Research and Resources

Research Articles (Summarized)

Annotated Bibliography of Tobacco Use Prevention Education Research

List of Articles

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Albrecht, S. A., Higgins, L. W., & Stone, C. (1999). Factors relating to pregnant adolescents decisions to complete a smoking cessation intervention. Journal of Pediatric Nursing, 14(5), 322–328.

Allen, O., Page, R. M., Moore, L., & Hewitt, C. (1994). Gender differences in selected psychological characteristics of adolescent smokers and nonsmokers. Health Values: The Journal of Health Behavior, Education and Promotion, 18(2), 34–39.

Altman, D. G., Wheelis, A. Y., McFarlane, M., Lee, H., & Fortmann, S. P. (1999).The relationship between tobacco access and use among adolescents: A four community study. Social Science and Medicine, 48, 759–775.

Aveyard, P., Cheng, K. K., Almond, J., Sheratt, E., Lancashire, R., Lawrence, T., Griffin, C., & Evans, O. (1999).Cluster randomised controlled trial of expert system based on the transtheoretical (“stages of change”) model for smoking prevention and cessation in schools. British Medical Journal, 319(7215), 948–953.

Black, D. R., Tobler, N. S., Siacca, J. P. (1998). Peer helping/involvement: An efficacious way to meet the challenge of reducing alcohol, tobacco, and other drug use among youth. Journal of School Health, 68(3), 87–93.

Botvin, G. J., Baker, W., Dusenbury, L., Botvin, E. M., & Diaz, T. (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association, 273(14), 1106–1112.(GR)

Botvin, G. J., & Botvin, E. M. (1992). Adolescent tobacco alcohol, and drug abuse: Prevention strategies, empirical findings, and assessment issues. Developmental and Behavioral Pediatrics, 13(4), 290–300. (GR)

Bowen, D. J., Kinne, S., & Orlandi, M. (1995). School policy in COMMIT: A promising strategy to reduce smoking by youth. Journal of School Health, 65(4), 140–144.

Brooks, A. J., Stuewig, J., & LeCroy, C. W. (1998). A family based model of Hispanic adolescent substance use. Journal of Drug Education, 28(1), 65–86.

Coleman-Wallace, D., Lee, J.W., Montgomery, S., Blix, G., Want, D. T. (1999). Evaluation of developmentally appropriate programs for adolescent tobacco cessation. Journal of School Health, 69(8), 314–319.

Dalis, G.T. & Dodd, G.R. (2001). The effect of Personal/Social Skills Lessons: The Missing Link in Prevention curricula on urban middle school student tobacco use. American Journal of Health Education, 32, 199–205.

Dent, C. W., Sussman, S., Stacy, A. W., Craig, S., Burton, D., & Flay, B. R. (1995). Two-year behavior outcomes of Project Towards No Tobacco Use. Journal of Consulting and Clinical Psychology, 63(4), 676–677. (GR)

Summary of three related studies: Ellickson & Bell (1990), Bell, Ellickson & Harrison (1993), Ellickson, Bell & McGuigan (1993). (GR)

Ellickson, P. L., & Bell, R. (1990). Drug prevention in junior high: A multi-site longitudinal test. Science, 247, 1299-1305. (GR)

Bell, R. M., Ellickson, P. L., & Harrison, E. R. (1993). Do drug prevention effects persist into high school? How Project ALERT did with ninth graders. Preventive Medicine, 22, 463–483. (GR)

Ellickson, P. L., Bell, R. M., & McGuigan, K. (1993). Preventing adolescent drug use: Long-term results of a junior high program. American Journal of Public Health, 83(6), 856–861. (GR)

Doi, S. C., & DiLorenzo, T. M. (1993). An evaluation of a tobacco use education-prevention program: A pilot study. Journal of Substance Abuse, 5, 73–78.

Eakin, E., Severon, H., & Glasgow, R. E. (1989). Development and evaluation of a smokeless tobacco cessation program: A pilot study. NCI Monograph, 8, 95–100.

Eckhardt, L., Woodruff, S. I., & Elder, J. P. (1997). Relative effectiveness of continued, lapsed, and delayed smoking prevention intervention in senior high school students. American Journal of Health Promotion, 11(6), 418–421.

Edwards, C. C., Elder, F. P., de Moor, C., Wildey, M. B., Mayer, J. A., & Senn, K. L. (1992). Predictors of participation in a school-based anti-tobacco activism program. Journal of Community Health, 17(5), 283–289. (GR)

Elder, J. P., Sallis, J. F., Woodruff, S. I., & Wildey, M. B. (1993a). Tobacco-refusal skills and tobacco use among high-risk adolescents. Journal of Behavioral Medicine, 16(6), 629–642.

Elder, J. P., Wildey, M., de Moor, C., Sallis, J. F., Eckhardt, L., Dewards, C., Erickson, A., Golbeck, A., Hovgell, M., Johnston, D., Levitza, M. D., Molgaard, C., Young, R., Vito, D., & Woodruff, S. I. (1993b). The long-term prevention of tobacco use among junior high school students: Classroom and telephone interventions. American Journal of Public Health, 83, 1239–1244. (GR)

Elder, J. P., Woodruff, S. I., & Eckhardt, L. (1994). Participation in a telephone-based tobacco use prevention program for adolescents. American Journal of Health Promotion, 9(2), 92–95.

Elder, J. P., Woodruff, S. I., Sallis, J. F., deMoor, C., Edwards, C. & Wildey, M. B. (1994). Effects of health facilitator performance and attendance at training sessions on the acquisition of tobacco refusal skills among multi-ethnic, high-risk adolescents. Health Education Research, 9(2), 225–233.

Flay, B. R. (1985). Psychosocial approaches to smoking prevention: A review of findings. Health Psychology, 4(5), 449–488. (GR)

Flay, B. R., Hansen, W. B., Johnson, C. A., Collins, L. M., Dent, C. W., Dwyer, K. M., Grossman, L., Hockstein, G., Raugh, J., Sobel, J. L., Sobel, D. F., Sussman, S., & Ulene, A. (1987). Implementation effectiveness trial of a social influences smoking prevention program using schools and television. Health Education Research: Theory and Practice, 2(4), 385–400. (GR)

Glover, E. D., Wang, M. Q., & Glover, P. N. (1994). Development of a high school smokeless tobacco cessation manual. Health Values: The Journal of Health Behavior, Education and Promotion, 18(2), 28–33.

Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980–1990. Health Education Research, 7(3), 403–430. (GR)

Hansen, W. B., & Graham, J. W. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine, 20(3), 414–430.

Hansen, W., B., Malotte, C. K., & Fielding, J. E. (1988). Evaluation of a Tobacco and Alcohol Abuse Prevention Curriculum for Adolescents. Health Education Quarterly, 15(1), 93–114. (GR)

Herrmann, D. S., & McWhirter, J. J. (1997). Refusal and resistance skills for children and adolescents: A selected review. Journal of Counseling and Development, 75, 177–187.

Higgs, P. E., Edwards, D., Harbin, R. E., & Higgs, P. C. (2000). Evaluation of a self-directed smoking prevention and cessation program. Pediatric Nursing, 26(2), 150–153.

Josendal, O., Aaro, L. E., & Bergh, I. H. (1998). Effects of a school-based smoking prevention program among subgroups of adolescents. Health Education Research, 13(2), 215–224.

Lamb, J. M., Albrecht, S. A., & Serika, S. (1998). Consideration of factors prior to implementing a smoking cessation program. Journal of School Nursing, 14(1), 14–19.

Langlois, M. A., Petosa, R., & Hallam, J. S. (1999). Why do effective smoking prevention programs work? Student changes in social cognitive theory constructs. Journal of School Health, 69(8), 326–331.

McCormick, L. K., Steckler, A. B., & McLeroy, K. R. (1995). Diffusion of innovations in schools: A study of adoption and implementation of school-based tobacco prevention curricula. American Journal of Health Promotion, 9(3), 210–219.

Myers, M. G. (1999). Smoking intervention with adolescent substance abusers: Initial recommendations. Journal of Substance Abuse Treatment, 16(4), 289–298.

Peck, D. D., Acott, C., Richard, P., Hill, S., & Schuster, C. (1993). The Colorado tobacco-free schools and communities project. Journal of School Health, 63(5), 214–217.

Pentz, M. A., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., Hansen, W. B., Want, E. Y. I., & Johnson, A. (1989). A multicommunity trial for primary prevention of adolescent drug abuse: Effects on drug use prevalence. Journal of the American Medical Association, 261, 3259–3266. (GR)

Perry, C. L., Kelder, S. H., Murray, D. M., & Klepp, K. (1992). 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),1210–1216. (GR)

Perry, C. L., Murray, D. M., & Griffin, G. (1990). Evaluating the statwide dissemination of smoking prevention curricula: Factors in teacher compliance. Journal of School Health, 60(10), 501–504. (GR)

Prince, F. (1995). The relative effectiveness of a peer-led and adult-led smoking intervention program. Adolescence, 30(117), 187–194.

Severson, H. H., Glasgow, R., Writ, R., Brozovsky, P., Zoref, L., Black, C., Biglan, A., Ary, D., & Weissman, W. (1991). Preventing the use of smokeless tobacco and cigarettes by teens: Results of a classroom intervention. Health Education Research: Theory and Practice, 6(1), 109–120. (GR)

Sussman, S., Dent, C. W., Stacy, A. W., Hodgson, C. S., Burton, D., & Flay, B. R. (1993a). Project Towards No Tobacco Use: Implementation, process and post-test knowledge evaluation. Health Education Research: Theory and Practice, 8(1), 109–123. (GR)

Sussman, S., Dent, C. W., Stacy, A. W., Sun, P., Craig, S., Simon, T. R., Burton, D., & Flay, B. R. (1993b). Project Towards No Tobacco Use: 1-year behavior outcomes. American Journal of Public Health, 83(9), 1245–1250. (GR)

Sussman, S., Dent, C.W. & Stacy, A.W. (2002). Project Towards No Drug Abuse: A review of the findings and future directions. American Journal of Health Behavior, 26, 354–365. (GR)

Sussman, S., Lichtman, K., Ritt, A., & Pallonen, U. (1999). Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Substance Use and Misuse. (GR)

Thomas, S. M., Fick, A. C., & Henderson, J. A. (1992). Meeting the needs of special populations: A formative evaluation of a school-based smoking prevention program. Journal of the Louisiana State Medical Society, 144(4), 157–161.

