Addicted to Nicotine
A National Research Forum

Section III: Nicotine-Environmental Risk Factors for Initiation
Nancy J. Kaufman, R.N., Chair

EFFECTIVE PREVENTION PROGRAMS FOR TOBACCO USE

Mary Ann Pentz, Ph.D.
Norris Cancer Center
University of Southern California

Introduction

Several types of prevention programs have been shown to delay or reduce youth tobacco use for periods of 1 to 5 years and more. These are evidence-based programs. However, they are not widely used. With few exceptions, adolescent tobacco use rates have been stable or have increased in the 1990s. The challenge for prevention researchers is to identify critical components shared by these effective prevention programs and then to evaluate factors that are most likely to promote their adoption, implementation, and diffusion to schools and communities throughout the United States.

What We Know

Prevention programs, unlike policy and community organization interventions, require the direct participation of youth. Effective programs train youth in psychosocial theory-based resistance skills and/or general social skills, with an emphasis on resistance and assertiveness. Some programs include skills to counteract social influences on tobacco use, for instance, the glamorized images of tobacco use in the media and peer pressure. Others use the social learning theory techniques of instruction, including modeling, role-playing, discussion, and extended skills practice involving group interaction between youth and trainers. In contrast, didactic, atheoretical, knowledge programs have no effect on tobacco use.

Effective prevention programs engage the school, parents, and media programs or combinations of these. The majority of prevention programs are based in schools. For these, effects depend on the use of standardized teacher (or other leader) training, fidelity of program implementation (program delivery as designed), and interactive homework activities to extend skills practice. Magnitude and maintenance of effect depend on the number of sessions and the use of staggered booster sessions; 1- to 3-year effects on tobacco use onset and monthly use have been reported with a minimum of seven sessions, and effects up to 5 years were shown with a 30-session program involving boosters.

School programs adapted to community agency settings, such as the Boys and Girls Clubs, have also shown effects on onset and monthly use for up to 2 years. Parent programs, by themselves, have increased parent-child communication about tobacco use. Mass media programs, by themselves, specifically television programs illustrating prevention skills and/or the social consequences of using tobacco, have shown some effect on changing youth attitudes, perceived norms, and risk of tobacco use. Parent and/or media programs delivered with a school program, however, have shown effects on monthly and weekly tobacco use that exceed a school program alone and last up to 4 years. Finally, multicomponent community programs that have as a basis a school program, with supportive parent, media, and community organization components, have shown effects lasting up to 8 years, on daily as well as monthly and weekly tobacco use.

Program adoption by schools and communities is associated with readiness for prevention as indexed by needs assessment, public commitment, and set-aside resources for the program. Program implementation, limited to the study of school programs, is associated with school climate, specifically principal support of teachers to teach a prevention program. Prevention program diffusion appears to be related to existing credible networks to sanction and diffuse a program.

The following three aspects of tobacco use prevention programs constitute current research knowledge:

• Significance and Size of Program Effects. Basis in psychosocial theory; skills to counteract social influences to use tobacco; use of interactive social learning methods of training; standardized teacher (or other program leader) training; interactive homework activities; fidelity of implementation; and multiple program components in addition to a school program.

• Maintenance of Effect. Boosters, multiple program components in addition to a school program with community support.

• Adoption, Implementation, and Diffusion. School or community readiness for prevention; principal (for school program) support for teaching a prevention program; existing, credible networks for diffusion.

What We Need To Know More About

It is not clear whether tobacco use prevention programs alone or drug abuse prevention programs that include tobacco are more effective. The question may be important in schools and communities where immediate public priorities and funding for prevention vary, for example, in communities that have just adopted a no-smoking ordinance versus communities that are fighting an illicit drug problem. This question bears on readiness for prevention.

Research on predictors of adoption, implementation, and diffusion of evidence-based programs is scanty relative to outcome research. Studies assigning schools or communities to different prevention program options could be designed, either randomly or by choice, with variables such as perceived relative advantage used to predict adoption and diffusion. Predictors of implementation need to be identified, and interventions then should be designed to enhance implementation.

While comprehensive school programs and multicomponent community programs that include a school program appear to produce the largest and most lasting effects on youth tobacco use, little is known about why this is the case. Is it the number and frequency of prevention messages across different community settings, or staggering of program delivery across years, or both? Answers to these questions have important implications for designing future tobacco use prevention programs. For example, if number and frequency is the issue, then an effective tobacco use prevention program could be easily implemented in schools, without requiring the time or resources to involve the rest of the community. New and existing studies could vary some of their program parameters to evaluate these questions, perhaps as component studies within larger research designs.

Little is known about the relationship of prevention program effects to youth tobacco access and policies in the community in which a program is implemented. Specifically, are prevention program effects larger if the program teaches or cues youth to existing policy, or vice versa? Are their messages consistent, for example, and are programs and policies support oriented rather than punishment oriented? Do tobacco vendors or law enforcement officers refer youth violators to prevention programs? These questions could be addressed immediately in current prevention studies by systematically evaluating program and policy content and communications among program deliverers, enforcement personnel, and vendors.

Finally, two questions relate to the effectiveness of prevention programs for preventing addictive tobacco use. First, although more comprehensive prevention programs have shown to delay and reduce daily as well as monthly tobacco use prevalence rates, relatively little is known about whether prevention programs have differential effects on youth who may have different natural trajectories of tobacco use. For example, is a prevention program effective for youth who are not currently exposed to tobacco and therefore would not normally use tobacco for a year or more after the program (a delayed trajectory)? Is the pressure resistance taught in a prevention program enough to make a half-a-pack-a-day smoker want to quit? Second, what is known about the capacity of universal (whole population) prevention programs to recruit, link, or otherwise encourage current smokers to participate in cessation programs? The first question could be evaluated in existing longitudinal prevention studies. The second may require new research studies and the development of adolescent smoking cessation programs.

The following questions about tobacco use prevention programs require answers:

• Is tobacco-specific prevention or drug abuse prevention that includes tobacco more effective?

• What predicts adoption, implementation, and diffusion of evidence-based prevention programs?

• Why are multicomponent programs that include a school program more effective overall than school programs?

• Is the degree of effectiveness of a prevention program related to youth tobacco access and policy in the community in which the program is implemented?

• What is the capacity of universal prevention programs to affect youth who are at different stages of tobacco use during intervention and to prevent addictive smoking?

Recommended Reading

Dusenbury, L., and Falco, M. Eleven components of effective drug abuse prevention curricula. J Sch Health 65(10):420-425, 1995.

Pentz, M.A. Prevention. In: Kleber, H., and Galanter, M., eds. American Psychiatric Press Textbook of Substance Abuse. 2nd ed. Washington, DC: American Psychiatric Press, Inc., in press.

Rogers, E.V. The impact of drug abuse prevention programs: Project Star in Kansas City. In: Backer, T.E., and Rogers, E.M., eds. Organizational Aspects of Health Campaigns. Newbury Park, CA: Sage Publications, 1992.