Health Education Research, Vol. 19, No. 2, 125-137,
April 1, 2004
© 2004 Oxford University Press
Fifteen-month follow-up results of a school-based life-skills approach to smoking prevention
1 Institute for Therapy and Health Research, IFT-Nord, 24105 Kiel and 2 Department of Child and Adolescent Psychiatry, University of Hamburg, 20246 Hamburg, Germany 3 Correspondence to: R. Hanewinkel; e-mail: hanewinkel{at}ift-nord.de
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Abstract |
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The life-skills approach to smoking prevention was tested in this study. In total, 1024 pupils (mean age 11.4 years, SD = 0.90) from Austria, Denmark, Luxembourg and Germany were recruited as an experimental group, and a sample of 834 matched pupils served as a control group. While the pupils from the control group received no specific intervention, the pupils in the experimental group participated in an intervention programme which was based on the life-skills approach and consisted of 21 sessions. The aims of the programme were to promote fundamental social competencies and coping skills. In addition, specific information on cigarette smoking was given and skills for resisting social influences to smoke were rehearsed. The programme was conducted by trained school teachers during a course of 4 months. Anonymous questionnaires were administrated (1) before the programme was implemented and (2) 15 months after the programme had started. Teachers as well as pupils showed a high level of satisfaction with the programme idea and the materials. With regard to the outcome variables, the programme had no differential effect on current smoking (4-week prevalence). The programme showed a weak effect (P < 0.1) on lifetime smoking prevalence and experimental smoking. There was also an effect of the programme on smoking knowledge, on the social competences of the pupils as well as on the classroom climate. No effects were found on susceptibility to smoking among never-smokers, attitudes towards smoking and the perceived positive consequences of smoking. The results indicate that prevention programmes that are run for only a few months can have a positive impact on variables considered to be protective with regard to smoking uptake.
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Introduction |
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Smoking remains the leading preventable cause of premature disease and death worldwide (WHO, 1997
). It is estimated that in the next 20–30 years, 10 million people per year will die from tobacco-related diseases such as cancer, cardiovascular disease, chronic obstructive pulmonary disease and others (Satcher, 2001).
Epidemiological studies indicate that smoking prevalence among youth underwent a sustained and substantial decline in the 1970s and 1980s, but during the 1990s smoking prevalence increased among adolescents in the US (Ferrence et al., 2000) and also in Europe (WHO, 2000). In addition, little progress has been made over the years in improving cessation rates among smokers and relapse is still the rule rather than the exception in treatment studies. Thus, effective primary prevention programmes for youth smoking are urgently required. Over the past decades several different educational models for smoking prevention have been established and evaluated (US Department of Health and Human Services, 2000).
The earliest evaluated programmes designed to prevent children and adolescents from beginning to smoke were based on an information deficit model (US Department of Health and Human Services, 1994). The assumption of this approach is that adolescents would refrain from smoking if they were supplied with adequate information regarding the harmful effects of smoking. Factual information concerning the nature, pharmacology and harmful consequences of tobacco is given based on the belief that once individuals are aware of the hazards of using tobacco, they will develop anti-tobacco attitudes, and make a rational and logical decision not to use tobacco. Reviews and meta-analysis indicate that this approach leads to an increase in knowledge, but neither affects the attitudes towards smoking nor the actual behavior (Hansen, 1992; Bruvold, 1993; Tobler and Stratton, 1997; Tobler et al., 2000).
Recognizing the limitations of this approach, other educational interventions have been developed in order to prevent youth smoking (Durlak, 1995). The underlying assumption of the affective education model is that reduced levels of perceived self-esteem, and poor attitudes towards family, school and community cause smoking initiation. Therefore, a broad range of educational strategies were established in order to clarify values, build up self-esteem and develop skills for decision making. Several evaluations of this prevention approach show that it is not more effective in influencing adolescents attitudes and behaviors than programmes which are based on the information deficit model (Lynch and Bonnie, 1994; Vartiainen et al., 1994).