Vartiainen, E., Fallonen, U., McAlister, A., & Puska, P. (1990). Eight-year follow-up results of an adolescent smoking prevention program: The North Karelia Youth Project. American Journal of Public Health, 80(1), 78–79.

Wang, M. Q., Fitzhugh, E. C., Eddy, J. M., Fu, Q., & Turner, L. (1997). Social influences on adolescents smoking progress: A longitudinal analysis. American Journal of Health Behavior, 21(2), 111–117.

Weinrich, S., Hardin, S., Valois, R. F. Gleaton, J., Weinrich, M., & Garrison, C. Z. (1996). Psychological correlated of adolescent smoking in response to stress. American Journal of Health Behavior, 20(1), 52–60.

Worden, J. K., Flynn, B. S., Solomon, L. J., Secker-Walder, R. H., Badger, G. J., & Carpenter, J. H. (1996). Using mass media to prevent cigarette smoking among adolescent girls. Health Education Quarterly, 23(4), 453–468. (GR)

Young, R. L., Elder, J., P., Green, M., de Moor, C., & Wildey, M. B. (1988). Tobacco use prevention and health facilitator effectiveness. Journal of School Health, 58(9), 370–373.

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Article Summaries

Albrecht, S. A., Higgins, L. W., & Stone, C. (1999). Factors relating to pregnant adolescents' decisions to complete a smoking cessation intervention. Journal of Pediatric Nursing, 14(5), 322-328. This study examined differences between pregnant adolescent girls who completed a smoking cessation program and those who decided not to complete the program. The researchers examined variables such as personal characteristics (e.g., age, race, anxiety level, school attitudes, attitudes, toward smoking, and duration of smoking), familial characteristics (e.g., parental smoking behavior, and parental attitudes toward smoking), and peer influences (e.g., number of friends who smoke, and friends' attitudes toward smoking). The sample consisted of 53 pregnant teenagers. The girls ranged in age from 14 - 20 years old, with a mean age of 17.32. Students in sample were primarily African-American (49.1%) and White (43.4%), with four participants (7.5%) from other ethnic groups. All of the adolescents were enrolled in Teen FreshStart (TFS) Smoking Cessation Program developed by the American Cancer Society. The program consisted of 8 weekly sessions, each lasting approximately 50 minutes. Participants received information about (1) normal variations of pregnancy, (2) signs of complications (including those related to smoking during pregnancy), (3) effects of second-hand smoke, (4) relaxation techniques, and (5) labor and delivery. Results: The researchers found significant differences on a number of variables in the study. Pregnant adolescents who completed the smoking cessation program were younger, had smoked for a shorter period of time, and perceived greater parental disapproval of smoking. African American adolescents were also more likely than were the White teens to complete the cessation program. This finding may be confounded with nicotine dependence however, as African American teens also smoked fewer cigarettes per day. Their success may have been due to less nicotine dependence at program onset. The researchers also reported a trend in the data suggesting that the adolescents who were more successful in completing in completing the program held more positive religious attitudes (however this finding was not statistically significant).

Allen, O., Page, R. M., Moore, L., & Hewitt, C. (1994). Gender differences in selected psychological characteristics of adolescent smokers and nonsmokers. Health Values: The Journal of Health Behavior, Education and Promotion, 18(2), 34-39. This study examined the interactive effects of smoking status and gender on four psychosocial characteristics (shyness, sociability, loneliness, and hopelessness) among 1,915 adolescents. Student participants came from randomly selected high schools in a central Mississippi county. The gender distribution of the sample was fairly equal; males represented 48.8% and females, 51.2%. The majority of the students were White (73.1%), with 24.9% African-American, and 2% were from other ethnic groups. Students completed a survey in their homeroom classes, which included scales for shyness, loneliness, sociability, and hopelessness, as well as tobacco usage. The results indicated that adolescent male smokers are more likely to have low self-concept, lack coping skills, and report elevated scores for anxiety, loneliness and depression. Conversely, young female smokers are more likely to be to be socially competent and self-confident, and perceive smoking to be a social asset. These findings imply that perhaps current smoking prevention programs stressing social skills training and self-esteem enhancement may not be optimal for adolescent females, and that there is possible benefit to providing a program that includes different skills and information useful to both genders.

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Altman, D. G., Wheelis, A. Y., McFarlane, M., Lee, H., & Fortmann, S. P. (1999). The relationship between tobacco access and use among adolescents: A four community study. Social Science and Medicine, 48, 759-775. Researchers in this study examined the effect of a 3-year comprehensive community intervention aimed at reducing tobacco sales to minors, as well as decreasing adolescents use of tobacco products. The study was conducted in four rural communities in Monterey County, CA. These four communities were randomized into treatment and control conditions in the study. During the course of the program, a variety of interventions were implemented in the treatment communities (e.g., community education, merchant education, and voluntary policy change). County health department staff and 14 teenagers were involved in presenting educational messages and materials to city councils and local merchants. The goal of merchant education was to (1) increase awareness of the problem, (2) educate merchants regarding the laws and penalties associated with sales of tobacco products to minors, (3) illustrate community norms, which were against such sales to minors, and (4) demonstrate methods merchants could use to reduce sales to minors. Community education involved press releases, newspaper articles and editorials, community forums, community fairs, and mass mailings. The goal of the community education program was to increase awareness of the problem and seek community participation in the project. Middle and high school students in each of these communities completed surveys regarding their tobacco purchases and use of tobacco products. Results: The treatment program had a significant effect on the sales of tobacco products to minors. In the treatment communities, the proportion of stores selling tobacco to minors dropped from 75% (as measured in the pre-test) to 0% (at the post test). Those communities in the control condition had sales of 64% and 39%, respectively. The study also provides some evidence that reducing tobacco sales to minors lowers tobacco use among some adolescents. The treatment effect was strongest for the younger students (7th graders). The intervention did not significantly impact tobacco use among older students (9th and 11th grades) although the trends were in the predicted direction of 9th graders. The older youth reported still being able to obtain tobacco from other sources, despite the change in policies at local commercial outlets. A significant intervention effect was found for gender females in the intervention communities were less likely to use tobacco post-intervention than females in the comparison communities. The researchers conclude that tobacco sales to minors can be reduced through a broad-based intervention. However in order to reduce tobacco use by youths, a program would need to focus on other methods of supply as well as additional interventions with the teens themselves. Finally, although the program employed 14 adolescents as student advocates, the researchers did not evaluate the outcomes of participation for the students who served in this role.

Aveyard, P., Cheng, K. K., Almond, J., Sheratt, E., Lancashire, R., Lawrence, T., Griffin, C., & Evans, O. (1999). Cluster randomised controlled trial of expert system based on the transtheoretical ("stages of change") model for smoking prevention and cessation in schools. British Medical Journal, 319(7215), 948-953. This study evaluates the effectiveness of a smoking prevention and cessation program that used individualized computer sessions along with classroom instruction based on the trans-theoretical model of behavior change. The participants in the program were 8,352 students from 52 schools in the West Midlands region on the United Kingdom. The students were in their 9th year on school (i.e., 13-14 year olds). The treatment program involved three class lessons, as well as three sessions using interactive computer-based follow-up lessons. A control group was exposed only to health education as part of the English national curriculum. Of the 8,352 students recruited, 7,444 (89.1%) were followed up at 12 months. Results: The researchers found that the program had no effect on the smoking prevalence among the participants when compared to the students in the control group. The researchers report finding no evidence supporting the advantages of the program's theoretical basis or the use of computer sessions. This article is one of few that use a computer-based technology to implement a tobacco use prevention program. These findings suggest that the program, not necessarily the computer component, may have contributed to the lack of positive outcomes.

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Black, D. R., Tobler, N. S., Siacca, J. P. (1998). Peer helping/involvement: An efficacious way to meet the challenge of reducing alcohol, tobacco, and other drug use among youth. Journal of School Health, 68(3), 87-93. This meta-analysis reviewed the results of 120 drug prevention programs that concurrently addressed the use of alcohol, cigarettes, cannabis, and other illicit drugs. Most studies were conducted with children in grades six to eight and were targeted at the general student population. Cigarette and Other Drug Use Results: Interactive programs were superior to non-interactive programs in preventing cigarette, alcohol, cannabis, and other illicit drug use. Interactive programs were defined as Social Influences, Comprehensive Life Skills and others that focused on: interpersonal competence, knowledge about short- and long-term consequences of drug and prodrug influences, drug refusal skills taught under realistic conditions to build confidence, and challenging perceptions of drug use via local statistics. Interactive programs that included the components above and combined strengthening personal competence and intrapersonal functioning, self-esteem building, decision making, coping skills, and public commitment activities were also superior to non-interactive programs. The researchers conclude that the most effective programs dispel the myth that everyone is using drugs by including components that acquaint participants with local statistics, teach drug refusal skills under conditions that can be transferred and used in real life situations, and present the negative consequences (e.g., physical, social, emotional, and economical problems) of using drugs. The delivery method that was most effective was not didactic, but highly interactive and participatory. The length of 68% of the interactive programs was only 6 hours and produced behavior changes.1 Programs of 18 hours did only marginally better. However, researchers note that the "dose-response" relationship needs further research. Peer Leaders Results: The effect sizes for interactively delivered drug use prevention programs were equivalent for teacher, peer, and other leaders, and especially high for delivery by mental health clinicians. However, all leaders, regardless of educational level, need to be trained to be effective facilitators and peer helpers. In particular, the researchers cited one model study relevant to the efficacy of peer leaders delivering tobacco use prevention programs. As described in this review article, research by Botvin et al (1984) found that peer-led programs had a greater impact than teacher-led and control groups on cigarette use, knowledge and attitude measures, as well as on locus of control and ability to influence smoking. Researchers note that in this study teachers received no monitoring or assistance. Conversely, peer leaders were trained and the research staff monitored their programs. The researchers conclude that drug use prevention programs using peer leaders should comply with the National Peer Helpers Association (NPHA) standards including comprehensive peer leader training focusing on the consequences of drug use, the role of the peer helper, listening and communication skills, problem solving and decision making strategies, provision of local drug use norms, and classroom management skills. Peer leaders should receive on-going supervision. Prior to program implementation careful planning should take into account the rationale, purpose, goals and objectives of the program, and students should be screened carefully to identify potential peer leaders who are helpful, trustworthy, concerned for others, good listeners, and positive role models.

