Perspectivies: Physician-Delivered Interventions for Smoking Cessation: Strategies for Increasing Effectiveness." Preventive Medicine 16 (1987): 723-737.

107. Stevens, Victor J., H. H. Severson, E. Lichtenstein, S. J. Little, and J. Leben. "Making the Most of a Teachable Moment: Smokeless Tobacco Intervention in the Dental Office Setting." American Journal of Public Health. (In press.)

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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"5 PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAMS." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths Get This Book
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Tobacco use kills more people than any other addiction and we know that addiction starts in childhood and youth.

We all agree that youths should not smoke, but how can this be accomplished? What prevention messages will they find compelling? What effect does tobacco advertising—more than $10 million worth every day—have on youths? Can we responsibly and effectively restrict their access to tobacco products?

These questions and more are addressed in Growing Up Tobacco Free, prepared by the Institute of Medicine to help everyone understand the troubling issues surrounding youths and tobacco use.

Growing Up Tobacco Free provides a readable explanation of nicotine's effects and the process of addiction, and documents the search for an effective approach to preventing the use of cigarettes, chewing and spitting tobacco, and snuff by children and youths. It covers the results of recent initiatives to limit young people's access to tobacco and discusses approaches to controls or bans on tobacco sales, price sensitivity among adolescents, and arguments for and against taxation as a prevention strategy for tobacco use. The controversial area of tobacco advertising is thoroughly examined.

With clear guidelines for public action, everyone can benefit by reading and acting on the messages in this comprehensive and compelling book.

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