Beginning in the 1970s, new approaches to smoking prevention have been developed, which mostly use psychological inoculation techniques and behavioral rehearsal to strengthen attitudes and skills that aid in resisting pressures towards tobacco use. The goal of this approach is to equip adolescents with specific skills and resources that they need to resist social influences, e.g. peer pressure, to try smoking cigarettes (Evans et al., 1978; McAlister et al., 1980; Perry et al. 1980). A number of studies and reviews indicated that social influence strategies can prevent or delay the onset of smoking in adolescence. Nevertheless, follow-up studies indicated that over time the effects of these prevention programmes tend to decay (Resnicow and Botvin, 1993; Vartiainen et al., 1998). Only a few studies show promising long-term follow-up results. One of the most promising results was demonstrated by the comprehensive life-skills training approach (Botvin, 2000). In a study conducted by Botvin et al. (Botvin et al., 1995), data were collected 6 years after the initial 56 schools had been randomized to treatment and control condition. For this sample of 3597 predominately white Grade 12 students, a relative reduction in smoking prevalence of 18% could be found. Other studies conducted by the same research group within different settings and youth groups support empirical evidence that life-skills training is an effective approach to prevent tobacco, alcohol and other drug use (Botvin et al., 1992; Griffin et al., 2003). This training uses different behavior modification techniques in order to improve general problem-solving skills as well as cognitive and behavioral skills for resisting interpersonal or media influences to smoke. In addition, skills for increasing self-control and self-esteem as well as coping strategies relieving stress and anxiety are taught. There are also components designed to enhance general interpersonal skills as well as general assertiveness skills.
This paper describes the process and outcome evaluation of a school-based life-skills programme. Classes in this study were assigned to the following conditions: (1) intervention group or (2) control group. A process evaluation was carried out to determine weaknesses and strengthens of the materials, and the concept of the teaching units. Due to the fact that the programme concept and materials had been developed in cooperation with teachers working with the target group and psychologists, it was hypothesized that, in general, the material and the different units would find teachers’ and pupils’ approval. With regard to the outcome evaluation, it was expected that the prevention programme would be more effective in preventing and delaying smoking in students from secondary schools than ‘regular’ education. Further, we hypothesized that the programme would result in increased knowledge about the effects of smoking, less favorable attitudes towards smoking, lower susceptibility to smoking, improved social competencies and an improved classroom atmosphere.
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Methods |
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Participants and design
To evaluate the effectiveness of the prevention programme, a quasi-experimental control group-design with repeated measurement was applied.
At the beginning of the study, a total of 106 classes from 54 secondary schools participated. Fifty-five of the classes underwent the intervention and 51 classes did not take part in any specific intervention during the duration of the study. The classes were recruited from German-speaking schools in Austria, Denmark, Germany and Luxembourg. Data was assessed at pre-test (April 1998) and 15 months after the implementation of the programme in schools (July 1999).
At pre-test, 1858 students (N intervention group = 1024; N control group = 834) completed the questionnaires. As far as possible, the classes in the control group were selected from parallel classes of the intervention group (21 of 51 classes).
The retention rate over the course of the study [87.5% (1625 pupils; 921 pupils in the intervention group and 704 pupils in the control group) of the original sample] is comparable to retention rates for similar school-based studies (Mellanby et al., 2000).
The intervention was implemented in Grades 5 and 6.
Experimental and control groups differed significantly with regard to age [control group: 11.59 (0.92) years at pre-test; experimental group: 11.42 (0.90) years at pre-test; t(1828) = 4.03, P < 0.01].
There was no significant difference between the groups with regard to sex [50.1% boys in the experimental group and 54.2% boys in the control group; 
2(1) = 2.97; NS].