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1The researchers note a comparison to medical research that may be a useful piece of information: "The difference of 8.5% change between the interactive and non-interactive programs is important, especially when compared to the use of medicine such as aspirin to treat coronary heart disease. ...(in) double-blind studies on the effects of aspirin and heart disease, the success rate among the 22,000 physicians who had participated in the study was only 3.5%. This percentage is less than half of the change produced by peer drug prevention programs. Yet, authors of the medical study on aspirin and heart disease concluded that it was unethical not to offer aspirin to the control group because of the reduction in heart attacks. If similar logic were applied to drug use, it seems it would be unconscionable not to advocate a peer-led program as a viable option for drug reduction or prevention." (p. 90)

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Botvin, G. J., Baker, W., Dusenbury, L., Botvin, E. M., & Diaz, T. (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association, 273(14), 1106-1112. (GR) This study examined the long-term (six year) impact of a junior high school tobacco, alcohol and marijuana use prevention program (Life Skills Program) derived in part from social learning theory. The program included 15 sessions in 7th grade, 10 booster sessions in 8th grade, and five booster sessions in 9th grade. Content emphasized general life skills (such as resisting advertising pressure, managing anxiety, and communicating effectively) as well as specific skills for resisting social influences to use tobacco, alcohol, and marijuana. Impact was assessed for 56 public schools implementing the program and for those schools with highest implementation fidelity. The program was implemented by regular classroom teachers with either one-day inservice or two-hour video training. Impact analyses were conducted for regular and high fidelity program implementation. Participating students were predominantly white middle class. Tobacco Results: Regular implementation: Four of six analyses showed statistically reliable lower levels (p<.05) of tobacco use by 12th grade students exposed to the program in junior high school compared to control group students. High fidelity implementation: Six of six analyses showed statistically reliable lower levels of tobacco use by 12th grade students exposed to high fidelity program implementation in junior high school. Alcohol Results: Regular implementation: Only two of eight analyses showed lower levels of alcohol use (drunkenness measure: getting drunk one or more times per month) by 12th grade program students compared to control group students. High fidelity implementation: Seven of eight analyses showed lower levels of alcohol used (monthly, weekly, 3+ drinks, and drunkenness measure) by 12th grade program students exposed to high fidelity program implementation in junior high school compared to control group students. Marijuana Results: Regular implementation: No results (zero of four analyses) showed statistically reliable differences in marijuana use between 12th grade program and control group students. High fidelity implementation: Three of four analyses showed statistically reliable lower levels of marijuana use by 12th grade students exposed to the high fidelity program implementation in junior high school compared to control group students. Polydrug Results: Regular implementation: Two of four analyses showed statistically reliable lower levels of polydrug use (cigarette smoking, alcohol use, and marijuana use) by 12th grade program students compared to control group students. High fidelity implementation: Three of four analyses showed statistically reliable lower levels of polydrug use by 12th grade students exposed to the high fidelity program implementation in junior high school compared to control group students. Summary: Regular program implementation results indicate weak to good long-term (6 year) impact of the junior high school program on students tobacco, alcohol and polydrug use, and no impact on marijuana use. When the program was implemented with high fidelity, the results indicate a strong, consistent six-year impact on 12th grade students' tobacco, alcohol, marijuana and polydrug use compared to control group students. Researchers suggest the empirically demonstrated longterm positive impact is due to (a) the strong intervention dosage (15 sessions during the primary year of intervention with 15 booster sessions over two additional years), (b) program implementation fidelity, and (c) program content targeting social influences promoting drug use combined with resistance skills and general "life skills" to enhance individual competence and reduce vulnerability to drug use.

Botvin, G. J., & Botvin, E. M. (1992). Adolescent tobacco alcohol, and drug abuse: Prevention strategies, empirical findings, and assessment issues. Developmental and Behavioral Pediatrics, 13(4), 290-300. (GR) This overview article summarizes the etiology of drug abuse concluding that social and psychological factors (e.g., illusion of control, significant others, popular media, individual psychological characteristics, cognitive development and identify formation) appear to be primarily responsible for the initiation of substance use, with pharmacological factors becoming increasingly important in maintaining use. Social Learning Theory and Problem Behavior Theory are described as a basis for developing effective tobacco use prevention strategies. Two prevention strategies are detailed: (1) the Social Influences Approach involves (a) making students aware of the social influences promoting use that they might be exposed to, (b) teaching specific skills (e.g., refusal skills) with which to resist those influences, and (c) correcting misperceptions of social norms regarding use (e.g., making students aware that most adults and adolescents do not smoke cigarettes. (2) The Personal and Social Skills Approaches typically include two or more of the following types of skills trainings: (a) probleml-solving and decision-making skills, (b) cognitive skills for resisting negative social influences (e.g., formulating counterarguments to the messages in cigarette ads), (c) skills for increasing self-control and self-esteem (e.g., self-instruction, self-reinforcement, goal setting, principles of self-change), (d) adaptive coping strategies for relieving stress and anxiety through the use of cognitive coping skills or behavioral relaxation techniques, (e) interpersonal skills (e.g., initiating social interactions, complimenting conversational skills), and (f) assertive skills (requests, refusals, expressing feelings and opinions). Researchers note that the intent of personal and social skills approaches are to teach general skills for coping with life, but where appropriate the application of these skills to specific situations (e.g., tobacco use) is emphasized. Tobacco Results: Researchers conclude that research indicates that both the Social Influences and the Personal Social Skills approaches have demonstrated statistically reliable reductions in smoking behavior (especially the incidence of new smoking). They note that the Personal and Social Skills Approaches show somewhat stronger results, but that these programs also tend to be more comprehensive and longer length than the Social Influences. They also report that the program effects tend to decay over time, suggesting the need for ongoing intervention throughout much of adolescence.

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Bowen, D. J., Kinne, S., & Orlandi, M. (1995). School policy in COMMIT: A promising strategy to reduce smoking by youth. Journal of School Health, 65(4), 140-144. Organizational smoking policies have has been identified, as a possibly effective way to influence health behavior of the persons working or attending schools at those organizational sites. Data for this study were collected through the Community Intervention Trial for Smoking Cessation (COMMIT), a seven-year multi-center cooperative research project interested in increasing smoking cessation rates, particularly among heavy smokers. Two hundred thirty-nine schools were surveyed as part of the COMMIT project in 1991. Schools were questioned about their school smoking policies, rate of compliance with those policies, and resources available to promote smoking cessation programs. The majority of those personnel responding to the school survey were principals at the sites (70%). Three types of school policies were identified based on reports from the schools: (1) a complete ban on smoking on the school grounds, (2) smoking allowed outside the building but on school grounds, and (3) smoking allowed in an indoor designated smoking area. Results: The stringency of the policy varied by the age of the students in the school. Schools with younger students reported more restrictive policies. All elementary schools surveyed, reported banning smoking on school grounds. High schools and college were more likely to report less restrictive policies. High schools and colleges were also more likely to allow smoking at after-school functions, than were the elementary schools surveyed. Existing policies that differ by grade level provide conflicting messages about the appropriateness of smoking. In general, the authors of the article found that resources to support existing policies are also lacking. Many schools (over 50%) offer classes on knowledge of the negative health effects of smoking, but fewer than half of the schools teach the psychosocial skills necessary to resist tobacco use. Less than 20% of the high schools offered any smoking cessation courses.

Brooks, A. J., Stuewig, J., & LeCroy, C. W. (1998). A family based model of Hispanic adolescent substance use. Journal of Drug Education, 28(1), 65-86. The authors of this study emphasize that while there has been considerable research over the last few decades on adolescence substance use, Hispanic adolescent substance use has received only limited attention. Studies exploring predictors of Hispanic adolescent substance use have failed to adequately address the contribution of the family on teens' substance use. This study examined the relative influence of family, school and peers variables on student substance use among Hispanic early adolescents. Participants in the study were 413 Mexican-American early adolescents from two low-income middle schools in a large Southwestern city. The students' ages ranged from 11-15 (with a mean of 12.7 years). The sample was composed of 53% males, and 47% females. Students completed questionnaires addressing such factors as, acculturation, family cohesion, conflict, involvement and substance use, peer attachment and affiliation, and school attachment, involvement, and achievement. The researchers used structural equations program to create a model demonstrating the relationships between the different variables. Results: The findings varied for males and females, and the researchers created models for the two genders that show different strengths between the factors. Family functioning and family substance use directly influenced substance use for males. Family functioning influenced school and peer variables for the males, however these factors were unrelated to the students' substance use. For females, family functioning influenced family use, and school and peer attachments. School and peer attachment predicted perceived student use. While the family influence on young adolescent girls substance use is more indirect, both the male and female models suggest family substance use may have a primary role in influencing Hispanic students' tobacco use. This research suggests the possible efficacy of family involvement strategies with this population.

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Coleman-Wallace, D., Lee, J.W., Montgomery, S., Blix, G., Want, D. T. (1999). Evaluation of developmentally appropriate programs for adolescent tobacco cessation. Journal of School Health, 69(8), 314-319. This quasi-experimental study evaluated two programs based on the stages of change model. The educational program, Tobacco Education Group (TEG), was intended for adolescents who are not yet thinking about quitting. The cessation program, Tobacco Awareness Program (TAP), was intended for adolescents who want to quit. The programs consisted of eight, one-hour sessions designed for small groups of eight to 12 adolescents with an adult facilitator. TEG was designed to motivate tobacco users to have the desire to quit using tobacco and addressed the following components: personal reasons for smoking or chewing tobacco, pressures to use tobacco, demonstrations of short-term consequences of tobacco use, and discussions of long-term consequences of tobacco use. TAP was designed for adolescents who desire to quit using tobacco and addressed the following components: short-term and long-term consequences of smoking, triggers to tobacco use and coping strategies, pitfalls to be expected during and after quitting, use of culturally sensitive materials, and individual choice of methods. TAP also addressed weight management. Trained facilitators implemented the programs. The control group was comprised of adolescent smokers who did not attend either program. TEG was conducted during lunch time as punishment for using tobacco in violation of the tobacco-free school policy. Students wanting to quit tobacco use attended the TAP cessation program during a regular class period. Participants average age was 15.5 years, with 12 years reported as the average age of smoking initiation. More girls voluntarily participated in TAP (55%) than were required to attend TEG (29%). Results: At the end of the program participants in both TEG and TAP significantly reduced the amount of cigarettes used daily, while controls did not decrease smoking. Self-efficacy was predictive of end-of-program use for both TEG and TAP programs. Self-efficacy, close friends, and family influence combined explained about half of the variance in tobacco use for TAP participants (while controlling for initial use) and about 24% of the variance in tobacco use among TEG participants.

