Researchers at the Fred Hutchinson Cancer Research Center in Seattle have found that a curriculum-based approach to prevent youth smoking was ineffective when used alone in a school setting. The study was conducted over a 15-year period, from 1984 through 1999, in 40 Washington state school districts.

Arthur V. Peterson Jr., Ph.D., and colleagues from the Hutchinson Center, published their results in the Dec. 20, 2000, issue of the Journal of the National Cancer Institute.* The researchers tested a social-influences approach in a school-based setting, which aimed to make youth more aware and better able to resist the social factors that might lead them to smoke.

"Although the study demonstrated that this approach alone had no effect, it provides a valuable contribution to our knowledge about youth smoking behavior," said Richard Klausner, M.D., director of the National Cancer Institute (NCI). "Carefully conducted studies such as this one help us to understand what works and what does not in preventing youth smoking."

The Hutchinson Smoking Prevention Project (HSPP) was a randomized trial involving 8,388 children in 20 intervention and 20 control school districts. The intervention school districts instituted a curriculum-based third- through 12th-grade social-influences intervention, while control districts continued their usual health promotion and tobacco prevention activities already in place.

The intervention included HSPP-developed anti-smoking curriculum units from grades three through 10 using the social-influence approach. These units were taught by the schools' regular teachers, who attended HSPP training. Supplemental high school components were available to students from ninth through 12th grade, including motivational and self-help cessation materials, faculty training on how to encourage and support teen smoking cessation efforts, as well as posters and school newspaper advertisements with anti-smoking elements.

The primary endpoints of the trial were daily smoking at grade 12 and at two years after high school (Plus Two). The original cohort of 8,388 was followed to these long-term outcomes with a 94 percent follow-up rate.

The results indicate that there was no substantial difference in smoking prevalence for students in the control and intervention groups, for either boys or girls, as assessed at grade 12 and at Plus Two. At grade 12, 25.7 percent of adolescents in the control group were daily smokers and 25.4 percent in the intervention group were daily smokers. At Plus Two, 29.1 percent in the control group were daily smokers and 28.4 percent in the intervention group were daily smokers.

"The similarity in smoking prevalence between the intervention and control conditions is striking. Because of the high degree of rigor achieved in this trial, the failure to observe reduced smoking prevalence in the intervention group is attributable only to the failure of the intervention," Peterson states.

The social-influences approach, an influential perspective in smoking prevention research for the past 20 years, focuses on helping youth to identify and resist social influences to smoke. The HSPP curriculum-based intervention incorporated such social-influence components as: bolstering skills to recognize the social influences of smoking, including advertising and peer pressure; fostering skills for resisting those influences to smoke; and increasing awareness of and promoting tobacco-free social norms.

The HSPP intervention met curriculum components of the Centers for Disease Control and Prevention's (CDC's) recommended guidelines for school-based prevention programs, and included the 15 essential elements for school-based tobacco prevention that were recommended by a national Expert Advisory Panel convened by the NCI in 1987. Given the magnitude of the youth smoking problem at that time, experts gathered to address the question of how schools could help to reduce smoking among youth. Panelists were asked to provide a "snapshot" of the field at that moment, leading to the development of the 15 elements. Members of the panel, however, cautioned that recommendations were based on the best knowledge at that time and much more work needed to be done, both in completing current studies and in designing future research.

The results of the HSPP emphasize the need for additional research to identify the components of effective tobacco-use prevention efforts, like those produced in states such as Florida, Massachusetts, and Oregon. Robert Croyle, Ph.D., associate director for behavioral research at the NCI, notes that "NCI is continuing to support a wide range of research studies on tobacco use among youth, and several of these studies are already beginning to provide valuable new insights." NCI currently supports 50 research projects addressing tobacco and youth, including etiology, prevention, and cessation. Some current projects are examining the effects of multifaceted interventions such as those that combine both school- and community-based intervention components, which Peterson cites as an area for future research.

In an accompanying editorial, Richard Clayton, Ph.D., and his colleagues at the Kentucky Prevention Research Center and the Kentucky School of Public Health, in Lexington, commented on the elegance of the research design and the scientific rigor sustained for 15 years.** They also point to areas of future research in light of the HSPP results. Clayton notes the importance of examining individual pathways and contextual factors in future analyses of the HSPP data; he states that the method and frequency of data collection in future studies could be modified to better understand turning points in tobacco use; he also comments on possible reasons why the social-influences approach failed, including its possibly inaccurate assumption that all decision-making is rational and unaffected by mood or state of mind. Clayton and colleagues call for a re-examination of health behavior theories to identify new and more robust models.

A large portion of time and dollars for smoking prevention research is geared toward prevention projects for youth, as those who begin smoking at young ages are more likely to become heavy smokers and have a higher risk of smoking-attributable death. Although smoking rates among U.S. high school students may have leveled or begun to decline following years of increased rates, the CDC's 1999 Youth Risk Behavior Survey found that 34.8 percent of U.S. high school students smoked at least once a month.

* The authors of the article are Arthur V. Peterson Jr., Kathleen A. Kealey, Sue L. Mann, Patrick M. Marek, and Irwin G. Sarason. The title of the article is "Hutchinson Smoking Prevention Project: Long-Term Randomized Trial in School-Based Tobacco Use Prevention. Results on Smoking." Journal of the National Cancer Institute, Dec. 20, 2000, Volume 92, Number 24.

**The authors of the editorial are Richard R. Clayton, F. Douglas Scutchfield, and Stephen Wyatt. The title of the editorial is "Hutchinson Smoking Prevention Project: A New Gold Standard in Prevention Science Requires New Transdisciplinary Thinking." Journal of the National Cancer Institute, Dec. 20, 2000, Volume 92, Number 24.

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