Prevention programme
The presented programme is the third module of a curriculum which starts in the first grade of primary school (Burow et al., 1998; Aßhauer et al., 1999; Ahrens-Eipper et al., 2002). The modules are independently constructed and evaluated. They can be used in any grade regardless of whether the pupils have participated in the curriculum before. Table I gives an overview of the 21 lessons of the module for Grades 5 and 6. Each lesson except the final lesson had the same structure:
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• Introduction/opening
• Discussion of homework assignments (in the provided lessons)
• Relaxation phase
• Main topic
• Distribution of new homework assignments (in the provided lessons)
• Joint conclusion
Teachers were provided with detailed written instructions for each lesson. The sample of the present study started with the programme in Grade 5, respectively, 6.
Procedure
The intervention was carried out by classroom teachers. Prior to the beginning of the programme, the teachers of the experimental classes attended a 2-day training workshop. The main emphasis of the workshop was placed on demonstration and rehearsal of behavior modification techniques.
Questionnaires for the outcome and process evaluation were distributed among pupils by teachers. Respondents were assured of confidentiality and that no one but the researchers had access to the data. At each assessment, pupils provided an identification code consisting of the initials of the mother, date of birth, initials of the father, gender, school and class. After respondents had finished their questionnaire, teachers put the papers in an envelope in front of the pupils, sealed it in the classroom and sent it to the researchers.
During the programme implementation the teachers were asked to fill in a questionnaire after each unit carried out, in order to evaluate feasibility, weaknesses and barriers of the different units. After the last lesson of the programme, the teachers (N = 55) from the intervention group as well as the pupils (N = 970) filled out a questionnaire assessing general aspects of the programme.
Measures
Process evaluation questionnaire for teachers
Teachers reported for each unit carried out how much of the planned activities could be realized in the proposed form, and scored the programme and the materials on a five-point scale (1 = very good; 5 = very bad) with regard to practicability, age appropriateness and time needed to carry out a unit. Moreover, they were assessed how strongly they would agree with the statements (1) the pupils liked the unit and (2) the unit was disturbed by some of the pupils. Answers were given on a five-point scale (1 = fully true; 5 = not true at all).
Final assessment of the programme
• Teachers. At the end of the programme, teachers were asked whether they would agree with the statements: (1) ‘From the programme, I have gained ideas that I can use in my lessons’, (2) ‘I would like to continue with the programme’, (3) ‘My relationship to the pupils could be improved’, (4) ‘Social climate in class improved during the programme’ and (5) ‘Non-smoking behavior in non-smokers could be established’. Answers were given on a five-point scale (1 = fully true; 5 = not true at all).
• Pupils. Pupils were asked to what extent they agreed with the statements: (1) ‘I enjoyed the units’, (2) ‘I learnt useful things’ and (3) ‘I got closer to my classmates’. Answers were given on a five-point scale (1 = fully true; 5 = not true at all).
Smoking status: ever and current smoking
One item measured whether students had ever tried a cigarette and one item measured current smoking, which was defined as any use of cigarettes within the past 30 days. These classifications have been used by several US national surveys, including the Youth Risk Behavior Survey (US Department of Health and Human Services, 1994; Anderson et al., 2002). We created three mutually exclusive groups on the basis of these items: (1) current smoker, (2) experimenters and (3) never-smokers. Current smokers responded positively to both the ever-smoking and current-smoking item, experimenters responded positively to the ever-smoking and negatively to the current-smoking item, and never-smokers responded negatively to both the ever-smoking and current-smoking item.
Cognitions and knowledge regarding smoking and psychosocial variables
• Susceptibility to smoking. The susceptibility to smoking (Jackson, 1998; Pierce et al., 1996) was assessed among never-smokers. To be classified as not susceptible to smoking a respondent had to answer ‘no’ to the ever-smoking question, then ‘definitely not’ to the item ‘will you smoke later on?’.
• Smoking-related knowledge. Ten items were administrated to measure smoking-related knowledge. The answering format was dichotomous (true versus false). The questions were summed to form one knowledge index (range 0–10), 0 indicating that all items were answered inappropriately to 10 indicating that all the questions were answered correctly.