Dalis, G.T. & Dodd, G.R. (2001). The effect of Personal/Social Skills Lessons: The Missing Link in Prevention curricula on urban middle school student tobacco use. American Journal of Health Education, 32, 199-205. This study evaluated the effectiveness of the Personal/Social Skills Lessons on 7th and 8th grade students' tobacco-related behaviors and behavioral intentions over 2 years. Twenty teachers in 10 urban and suburban Los Angeles County middle schools were matched and randomly assigned to experimental or control groups. During the first year, teachers assigned to the intervention group received a 6-hour curriculum training and were instructed to teach 6 of the 8 curriculum lessons. Teachers assigned to the control group were instructed to teach a minimum of 6 tobacco use prevention lessons from the curriculum normally used by their district. During the second year, an additional skill lesson was added to the curriculum. Teachers received a 2-hour curriculum training and were instructed to teach a minimum of 5 of the 9 curriculum lessons. Data were collected before implementation and 2 to 6 weeks following completion of the lessons each year using an anonymous student survey. Teachers were observed once during the study period to assess program fidelity. Data analyses were conducted for students' in classrooms that 1) received the program with fidelity based on classroom observations and 2) 64% or more of these students learned the skills taught based on student proficiency evaluations. Among students who received the curriculum for 2 years, positive significant findings were found for the quantity of cigarettes smoked within the past 7 days and the frequency of combined use of alcohol and tobacco. Among students who received the curriculum in 8th grade only, positive significant findings were found for quantity of cigarettes smoked in the past 24 hours and the quantity of chewing tobacco/snuff used in the past 24 hours.

Dent, C. W., Sussman, S., Stacy, A. W., Craig, S., Burton, D., & Flay, B. R. (1995). Two-year behavior outcomes of Project Towards No Tobacco Use. Journal of Consulting and Clinical Psychology, 63(4), 676-677. (GR) This study examined the relative effectiveness of three tobacco use prevention strategies designed to counteract: (a) normative social influence (yielding to peer pressure to achieve acceptance; e.g., refusal assertion skills training); (b) informational social acceptance (social image misperceptions of tobacco; e.g., correction of tobacco use prevalence overestimation), and (c) misperceptions regarding physical consequences of tobacco use. The programs were presented in 7th grade, with a booster session tied to the original curriculum in 8th grade. Sixty percent of the students were White, 27% Hispanic, 7% Black, and 6% Asian or other. Two-year follow up data on trial and weekly cigarette and smokeless tobacco use were collected. Results: The combined curriculum (all three strategies together) showed significantly less trial and weekly cigarette use than the control condition, but no impact on smokeless tobacco use. Each of the separate prevention strategies showed significantly less trial cigarette use, but no impact on weekly cigarette use. In addition, the physical consequences curriculum alone showed significantly less trial and weekly smokeless tobacco use. The researchers conclude that multi-component tobacco prevention program was most effective in reducing cigarette use. The physical consequences curriculum was effective at reducing smokeless tobacco use, they note may contradict previous research which found social influences programs to be superior to physical consequences programs. They note that the present physical consequences curriculum included several novel features, such as correcting myths about tobacco experimentation and addiction, role-playing that one has a disease, and presenting probabilities of consequences information in ways more personally relevant to youths.

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Summary of three related studies: Bell, Ellickson & Harrison (1993), Ellickson & Bell (1990), Ellickson, Bell & McGuigan (1993). (GR) These three studies evaluated the 3-, 12-, 15-, 24-, 36-, and 60-month impact of Project ALERT, a 7th 8th grade social influence tobacco, alcohol, and marijuana use prevention curriculum in 30 public schools (including 9 schools with greater than 50% ethnic minority enrollment). Curriculum is comprised of eight 7th grade lessons and three 8th grade booster lessons. Self-report targeted substance use data was presented separately for three groups of students for each substance (baseline nonusers, experimenters, baseline users), and for two program conditions (program presented by teacher only, program presented by teacher with assistance of teen leaders) in comparison to control groups which did not receive the program. Summary of the results of three studies: Only ten percent of the analyses showed statistically significant differences between students receiving the program and to control group students. The results, therefore, should be interpreted with caution and warrant further study. The results suggest that the social influence approach as implemented in Project ALERT--especially when taught by teen leaders together with teachers--may reduce the likelihood of tobacco and marijuana use by 7th-8th grade students who have never used or have only experimented with these drugs. Conversely, the program may have a negative effect on 7th-8th grade students who are regularly using tobacco or marijuana, suggesting that alternative interventions such as readiness for cessation and cessation programs may be more appropriate for these students. The program showed no reliable impact on 7th-8th grade student alcohol use. Moreover, initial program impact on tobacco and marijuana use decayed before the end of high school, leading the researchers to conclude that ". . . teenagers need continued and strong reinforcement to resist drugs (or other high risk behavior) during the high school years . . ." and to call for research designed to determine what approaches are effective with older teens. The detailed results of the three studies are presented below:

Ellickson, P. L., & Bell, R. (1990). Drug prevention in junior high: A multi-site longitudinal test. Science, 247, 1299-1305. (GR) Alcohol Results: Two of 54 program/control comparisons showed positive program results (at p<.05) for nonusers in the teen-leader condition reporting significantly lower levels of alcohol use ever and in the past month than control group. One other significant result showed negative program impact with baseline experimenters reporting higher prior-month use than controls one year after program. Tobacco Results: Twelve of 64 program/control comparisons showed significant results at p<.05. Seven of these comparisons showed baseline cigarette experimenters reporting significantly lower levels of tobacco use and higher levels of quitting in the teen-led condition and teacher-only conditions. In contrast, five analyses demonstrated higher levels of tobacco use by baseline users in the program conditions compared to control group. Marijuana Results: Six of 46 program/control comparisions were significant at the .05 level. Baseline nonusers in both program conditions (teacher-only and teen-leader) showed significantly lower rates of marijuana use initiation one year after 7th grade program than control groups. Summary: The overall findings of this study showed small substance use differences between program and control students. Only ten percent (15) of the 164 program/control comparisons in this study showed statistically significant positive program impact. Four percent (6) of the analyses showed negative program impact. The results indicate no reliable program impact for student alcohol use. Results suggest positive program impact on the tobacco use levels of baseline experimenters. Conversely results suggest possible negative program impact on the tobacco use levels of baseline tobacco users. Results also suggest positive program impact on marijuana use levels of baseline nonusers.

Bell, R. M., Ellickson, P. L., & Harrison, E. R. (1993). Do drug prevention effects persist into high school? How Project ALERT did with ninth graders. Preventive Medicine, 22, 463-483. (GR) Cognitive Results: In some analyses, lower-risk students (i.e., baseline non-users and experimenters) in the teen-leader condition demonstrated cognitions (e.g., perceptions of social consequences and normative perceptions) consistent with avoiding tobacco and other drug use. Higher-risk students and students in the teacher-only condition generally showed no differences or (in some analyses) significantly more pro-drug cognitions than students in the control condition. Students in program conditions showed significantly stronger (p<.05) resistance self-efficacy (RSE) in only three of 36 program/control comparisons. This RSE impact occurred in lower-risk students in the teen leader condition. No program condition demonstrated impact on students' expectations to use alcohol, tobacco or marijuana in the next 6 months. Behavioral Results: Only two of 78 program/control comparisons showed significant differences in tobacco, alcohol or marijuana use two years after the 7th grade program. These results could occur by chance. Therefore the data provide unreliable evidence of impact on students' future substance use. Summary: This study provides limited evidence that 24-months after receiving a 7th grade social-influence tobacco, alcohol, marijuana prevention program presented by teen-leaders, lower-risk students demonstrated higher levels of anti-drug use cognitions compared to similar students in the control group. Higher-risk students, and students receiving programs presented by teachers without teen leaders showed few differences in anti-drug cognitions, and some higher levels of pro-drug cognitions compared to control group. No program condition demonstrated behavioral impact 24-months after baseline.

Ellickson, P. L., Bell, R. M., & McGuigan, K. (1993). Preventing adolescent drug use: Long-term results of a junior high program. American Journal of Public Health, 83(6), 856-861. (GR) At 24-, 36, and 60- months (grades 9, 10, and 12) after receiving the Project ALERT tobacco, alcohol and marijuana use prevention curriculum in 7th grade (with three booster sessions in 8th grade), initial limited cognitive and behavioral differences between program and control students had generally eroded. Some anti-drug cognition differences were sustained somewhat longer (up to 36 months) than behavioral differences, but had disappeared by 60 months after the program.

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Doi, S. C., & DiLorenzo, T. M. (1993). An evaluation of a tobacco use education-prevention program: A pilot study. Journal of Substance Abuse, 5, 73-78. The authors of this study describe a pilot program designed to implement a psychosocial approach to prevention of cigarette and smokeless tobacco use with middle school age students. Participants in the study were 146 seventh-grade students from two rural mid-Missouri schools. One school was assigned to the treatment condition, and the other served as a control. The program consisted on approximately 5-hours of prevention curriculum presented in one-hour sessions over a 12-day period. The prevention program was presented by 11th and 12th grade peer leaders who had received an 8-hour training session. Program intervention consisted of oral and video presentations, and addressed parent, peer, and media influences on tobacco use, as well as teaching refusal skills for resisting social pressures to smoke or chew tobacco. Program effectiveness was examined in terms of three variables: knowledge (basic knowledge about tobacco facts), refusal skills (degree of self-reported assertiveness in refusing to use tobacco), and attitude (positive and negative attitudes toward tobacco). These variables were assessed before and after the implementation of the program, and in a 1-month follow-up assessment. Results: It was found that students in the treatment group of the program reported increased knowledge and improved resistance skills regarding the use of tobacco, when compared to those students in the control group. Attitudes toward tobacco were initially negative in both of the groups and did not change over the course of the intervention. A one- year follow-up assessment was conducted on the treatment group and the program effects of both knowledge and refusal skills were maintained. This study suggests the effectiveness of both a comprehensive tobacco-use prevention education that includes both accurate information and knowledge on social influences, as well as lending credence to the use of trained peer-facilitators.

Eakin, E., Severon, H., & Glasgow, R. E. (1989). Development and evaluation of a smokeless tobacco cessation program: A pilot study. NCI Monograph, 8, 95-100. This study is a multicomponent, cognitive-behavioral intervention program designed to decrease smokeless tobacco use among chronic adolescent users. The participants were 25 adolescent male users of smokeless tobacco who were referred to the program by counselors, health teachers, coaches, and dentists. The participants ranged in age from 14-18 years old, and had used smokeless tobacco for an average of 3 years. The average number of dips per day at the initial baseline measure was 5.78 (SD =3.1). The treatment program consisted of three small group meetings over a period of four weeks. At these group sessions, participants watched a video, engaged in discussions of the health risks of smokeless tobacco and learned coping skills to help them with cessation. In addition, participants engaged in self-monitoring of smokeless tobacco use, and received 8 follow-up phone contacts with counselors in the program. Saliva samples (monitoring for cotinine) were obtained as verification of participants self-reports of smokeless tobacco use, and information about participant characteristics was collected by survey at the start of the program and again at a 3-month follow-up assessment. Results: Twenty-one of the 25 subjects completed the treatment program. Nine participants were abstinent at the conclusion of the program, and 4 remained successful in quitting at the 3-month follow-up. Those participants who did not achieve complete abstinence reported substantial reductions in their smokeless tobacco use. The researchers found no increase in cigarette smoking among the program participants as a result of reducing or quitting use of smokeless tobacco. However, those participants who were successful in achieving cessation had used smaller amounts of smokeless tobacco at the onset of the program, and were more likely to be involved in school athletics. When discussing the relative merits of the different elements of the program, the authors report that the telephone contacts were considered to be one of the most powerful components of the treatment program.

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Eckhardt, L., Woodruff, S. I., & Elder, J. P. (1997). Relative effectiveness of continued, lapsed, and delayed smoking prevention intervention in senior high school students. American Journal of Health Promotion, 11(6), 418-421. This study reports on the final year of the Project S.H.O.U.T. ( Students Helping Others Understand Tobacco) and examines the relative effectiveness of continued, lapsed, and delayed smoking prevention interventions. Project S.H.O.U.T. initially began as a school-based tobacco-use prevention education program at 22 junior high schools in San Diego County. These schools were randomly assigned to either a control or treatment condition. A total of 2,668, 7th through 9th graders participated. The ethnic breakdown of the sample was 59% White, 24% Hispanic, and 17% of other ethnic groups. Forty-six percent of the students were male, 54% were female. The students in the treatment program received 18 classroom lessons in 7th and 8th grade, which focused on refusal skills training, recognizing media influences, learning about addiction to and cessation from tobacco products, and discussion of normative perceptions. The program was facilitated by college-age, peer-leaders who had received 15 hours of training. The intervention was reintroduced in the 11th grade to one-half of treatment students (continued intervention group), was withdrawn from the other half (lapsed intervention group), and was initiated with one-half of control students (delayed intervention group). The smoking rates of these three groups at 11th grade were compared to those of a fourth group, a continued control group. Results showed that continued intervention students reported smoking significantly less during the previous month, than did continued control students. The continued intervention students also had a lower smoking rate than did the lapsed intervention group, but the difference was not statistically significant. The delayed intervention group exhibited smoking rates lower than the lapsed intervention and continued control groups as well, but again the findings were not statistically significant. The authors of the study suggest that their findings "underscore the importance of continuing smoking prevention activities, as well as initiating these activities, in senior high school years." Certainly, their findings suggest a trend in that direction, however some findings are comparatively weak. A continued comprehensive intervention program does appear to have a significant effect on smoking rate when compared to no treatment.

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Edwards, C. C., Elder, F. P., de Moor, C., Wildey, M. B., Mayer, J. A., & Senn, K. L. (1992). Predictors of participation in a school-based anti-tobacco activism program. Journal of Community Health, 17(5), 283-289. (GR) This study examined the factors associated with the voluntary participation of 7th grade students from 10 schools in an extra-curricular anti-tobacco activism program, Project S.H.O.U.T., provided as a voluntary adjunct to an in-class tobacco prevention program. The study also examined whether participation factors predicted student use of tobacco. The activism activities included letter and petition writing, anti-tobacco poster contests, merchant education, peer surveys and magazine subscription cards. All of the activism activities involved identifying a tobacco-related social problem and suggesting alternatives or solutions. Activism Results: Students with a high SES and living in a rural location were more likely to participate in the activism activities (p<.01). Tobacco Results: Male gender, low grades, Anglo ethnicity, friends tobacco use and parents' tobacco use were all statistically related with "ever use" of tobacco (p<.05). Variables associated with "ever use" were not associated with participation in activism. Summary: Researchers suggest that the anti-tobacco activism activities elicited participation more from low-risk than high-risk adolescents.

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Elder, J. P., Sallis, J. F., Woodruff, S. I., & Wildey, M. B. (1993). Tobacco-refusal skills and tobacco use among high-risk adolescents. Journal of Behavioral Medicine, 16(6), 629-642. This study examined the effects of a comprehensive tobacco-use prevention program on 389 "high-risk" adolescents. These students were a subgroup of Project S.H.O.U.T. (Students Helping Others Understand Tobacco). This project initially began as a school-based program at 22 junior high schools in San Diego County. The students in this treatment program received 16 classroom lessons in 7th and 8th grade, from college-age peer-facilitators, which focused on refusal skills training, recognizing media influences, learning about addiction to and cessation from tobacco products, and discussion of normative perceptions. In 9th grade, students received follow-up telephone calls and newsletters from the treatment program staff. Students in the high-risk subgroup were chosen based on two criteria: (1) having had previously experimented with tobacco use (although used it only once a month at the baseline data collection), and (2) family or peer tobacco use, and school performance. The S.H.O.U.T. subgroup of 389 students ranged in age from 11-15 years old (with a median age of 12.2 years). About half of the group was White, 26% Hispanic, and 23 of other racial/ethnic groups. The subgroup was balanced for gender, S.H.O.U.T. treatment condition, and risk status. Results showed that the comprehensive prevention program produced a favorable trend in delaying or preventing the onset of tobacco use during the course of the 3-year program for this high-risk group, but the finding was not statistically significant. An even more unexpected finding is that quality of refusal skills was not related to overall tobacco use at any grade for these high-risk students. The authors describe how direct behavioral measures of refusal skills were collected as part of the assessment, by having subjects respond to audiotaped offers of tobacco. Then the quality of the students' responses were rated. The authors suggest a number of explanations for their findings. The refusal skills appropriate to teach a 12-year old may no longer be useful to a 14 or 15 year old. Moreover, the natural environment, can be more complex than the classroom, and hence the demands more persuasive.

Elder, J. P., Wildey, M., de Moor, C., Sallis, J. F., Eckhardt, L., Dewards, C., Erickson, A., Golbeck, A., Hovgell, M., Johnston, D., Levitza, M. D., Molgaard, C., Young, R., Vito, D., & Woodruff, S. I. (1993). The long-term prevention of tobacco use among junior high school students: Classroom and telephone interventions. American Journal of Public Health, 83, 1239-1244. (GR) This study evaluates the effectiveness of a junior high tobacco use prevention program, Project S.H.O.U.T., over a three year period. In 7th and 8th grade students in 11 schools received an in-class curriculum presented by trained college students. The curriculum included social influence components such as resisting peer pressure, decision-making and learning the antecedents and social consequences of tobacco use. It also included activism activities such as writing to tobacco companies, community action projects, and learning methods to encourage parents and others to quit smoking. In 9th grade program students received the booster intervention in which they received five newsletters and two personalized telephone calls per semester by trained college students, which included refusal skills, tobacco news, and tobacco cessation; and ended with a plug for a local free cessation help line. During this year the parents of program students also received two newsletters. Tobacco Results: At the end of 7th grade and 8th grade (classroom interventions) there were no statistically significant differences in tobacco use between program and control group students. At the end of 9th grade (newsletter and telephone intervention), program students showed significantly lower tobacco use (both smoking and smokeless tobacco use) than control group students. These effects were evident across school and student characteristics, but somewhat stronger for medium-to smaller-size schools and for the Hispanic ethnic group.

Elder, J. P., Woodruff, S. I., & Eckhardt, L. (1994). Participation in a telephone-based tobacco use prevention program for adolescents. American Journal of Health Promotion, 9(2), 92-95. The purpose of this study was to examine the effectiveness a telephone-based intervention in circumventing some of the problems maintaining the involvement of high-risk participants in school-based tobacco use prevention programs. Some programs are criticized for the nonparticipation and attrition rate of adolescents considered to be high-risk for tobacco use. This article addresses what the authors describe as a "promising strategy for delivering health promotion interventions"-- telephone contacts with counselors. The sample for this study was 1,174 ninth graders who were serving as treatment group participants in of Project S.H.O.U.T. (Students Helping Others Understand Tobacco). This project began as a school-based program at 22 junior high schools in San Diego County. The students in this treatment program received 8 to 10 classroom lessons in both 7th and 8th grade, from college-age peer-facilitators, which focused on refusal skills training, recognizing media influences, learning about addiction to and cessation from tobacco products, and discussion of normative perceptions. In 9th grade, students received follow-up telephone calls and newsletters from the treatment program staff. Students in this treatment group ranged in age from 14-17 (with a median age of 15.1). They were approximately equally divided between males (48%) and females (52%). The racial/ethnic distribution of the group was 50% White, 31% Hispanic, 5% Filipino, 5% Asian, 4% African-American, and 5% of other ethnic/racial backgrounds. Results: The researchers concluded that in this study, the telephone did not provide greater access to students than did the traditional avenues of communication. Less than half of the students were available to receive more than two of the four scheduled calls (the mean number of call received was 1.74, SD =1.45). In particular, boys, older students, Hispanic students, and students living in one-parent households were more difficult to contact than other program participants. The authors suggest the need for further innovation in the use of telephone contact as means of reaching high-risk students in tobacco-use prevention education.