• Attitudes towards smoking. Six items were used to measure attitudes towards smoking. Three of them represented a positive attitude (‘cigarette commercials are cool’, ‘smoking is somehow quite tough’ and ‘smoking is exciting’) and three items indicated a negative attitude (‘smoking is disgusting’, ‘smoking is stupid’ and ‘smoking is out’). Attitudes were assessed on a four-point scale (range 3 = ‘strongly agree’; 0 = ‘disagree’) (Cronbach’s 
= 0.88).
• Perceived positive consequences of smoking. Eight items were designed to measure perceived positive consequences of smoking (e.g. ‘people who smoke have more fun’) using a four-point scale (range 3 = ‘strongly agree’; 0 = ‘disagree’) (Cronbach’s = 0.71).
• Social competence. Thirteen items measured the ability to use specific assertive, social and communication skills, e.g. to talk in front of large groups, to return defective merchandise, to make friends or to say ‘no’. Responses ranged from 4 = ‘very easy’ to 0 = ‘very difficult’ (Cronbach’s = 0.73).
• Classroom atmosphere. Ten items were designed to assess classroom atmosphere (e.g. ‘I enjoy being in this class’, ‘we help each other in our class’, ‘other classmates annoy me quite often’) using a four-point scale (range 3 = ‘strongly agree’; 0 = ‘disagree’) (Cronbach’s = 0.74). Validation of self-reports via biochemical tests was not feasible because of organizational and financial constraints. Biochemical markers for smoking are in widespread use as methods to substantiate self-reports of smoking in intervention studies (Murray et al., 1993). Smoking levels have been estimated by measuring the components or byproducts of inhaled cigarette smoke in the serum, salvia, urine or expired alveolar air (Irving et al., 1988; Schneider et al., 1997). Mostly used in research with adolescents is the biochemical assessment as a bogus pipeline procedure (Murray and Perry, 1987). In this case the biochemical test is collected, but not evaluated. Nevertheless, the subjects believe that biochemical validation occurs. However, Velicer et al. (Velicer et al., 1992) reviewed research findings which suggest that an effective procedure to ensure anonymity can reduce the potential pressure among young people to not truthfully report smoking activities, so that the bogus pipeline procedure is not essential.
Statistical analyses
Characteristics of the sample at baseline were analyzed with t-tests and 2-tests. To examine the effects of the programme, a logistic regression analysis was conducted. Group condition (‘control group’ versus ‘intervention group’) served as a dependent variable. The smoking status as well as cognitions and knowledge regarding smoking and psychosocial variables were used to describe (predict) the dependent variable. This analysis was adjusted for the factors age and smoking status at baseline (never-smoking at baseline).
The data analyses were carried out by SPSS.
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Results |
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Pre-test equivalence
Table II provides a comparison of the prevention and the control condition at baseline. Logistic regression analyses, t-tests and a
2-test were computed to determine the comparability of the intervention and the control condition with respect to the outcome data assessed at follow-up.
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No significant differences were found across conditions for any of the variables with the exception of social competence, which was significantly higher in the control condition, and age, which was higher in the control condition. Overall, these analyses indicate a high degree of comparability between the conditions at baseline.
Attrition analyses
In order to examine the potential sample bias introduced by the loss of pupils, a comparison of the pupils that dropped out of the study and the pupils that remained in the study was conducted. For this purpose, a logistic regression analyses was carried out, in which the ‘selection variable’ (‘retained sample’ versus ‘attrition sample’) served as the dependant variable. In the first block, group condition (‘experimental group’ versus ‘control group’), age, sex and smoking status (current smoking) served as independent variables. In the second block, the interaction term ‘group condition’ x ‘smoking status (current smoking)’ was included as a covariable. While there was no difference between the groups with regard to smoking status [odds ratio (OR) = 0.71 (0.45–1.12); NS], the pupils who dropped out of the study were older than those in the retained sample [11.72 versus 11.41 years; OR = 0.75 (0.64–0.87); P < 0.001]. In addition, more male than female pupils dropped out of the study [OR = 0.72 (0.54–0.97); P < 0.05] and, overall, more pupils in the control condition dropped out compared to pupils in the experimental condition [OR = 1.53 (1.1–2.1); P < 0.05]. No significant interaction could be found for smoking status and group condition [OR = 0.93 (0.49–1.73); NS] among the attrition and the retention sample.