Elder, J. P., Woodruff, S. I., Sallis, J. F., deMoor, C., Edwards, C. & Wildey, M. B. (1994). Effects of health facilitator performance and attendance at training sessions on the acquisition of tobacco refusal skills among multi-ethnic, high-risk adolescents. Health Education Research, 9(2), 225-233. This study examined the effectiveness of a psychosocial tobacco use prevention intervention in teaching refusal skills to 389 "high-risk" adolescents. These seventh-grader students, a subgroup of Project S.H.O.U.T. (Students Helping Others Understand Tobacco), were participating as intervention and control subjects in this tobacco-use prevention program. This project initially began as a school-based program at 22 junior high schools in San Diego County. The students in this treatment program received classroom instruction sessions in 7th and 8th grade, from college-age peer-facilitators, which focused on refusal skills training, recognizing media influences, learning about addiction to and cessation from tobacco products, and discussion of normative perceptions. In 9th grade, students received follow-up telephone calls and newsletters from the treatment program staff. Students in the high-risk subgroup were chosen based on two criteria: (1) having had previously experimented with tobacco, and (2) family or peer tobacco use, and school performance. The S.H.O.U.T. subgroup of 389 students ranged in age from 11-15 years old (with a median age of 12.2 years). About half of the group was White, 26% Hispanic, and 23 of other racial/ethnic groups. The subgroup was balanced for gender, S.H.O.U.T. treatment condition, and risk status. One of the measures that the researchers collected during the course of the program was a direct behavioral measure of refusal skills. The adolescents listened to audiotaped peer offers of cigarettes and smokeless tobacco. The participants' responses were then rated for their content and quality. Results: High-risk intervention students gave significantly higher quality tobacco-refusal responses than did those in the control group. In particular, the treatment group was more likely to give a reason for their refusal. Results suggested that Hispanic adolescents were particularly receptive to the refusal skills training. In addition, the study also looked at health facilitator performance, and student attendance at training sessions. Health facilitator performance varied by ethnicity. Hispanic students tended to attain higher skill quality if taught by a "better" facilitator. White treatment students had lower scores those in the control group, when taught by "poor" facilitators. Attendance at the training sessions was related to higher quality responses only in the Hispanic students.

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Flay, B. R. (1985). Psychosocial approaches to smoking prevention: A review of findings. Health Psychology, 4(5), 449-488. (GR) This paper reviewed twenty-seven school-based studies of psychosocial approaches to smoking prevention. Some studies evaluated programs using the social influences approach, which includes information on the short- and long-term physiological and social consequences of smoking and the prevalence of smoking, and focuses on correcting students' perceptions of social norms regarding smoking, teaching students about the social influences to smoke, and providing students with behavioral skills with which to resist those influences. Some studies evaluated programs using broader life/social skills approaches that include the foregoing components, emphasize enhancing students' personal skills and/or self-esteem, and provide students with general social competence skills. Some studies evaluated psychosocial programs that added components of peer leadership, public commitment, behavioral learning techniques (role playing, practice, and reinforcement), and cognitive-behavioral approaches which added components on decision making and problem solving. Conclusions: The findings of the 21 earlier studies (some showing reductions in the prevalence of smoking among program students by up to 79%) cannot be used with confidence because of serious methodological limitations which permit alternative explanations. Nonetheless, these earlier studies provided encouragement that psychosocial approaches might be efficacious and laid the groundwork for conceptual and methodological improvements in the later studies. Certain methodological problems remained with all six of the later studies, but the two most rigorous research designs demonstrated short and long-term positive impact on tobacco use by both high- and low-risk students. The researcher concludes: "Although the results of the (later) studies support the suggestion of the (earlier) studies that the social influences approach to smoking prevention is efficacious, much more research is needed on the conditions under which the social influences programs are effective, for whom them are effective, and why they work." (pp. 473-476). Effective Components: The two most rigorous studies demonstrating positive program impact had certain elements in common: (a) media material (e.g., video tapes) with similar-age peers, (b) information on the immediate physiological effects of smoking, (c) correction of misperceptions about the prevalence of smoking, (d) discussion of family and media influences on smoking, and ways of dealing with them, (e) role playing and explicit learning of behavioral skills, (f) a public commitment procedure, and (g) they were of extended duration. However, the researcher cautions: "Although this list of common elements is suggestive, we really know very little at this time about which of these program components are necessary for program effectiveness or how other components (e.g., health information) or methods (e.g., use of peer leaders) might or might not add to program effectiveness." (p. 478).

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Flay, B. R., Hansen, W. B., Johnson, C. A., Collins, L. M., Dent, C. W., Dwyer, K. M., Grossman, L., Hockstein, G., Raugh, J., Sobel, J. L., Sobel, D. F., Sussman, S., & Ulene, A. (1987). Implementation effectiveness trial of a social influences smoking prevention program using schools and television. Health Education Research: Theory and Practice, 2(4), 385-400. (GR) This quasi-experimental study was designed to determine the effectiveness of a social influences program implemented under realistic everday conditions (opposed to experimental research conditions). In addition, the study sought to evaluate the value of (a) positive mass media influence by enhancing the school-based program with network television segments about tobacco prevention and cessation, (b) positive school context by implementing the program in all 7th grade classrooms in schools versus half of the 7th grade classes in a school, and (c) parent involvement by activities encouraging family involvement and a smoking cessation program for parents. Implementation Results: The quasi-experimental design allowed schools to self-select to participate, and control schools were matched from those schools that did not choose to participate. Results indicate that schools selecting to participate in the tobacco prevention program had students with less minority representation, who were at lower risk of becoming smokers for social influences reasons, and were less likely to have already tried smoking than students in schools that did not select to participate. Similarly, students self-selected themselves to view or not to view the television programming and their families self-selected themselves to participate or not participate with those viewing students. Results indicate that white and Asian students participated more than blacks or Hispanics. Girls were more likely to participate than boys. Students scoring high on motivation to comply, were more likely than others to participate or have their parents participate in program activities. However, baseline smoking and other psychosocial risk factors did not predict participation. There were significant differences between those who dropped out of the study and those who stayed in. Dropouts were more likely to be boys, at higher risk of becoming smokers and already smokers at baseline. Similarly, attrition was higher for students at non-participating schools than in the self-selected program schools. Program Results: Immediately after the program, only three of 19 analyses showed statistically significant differences between program and control students, with program students showing lower social perceptions of smoking norms than control students. Immediately post-program there were no differences between program and control students in the areas of knowledge, intention to smoke or smoking behavior. Similarly, at one-year and two-years after program, there were no differences between program and control students in any of 28 analyses related to knowledge, social perceptions, intentions to smoke or smoking behavior. Television Segment Viewing Results: The effects of the television component of the prevention program were analyzed for program students only. Students who viewed more tobacco prevention segments reported statistically significant lower lifetime cigarette use immediately after the program and at one- and two-year follow-ups than students viewing fewer segments. No significant differences were reported for current tobacco use, knowledge, social perceptions, or intentions to smoke. Parent Involvement Results: The effects of parent involvement were analyzed for program students only. Students with greater participation in the parent/child activity component of the prevention program showed smaller increases in current and lifetime tobacco use than students with less parent/child activity participation immediately after the program. These differences were no longer significant at one- and two-years after the program. In addition, students with greater participation in the parent/child activity component showed lower ratings of perceived peer approval of smoking at one-year follow-up, and greater intentions to refuse cigarette offers from friends and/or best friends at two-year follow-up. However, no significant differences were reported for knowledge or five other measures of social perceptions. Summary: The strongest and most consistent school-level and student-level results indicate that under real life implementation conditions, students at lowest risk were more likely to participate in the tobacco prevention program than higher risk students. Participation in the program showed no reliable differences compared to not participating. However, for program students, viewing the television segments was associated with some measures of reduced tobacco use, and more fully participating in the parent/child activity component was associated with some measures of anti-tobacco social perceptions.

Glover, E. D., Wang, M. Q., & Glover, P. N. (1994). Development of a high school smokeless tobacco cessation manual. Health Values: The Journal of Health Behavior, Education and Promotion, 18(2), 28-33. This article describes a pilot study evaluating a program for cessation of smokeless tobacco use. The program is based on the use of a self-help manual designed for high school seniors. The manual was developed by an advisory group of the National Public Education Committee of the American Cancer Society. The manual was complete in 1989, and it consists of three major sections (1) applied the theoretical bases of relapse prevention, (2) social contracting, and (3) peer education. The participants in the evaluation study were 23 chronic adolescent smokeless tobacco users. They ranged in age from 16 to 18 years old. The average number of years that they had been using smokeless tobacco was 7.5 (SD = 3.9). Participants were given the self-help manual. Baseline data was then collected from them. A subgroup of nine participants was used as a "focus" group, and data were collected for them at each session. Data were collected from the additional participants (the "comparison" group at the end of the program). Results show that 5 subjects in the focus group (56%) ceased using smokeless tobacco during the course of the program, as did 1 person in the comparison group (7%). Other participants in both groups attempted to quit or reduced their use of smokeless tobacco (this percentage was as high as 77% reducing their smokeless tobacco use in the comparison group). The evaluation study also examined the participants' reactions to the portions of the manual. The authors reported that the majority of the students found the manual's reasons for quitting, tips for dealing with withdrawal symptoms, and coping strategies helpful. The results of the evaluation study suggest some positive outcomes, however the small sample size limits the degree to which these results can be generalized. The authors stress the need for further study of the effectiveness of the program using larger numbers of students.

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Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980-1990. Health Education Research, 7(3), 403-430. (GR) This article details a meta-analysis of 45 evaluation studies conducted on tobacco, alcohol, and other drug abuse prevention curricula, grades 4-12, from 1980-1990. Most of the programs included multiple prevention components and nearly all of the programs included information about the consequences of using substances. For analysis, the programs were grouped into six categories: (1) Information/Values Clarification: Programs that include a primary emphasis on knowledge, plus programs that address values clarification (9 programs); (2) Affective Education: Programs that included multiple affective education approaches such as decision-making, values clarification, stress management and self-esteem components (10 programs); (3) Social Influence: Programs whose primary purpose is to teach students about peer and other social pressures and develop skills to resist these pressures. Many of these programs focused on resistance skill training and/or included pledges and norm setting (12 programs); (4) Comprehensive: These programs included the most diverse grouping of prevention components. All included information, decision-making, and resistance skills training. Some included pledge and norm setting. The only component entirely lacking in these programs was peer helping. (5) Alternatives: Programs that stressed life skills training and alternatives activities to drug use (2 programs); and (6) Incomplete: Programs shared information and norm setting but differ in other respects and did not fit with any other group of content-oriented programs. Conclusions: The researchers report problems with selection bias and lack of statistical power decreased the number of statistically significant differences between program and control groups in many of these studies. When questionable designs were eliminated from consideration the Comprehensive and Social Influence programs had the most consistent effectiveness at preventing the onset of substance abuse. The researchers conclude, "The most promisingstrategy appears to be a comprehensive one including multiple components representing a wide variety of approaches to prevention." (p.426) They caution however, that since both Comprehensive and Social Influence programs embodied many different strategies, narrowing comprehensive programs down to essential elements was not possible in their analysis. Similarly, the researchers note that although some elements, such as information about the consequences of substance use did not show consistent effectiveness as a primary program emphasis, information content was pervasive in the effective programs. They suggest that information of the consequences of substance use is a necessary but insufficient component of effective programs.

Hansen, W. B., & Graham, J. W. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine, 20(3), 414-430. Researchers for this study sought to compare the effects of substance abuse prevention education programs based on two different teaching strategies: (1) resistance skills training, and (2) correcting normative perceptions. The authors of the article point out that many adolescents may overestimate the prevalence of other teens who use alcohol, marijuana, and cigarettes. These erroneous impressions lead to the perception that "everyone is doing it" and set up group norms that legitimize substance abuse and experimentation. Consequently one goal of the study was to examine the effect of correcting erroneous normative perceptions and establishing more conservative group norms among the participants. Students in the program were from 12 junior high schools in the Los Angeles and Orange Counties of California (N = 3,011). They were divided into four experimental conditions: (1) resistance skill training and normative education (combined), (2) normative education alone, (3) resistance skill training alone, and (4) a control group (which received neither training). Students were pre-tested before beginning the program and post-tested 1 year after the conclusion of the program. Results of the program indicate a statistically significant main effect for normative education in for summary measures for the use of alcohol (p = .0011), marijuana (p = .0096), and cigarettes (p = .0311). There were no significant main effects for resistance skill training.

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Hansen, W. B., Malotte, C. K., & Fielding, J. E. (1988). Evaluation of a Tobacco and Alcohol Abuse Prevention Curriculum for Adolescents. Health Education Quarterly, 15(1), 93-114. (GR) This quasi-experimental study evaluated the effectiveness of a 15-lesson, 6th-7th social influence curriculum under real-life implementation conditions (as opposed to well-controlled experimental conditions). The program was presented by trained classroom teachers assisted by peer leaders. The curriculum incorporated the following elements: peer pressure resistance training, the correction of normative expectations, inoculation against mass media messages, information about parental influences, information about consequences of use, and making public commitments to not smoke and drink. Smoking and alcohol use by program students (at intervals between six months and 3.5 years post-program) was compared to comparison students receiving only factual consequence about tobacco and alcohol. Tobacco Results: Program and comparison students had similar rates of smoking in post-program analyses until after 9th grade (3.5 years post-program), when comparison students showed statistically significant high rates of onset of smoking than program students. Post hoc analyses indicate that the program was differentially effective for some students and some school settings. It was effective for females but not males, and white students but not Asians or other minorities. Moreover, the program was effective in some schools but not others. However, the factors accounting for these differences could not be determined by the research design. Alcohol Results: No statistically reliable differences in alcohol use by program versus comparison students were found.

Herrmann, D. S., & McWhirter, J. J. (1997). Refusal and resistance skills for children and adolescents: A selected review. Journal of Counseling and Development, 75, 177-187. The authors review the literature on refusal and resistance skills training as it has been implemented in tobacco-use education programs (cigarettes and smokeless tobacco), alcohol and substance abuse, and sexual activity. They review an extensive number of studies employing this type of strategy. Summary: The authors caution against making broad generalizations about the usefulness of refusal and resistance skills training programs. There are a number of mediating factors that can influence the success of this type of program, and it may not work equally well with all types of substance or behaviors. However, refusal and resistance skills trainings have often been effective in tobacco-use prevention education programs. Students in such programs have been found to be better able to recognize, discriminate between, and use refusal skills at the completion of their training, than are those students in comparison groups. However, refusal and resistance skills training strategies are most effective when imbedded in comprehensive prevention programs (e.g., those that also provide information about normative group behavior, knowledge base of accurate information, rationale for refusal, etc.).

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Higgs, P. E., Edwards, D., Harbin, R. E., & Higgs, P. C. (2000). Evaluation of a self-directed smoking prevention and cessation program. Pediatric Nursing, 26(2), 150-153. This study evaluates a tobacco-use prevention education and cessation program titled Breathe Easy! This program encourages active learning, and allowing adolescents to explore issues, discuss problems, and formulate their own solutions. Breathe Easy! is presented in five sections, which are organized into ten 45-minute periods. The program has a parent involvement component, which encourages parent-child communication. The participants in this evaluation study were recruited from a summer youth program, and ranged in age from 14 - 17 years old. Students came from four separate sites, and for the purposes of the study, two of those sites implemented the Breathe Easy! Program (treatment group, N = 357, median age = 15.2). The other two sites were used as a comparison group, and students did not take part in any anti-smoking program (control group, N = 192, median age = 15.4). There was no significant differences between the students in the treatment and control group in terms of gender, minority status, of the initial prevalence of smoking (11.5% and 8.8%, respectively). Results: The program participants (in both the treatment and control groups) were assessed 1-month after the completion of the program and again at 6-months after the program. At the, 1-month follow-up, there were no significant differences noted between treatment and control groups. At the 6-month follow-up assessment, the treatment group had experienced a decrease in smoking prevalence that was statistically significant (p = .005), whereas the control group had no significant decrease in smoking prevalence. Additional outcomes examined in the treatment group showed trends toward smoking cessation and prevention at higher rates than those of the control group.

Josendal, O., Aaro, L. E., & Bergh, I. H. (1998). Effects of a school-based smoking prevention program among subgroups of adolescents. Health Education Research, 13(2), 215-224. This study sought to examine the effect of comprehensive tobacco-use prevention programs in the Norwegian secondary schools. In particular, the study investigated programs that utilize both teacher and parent involvement components. Ninety-nine schools participated in the study with a total of 195 classes and 4,441 students. Students began the program when they were in 7th grade. The program involved 8 sessions throughout the school year, and revolved around the themes of personal choice, freedom from addiction, decision-making, resistance skills training, and information about the short-term consequence of smoking. The classroom curriculum was presented by trained teachers, and the parents were involved through materials sent home to promote communication between parent and child, provide information about tobacco refusal skills, and involve parents in discussions. The parent involvement component of the program also included a no-smoking contract signed by both the parent and the adolescent. Schools were assigned to one of four treatment groups: Group A, a control group (no program); Groups B, full treatment program, containing classroom intervention and parent involvement; Group C, like B, but without teacher courses; Groups D, like B but without parental involvement. Baseline data were collected at the beginning of the program, when the students began 7th grade, and follow-up information was collected from students 6-months later. Results: At the 6-month follow-up, the proportion of smokers had increased by 8.3 % in the control group, whereas those students in the most extensive treatment group (Group B) had only increased their smoking by 1.9%. As could be expected, there were more smokers in Groups C (no teacher/classroom component) and D (no parent involvement) than there were in the most extensive treatment group (Group B). However, the percentage of students in Groups C and D who smoked was less than in the control group. In addition to examining the effect of the program elements, the study also investigated the relation of the program offerings to student characteristics. Students were assessed and categorized as either "high risk" or "low risk" based on the scores of scales measuring sensation seeking, physical maturity, antisocial behavior and parental smoking. The effect of the program appears too have been at least as effective, if not more so, for those students who were classified as "high risk."

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Lamb, J. M., Albrecht, S. A., & Serika, S. (1998). Consideration of factors prior to implementing a smoking cessation program. Journal of School Nursing, 14(1), 14-19. This study examine the feasibility of different program sites in terms of their ability to facilitate access, recruitment, and retention of pregnant African-American teenagers to a smoking cessation intervention program. School and clinic sites were compared. The program was adapted from the Teen Fresh Start Smoking Cessation Program developed by the American Cancer Society. The modified program was Teen Fresh Start Plus Buddy. The program was a cognitive-behavioral intervention designed to help teens change their attitudes and behaviors in order to quit smoking and maintain cessation. The program is divided into 8 weekly modules that increase awareness regarding the consequences of smoking, and build cessation skills. The standard curriculum involves role playing, positive reinforcement, written and audio-visual materials. The researchers added the component of social support by asking that each smoker enlist the help of a buddy (another smoker who wanted to quit and would attend the program with the pregnant teen) in order to promote mutual encouragement. Results: Of the two program sites, the school was more effective. Twelve participants were recruited at the clinic site, however only two completed the program. The clinic program was implemented during the summer time, and students seemed to have no structured schedules. They frequently missed prenatal clinic appointments, and consequently were not on site for the program sessions. Recruitment at the school was more effective. The school site program began with 21 students and 9 completed the program (attrition was due to pregnancy complications (2), a city-wide transit strike (4), an inability to find a buddy to join the program (5), and 1 other for personal reasons). The comfortable familiar setting and school personnel that already had developed a relationship with the teens helped promoted interest in the program. The stable routine of the school day allowed the 9 participants to attend all the sessions.