Implementation
The programme was implemented for a duration of 4 months. On average, 16.4 out of 21 teaching units (78.09%) were carried out and 76.16% of the planned activities were used by the 55 teachers in the intervention group.
Intervention evaluations
Process evaluation of the teaching units
With regard to the practicability of the teaching units, 29.2% of the teachers rated the materials as ‘very good’ and 43.9% as ‘good’; 38.9% of the teachers considered the age-appropriateness of the materials as ‘very good’ and 41.1% as ‘good’. Moreover, 8.6% of the teachers assessed the time needed to carry out a unit as ‘very good’, 21.5% as ‘good’, 26.1% as ‘medium’, 28.8% as ‘bad’ and 15.2% as ‘very bad’. 73.5% of the teachers were of the opinion that the pupils liked the teaching units, while only 8.6% reported that pupils disturbed the lessons.
Final assessment of the programme
The final assessment revealed that both teachers and pupils had a very positive general perception of the curriculum. For the pupils, 83.7% reported that they enjoyed the lessons, 88.6% stated that they learnt useful things and 64.7% felt that they got closer to the pupils in their class. For the teachers, 94% were of the opinion that non-smoking behavior in non-smokers could be established; 96.3% reported to having gained ideas, which they would use in their lessons, and 90.4% showed interest in continuing with the programme; 54.9% assessed an improved social climate in their classes during the programme and 48.1% reported an improved relationship to their pupils.
Impact on smoking status, cognitions and knowledge regarding smoking and psychosocial variables
Due to the comparability of the intervention and the control group at pre-test, only follow-up data were included in the data analyses to test the hypotheses of the present study. Table III gives an overview of the outcome variables. The logistic regression analysis did not reach a significant result with regard to the smoking status. There was only a marginal effect of the programme (P < 0.1) on the lifetime smoking experience (never-smokers) and experimental smoking. In the intervention group, there were more pupils who indicated never having smoked in their lives and less pupils indicating they had experimented with smoking compared to the control group.
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Regarding the variable ‘social competence’, at follow-up, no significant difference could be detected among the intervention and control groups, indicating an increase of social competence in the intervention group.
The programme showed significant effects on smoking-related knowledge and classroom atmosphere: pupils in the intervention group showed greater knowledge and reported an improved class climate, compared to the pupils in the control group condition. No differences were found for the variables ‘susceptibility to smoking’ among never-smokers, ‘attitudes towards smoking’ and ‘perceived positive consequences of smoking’ among the groups.
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Discussion |
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In this study, Grade 5 and 6 pupils from Austria, Denmark, Germany and Luxembourg participated in an intervention programme mainly designed to prevent the onset of smoking. Among the antismoking education programmes available today, the comprehensive life-skills approach appears to be the most successful in reducing the onset of smoking (US Department of Health and Human Services, 2000). Nevertheless, the results of this study reveal only a weak effect on the onset of smoking. The increase of pupils who started smoking from baseline to follow-up was 12.4% in the intervention group and 18.6% in the control condition. There was a 4.5% difference between experimental and control groups in the lifetime smoking prevalence at follow-up, 15 months after the programme was implemented in the schools. The size of the effect is comparable to the results of a meta-analysis of smoking prevention programs after adjustment for errors in the unit of analysis carried out by Rooney and Murray (Rooney and Murray, 1996
), in which they found an average reduction of smoking of 5%. At follow-up, there was a 3.5% difference between experimental and control groups in experimental smoking. No effects could be found with regard to current smokers. Of the never-smokers in the intervention group, 22.8% reported susceptibility to smoking, compared to 28.5% in the control group. However, these results did not show statistical significance.
Regarding the cognitive appraisal of smoking there were clear effects of the programme on smoking related knowledge. In addition, improvements could be shown for classroom atmosphere, a variable which is considered to be protective with regard to substance misuse (Hawkins et al., 1992). For none of the other assessed variables (attitudes towards smoking and perceived positive consequences of smoking) could significant differences among the control and intervention condition be detected in the follow-up measurement. With regard to the variable social competencies, at baseline, pupils in the control group showed more competencies than in the intervention group. At follow-up, the two groups did not differ any longer. In the course of the intervention the social competencies in the intervention group increased, while in the control group there were no changes. While there is no sufficient explanation for the differences among the groups at baseline, the results at follow-up show that the intervention had an effect on the social competencies in the intervention group. When interpreting the results of the study we have to keep in mind the relatively young age of the pupils (11.5 years). At 12 months after the end of the programme, pupils from the intervention group showed a marginally reduced increase in ever-smokers. In fact, most of the studies testing smoking prevention curricula at schools deal with older pupils. In addition, some studies testing the social influence approach have shown that booster sessions are helpful in enhancing the preventive effect (Dijkstra et al., 1999). Therefore, some activities for higher grades should be included in the present curriculum in order to strengthen its preventive effect.
Some limitations of the study have to be taken into account. A major problem might be that due to project restrictions—the available time period for the intervention was 4 months only. This enormous time pressure was criticized by many teachers and resulted in a reduced implementation in many classes. The mean number of conducted lessons was 16.4, from a total of 21. From the units that teachers implemented, on average they realized three-quarters (76.16%) of the programme contents, meaning that substantial elements and means of the programme such as intensive role-play were not put into practice in a way that the programme had foreseen. This might have had an effect on the results, too, and future modifications of the curriculum have to make sure that teachers have enough time to carry out all of the planned activities in the different units.
Furthermore, control group contamination might have occurred with regard to acquisition and implementation of the intervention by the control group teachers (Mann et al., 2000). In fact, the control classes were mainly recruited from the schools where the programme was implemented. This could have resulted in smaller differences between the two groups. It is well known that a tobacco control school policy influences pupils’ behavior (Centers for Disease Control and Prevention, 1994). Studies which involved the whole school showed promising results in the onset of smoking as well (Hanewinkel et al., 1994). Therefore, it could be hypothesized that the implementation of the programme in the school could modify the school norm on smoking in a positive way, and result in smaller differences between intervention and control groups.
The outcome variables (never-smokers, current smokers and experimenters) may be insensitive for the measurement of the continuum of smoking onset, and various researchers have published about this continuum and showed a cyclical process in which substantial proportions of adolescents in the earlier phases of this process go from ‘never smoking’ via a trying phase to either quitting the trying or to an experimental phase, in which smoking is more frequent (Mayhew et al., 2000 Kremers et al., 2001). The measures in the present study probably are not able to detect this process. In this study, we decided to use these outcome measures in order to be comparable to other studies, such as the US Youth Risk Behavior Survey (US Department of Health and Human Services, 1994; Anderson et al., 2002), as well as the Health Behavior of School-aged Children Study (WHO, 2000).
In any study measuring pre- and post-intervention variables, missing participants present problems, particularly when the follow-up time extents over several years (Hansen et al., 1985; Siddiqui et al., 1996). Johnson et al. (Johnson et al., 1986) noted an attrition of 65% at the end of the intervention, Luepker et al. (Luepker et al., 1983) around 50% and Ellickson and Bell (Ellickson and Bell, 1990) analyzed only 60% of their baseline sample. Nevertheless, in the present study the follow-up period was relatively short (15 months) and a number of pupils dropped out of the study. Therefore, an attrition analyses was carried in order to find out whether the retention sample differs from the attrition sample. The results showed that more male and older pupils dropped out of the study. In addition, a higher percentage of pupils in the control group dropped out from the study compared to the experimental group. However, neither the smoking status nor the interaction between group condition (‘experimental’ versus ‘control’ group) and smoking status reaches significance, which means that smokers were no more likely to drop out of the study than non-smokers. Furthermore, the number of smokers in the intervention group that dropped out from the study is not higher than the number of smokers that dropped out from the study in the control group.
Assessing the results of this study from the hypotheses that have been made, one could say that some hypotheses have been confirmed. It should be expected though that better results regarding the prevention of the onset of smoking would have been obtained if the pupils had already participated in the curriculum during primary school. Studies related to these earlier modules of the curriculum revealed quite promising results (Aßhauer and Hanewinkel, 1999; Hanewinkel and Aßhauer, 1999). Other studies report similar results and recommend beginning as early as possible with the implementation of prevention programmes (Centers of Disease Control and Prevention, 1994; Storr et al., 2002). Moreover, when targeting pupils aged 11 and older, the programmes which focus on smoking might have better effects than more general programmes, because at this age pupils start to experiment with smoking. Kremers et al. (Kremers et al., 2001) investigated the existence of subgroups within the precomtemplation phase of adolescent smoking acquisition. The large group of adolescents situated in acquisition precontemplation might be too diverse to provide accurate and general means of health education. The results indicate the necessity to develop tailored intervention modules for different subgroups of non-smoking pupils.
However, the relative weak outcome effect on smoking variables has nothing to do with the acceptability of the programme by the teachers and the students. A process evaluation revealed that both teachers and pupils had a very positive perception of the curriculum. From the 970 students which were surveyed after the end of the programme, 83.7% said that they enjoyed the lessons, 88.6% stated that they learnt useful things and 64.7% felt that they got closer to the pupils in their class. For the teachers, 94% were of the opinion that non-smoking behavior in non-smokers could be established, 96.3% reported having gained ideas that they would use in their lessons and 90.4% showed interest in continuing with the programme.
Recently, some serious questions have been raised regarding the long-term impact of the social influence and resistance skills approaches. For example, the Hutchinson Smoking Prevention Project, a large longitudinal study (N = 8388) conducted from September 1984 to August 1999, which has delivered Grade 3–12 intervention, could not show any significant difference in the prevalence of daily smoking neither at Grade 12 nor at 2 years after high school (Clayton et al., 2000; Kealey et al., 2000; Mann et al., 2000; Peterson et al., 2000; Sussman et al., 2001). Furthermore, Hansen and Graham (Hansen and Graham, 1991) found that a curriculum designed to correct erroneous normative perceptions regarding smoking was more effective than a curriculum on training resistance skills.
Life-skills programmes may not be the most cost-efficient way to prevent the onset of smoking. While these programmes are well received by teachers and pupils, and are well situated in the school setting, they are very time and personnel consuming. Furthermore, they may not be sufficiently equipped to influence the adolescent’s perceptions of the prevalence and acceptability of tobacco consumption within the wider peer group or the adult society (US Department of Health and Human Services, 2000), especially if they are not part of a comprehensive tobacco control strategy. Maybe programmes are necessary which involve all classes from one school, and in addition involve the family (Storr et al., 2002) and also the outside school sector (Brown et al., 2002) in order to overcome the pro-smoking cultural images and create a new positive image of a non-smoking lifestyle. These strategies do not necessarily have to be complex. One example for involving the whole school is non-smoking class competitions which are becoming more and more popular in Europe (Vartiainen et al., 1996; Hanewinkel et al., 1998; Wiborg and Hanewinkel, 2002).
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Acknowledgements |
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This study was supported by the European Commission within the ‘Europe against Cancer Programme’. We are grateful to Fritz Burow, Théid Faber, Maren Ihnen, Pascale Petry, Hubert Weiglhofer and Gudrun Zander who assisted with the collection of the data, and Gudrun Wiborg for her help with the manuscript.
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References |
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Received on June 10, 2001; accepted on February 27, 2003
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