Langlois, M. A., Petosa, R., & Hallam, J. S. (1999). Why do effective smoking prevention programs work? Student changes in social cognitive theory constructs. Journal of School Health, 69(8), 326-331. This study was designed to evaluate the impact of a psychosocial smoking prevention curriculum on the mediating variables considered responsible for decreasing adolescent initiation of cigarette smoking. In other words, which program components are responsible for impact? The study evaluated the Minnesota Smoking Prevention program, a social influences program that had previously demonstrated impact on student smoking behavior. The program was implemented with sixth grade students using health educators and trained peer leaders. Researchers reported that previous studies documented a 20% reduction in smoking initiation between this peer-led, social influences program and a health consequences, lecture-type comparison program, two years post-program. The current study did not evaluate behavioral impact, but examined program impact on four psychosocial variables theorized to mediate the impact of the program on tobacco use behavior. The four psychosocial variables were: (1) Behavioral capability to resist positive images-the ability to identify, evaluate, and reject favorable images of smoking presented through media and adult mentoring, (2) Refusal skill-efficacy-perceived ability to resist direct, indirect, hassle, and put-down type of cigarette offers made by best friends, groups of friends, and older students, (3) Total positive refusal expectations and importance-positive social outcomes anticipated by a student for refusing cigarette offers and the importance that a student puts on the expected outcome, and (4) Total negative refusal expectations and importance-negative social outcomes anticipated by a student for refusing cigarette offers and the importance that a student puts on the expected outcome. Results: The smoking prevention program had a significant impact on two of the four psychosocial variables: students' refusal skill-efficacy and total positive refusal expectations and importance. Refusal skill-efficacy was measured in situations of in-school and at a friends' house; by person making the cigarette offer of best friend, group of friends, and an older student;, and by direct, indirect, hassle, and put-down types of pressure. Descriptive data for the refusal skill-efficacy subscales indicate that students reported being most confident in saying "no" to a best friend, and report "hassle" as the hardest type of pressure to refuse, and report that saying "no" at a friend's house is more difficult than refusing cigarette offers at school. Researchers conclude that the results support the continued practice of role-playing cigarette refusal strategies-at least two, 40-minute periods--especially in situations that address various types of pressure, various types of students, and different locations. The positive refusal expectations and importance activities comprised only about 10-12 minutes of the curriculum, but still had a significant impact on students. However, researchers note that more time at these activities would likely strengthen impact. Researchers recommend the use of refusal role-plays with the inclusion of positive outcomes. Regarding the mediating variables that did not show impact researchers recommend expanding the print advertising materials to include audiovisual and other forms of media (such as movies) to better impact students' ability to resist positive images of smoking, and allotting more time to learning activities designed to decrease students' negative perceptions of refusing tobacco.

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McCormick, L. K., Steckler, A. B., & McLeroy, K. R. (1995). Diffusion of innovations in schools: A study of adoption and implementation of school-based tobacco prevention curricula. American Journal of Health Promotion, 9(3), 210-219. The goal of this study was to identify factors that enhanced or impeded adoption and implementation of new health education programs. The study used an experimental design; 22 school districts in North Carolina were randomly assigned to treatment and control conditions. The study involved two intervention phases: adoption and implementation. The three curricula that the school districts could choose for adoption were (1) Growing Healthy, (2) Teenage Health Teaching Modules (THTM), and (3) Project SMART. Districts/teachers were monitored to see the period of time required to adopt a health curriculum, and agree to teach a minimum of 5 lessons. During the implementation phase, in-depth teacher training was conducted on the use of the middle school tobacco prevention curriculum that had been adopted (for those districts in the treatment group). Independent variables of interest included organizational size and climate, teacher training, how long it took to make the adoption decision, and attitudes toward tobacco use prevention curricula. Results: Adoption time ranged from 9.57 to 19.86 weeks. Organizational size was found to be an indicator of the speed of adoption. Smaller school districts were more likely to adopt sooner. The authors suggest that smaller organizations may be able to make decisions more quickly, as mobilizing the persons in charge of decision-making may be less of an effort. However, program implementation hinged on different factors. Larger school districts were more likely to implement their new health education during the course of the study. The authors suggest that larger organizations, despite appearing slower in the initial decision-making process, had more resources to help individual teachers complete in the implementation process. In addition, in-depth training in the use of a newly adopted program was found to be one of the strongest predictors of curricula implementation. The researchers caution against the use of "second-hand" training where a single teacher or small group of teachers is trained and asked to disseminate the information to others at their school sites. The research suggests that for teachers to feel comfortable with new materials, they need direct on-going training with the opportunities for guided practice.

Myers, M. G. (1999). Smoking intervention with adolescent substance abusers: Initial recommendations. Journal of Substance Abuse Treatment, 16(4), 289-298. The author of this article reviews the literature on successful adolescent smoking interventions and recommends a number of elements that he feels are supported by research. Among his recommendations are addressing the issue of student motivation. Many teens have not yet developed the health problems that plague adult smokers, so they have less motivation to engage in a smoking cessation program. Myers recommends providing accurate information about the long and short-term consequences of smoking in order to provide teens with a reason too quit. The author also addressed the results from studies that support the implementation of social influences, peer-led, and parent involvement programs. In particular, he stresses the importance of peer influence on the adolescent smoker, and the success of programs that are based on refusal skills, awareness of social influences, and assertiveness training. Overall, this review provides additional support for the idea of comprehensive tobacco-use prevention education programs.

Peck, D. D., Acott, C., Richard, P., Hill, S., & Schuster, C. (1993). The Colorado tobacco-free schools and communities project. Journal of School Health, 63(5), 214-217. This article describes the efforts of the Colorado Tobacco-Free School and Communities Project. This program began in 1988, when only 8 of 176 school districts in Colorado were tobacco-free. The program has seen an effect since its implementation. By 1992, 80 districts in the state were tobacco-free (45%). The program provides workshops, materials, and referrals for schools interested in implementing a tobacco-free policy. In particular, the authors emphasize that those students who come from schools with stringent no-smoking policies, as less likely to start smoking. Tobacco-free schools provide a clear, consistent, and health-conscious message to youth. The article also provides a five-point rationale for school that wish to adopt a tobacco-free policy: (1)substance abuse is a learned behavior and school personnel are role models for their students, (2) the earlier students start to smoke, theless likely they are to quit, (3) nicotine is addictive and the gateway to other drug use, (4) chemical use is lower in adolescents in schools with firm policies regarding drug use, and (5) even nonsmokers are at risk from passive smoke.

Pentz, M. A., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., Hansen, W. B., Want, E. Y. I., & Johnson, A. (1989). A multicommunity trial for primary prevention of adolescent drug abuse: Effects on drug use prevalence. Journal of the American Medical Association, 261, 3259-3266.(GR) This article describes a quasi-experimental study of the initial effects of a coordinated school- and community-based drug abuse prevention program. The participating communities were primarily white, middle class, well educated, and stable. The 6th-7th grade school component consisted of a 10-session program addressing the psychosocial consequences of drug use, correction of beliefs about the prevalence of drug use, recognition and counteraction of adult, media, and community influences on drug use, peer and environmental pressure resistance, assertiveness in practicing pressure resistance, problem-solving for difficult situations that involve potential drug use, and statement of public commitment to avoid drug use. Methods of delivery of prevention skills included modeling and rehearsal (role-playing) of resistance skills, feedback with peer reinforcement through Socratic discussion, peer leader facilitation of teacher program implementation, and discussion of homework results. The school program also included homework sessions in which students interviewed parents and family members about family rules on drug use, successful techniques for avoiding drug use, and methods for family counteraction of media and community influences to use drugs. Homework material was collected and discussed in classroom sessions. The school program components were supplemented with mass media programming consisting of newspaper articles, television news clips, television and radio talk show interviews with project staff, and a televised press conference. Student tobacco, alcohol, and marijuana use were measured at baseline and one-year follow-up. Tobacco Results: As expected with developmental phenomenon, prevalence rates for each substance increased in both program and control groups over time. However, the increase in proportion of students using tobacco was significantly higher in control students than in program students one year post-program. The results were similar regardless of whether analyses were unadjusted or adjusted for grade, race, urbanicity, and socioeconomic status. Alcohol Results: The increase in proportion of students using alcohol was significantly higher in control students than in program students one year post-program. The results were similar regardless of whether analyses were unadjusted or adjusted for grade, race, urbanicity, and socioeconomic status. Marijuana Results: The increase in proportion of students using marijuana was significantly higher in control students than in program students one year post-program. The results were similar regardless of whether analyses were unadjusted or adjusted for grade, race, urbanicity, and socioeconomic status.

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Perry, C. L., Kelder, S. H., Murray, D. M., & Klepp, K. (1992). 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),1210-1216. (GR) This study evaluated the impact of a school-based smoking prevention program supported by a community-based cardiovascular disease prevention program encouraging healthy changes in eating exercise, and smoking patterns. The program and comparison communities were in North and South Dakota and Minnesota. The school program (the Minnesota Smoking Prevention Program, a six-lesson curriculum), initiated in the fall of 7th grade, addressed the prevention of tobacco use by influencing the social and psychological factors that encourage the onset of smoking. Students identified the short-term consequences of smoking, discovered that smoking is not a normative behavior for young adolescents, examined the reasons why adolescents smoke and explored positive alternatives to achieve the same goals, examined how smoking is promoted through advertising and peer and adult role models, learned and practiced skills to resist social influences to smoke, created anti-tobacco advertisements and practiced resistance skills, and made a public commitment to abstain from smoking. The learning activities were designed to require active student participation, and were often led by trained peer (same-age) leaders. The school-based intervention was complemented by a deliberate attempt to restructure the adult social and psychological environment with regard to heart-healthy behaviors and values, including risk factor screenings; health assessments; community education programs for eating, exercise and smoking; grocery and restaurant heart-health point-of-purchase food labeling; community task force organizing educational campaigns; continuing education of health professionals; mass media education via television, radio, newsprint; adult education in worksites, churches; and youth education. Tobacco Results: Every year of the program (7th & 12th grade) students in schools in the program communities showed significantly lower rates of tobacco use(both prevalence and number of cigarettes per week, 24 of 24 analyses) than students in schools in the comparison communities. The program was equally effective for male and female students. Analyses showed significant program/comparison differences when conducted with the subsample of students who participated in the program from the 7th grade, and when conducted with the full sample including students not present at baseline or new to the community. Ethnicity, SES and other risk factor variables were not reported. However, the authors note that "examination of these school-based, communitywide approaches appears to be warranted for youth with other high-risk social and health behaviors, and especially for youth in lower socioeconomic communities, where these problems are more accute and existing resources are scarcer." (p. 1215).

Perry, C. L., Murray, D. M., & Griffin, G. (1990). Evaluating the statwide dissemination of smoking prevention curricula: Factors in teacher compliance. Journal of School Health, 60(10), 501-504. (GR) This study evaluated the factors associated with teacher complaince and fidelity to the social influences model of tobacco use prevention. For this study, the following guidelines outlined the types of activities successfully implemented in social influences curricula: (1) Normative expectations: Most young people do not use tobacco; (2) Physiological consequences: There are positive physiological benefits to non-tobacco use; (3) Social consequences: Smoking has short-term negative consequences that may affect social relationships such as disapproval and smell; (4) Peer influences: Peers may directly or indirectly encourage tobacco use; (5) Resistance skills: Rehearsing how to resist peer influences is an important inoculation strategy against smoking; (6) Mass media influences: Students should develop counter-arguments for advertising; media role models portray smoking as positive and glamorous; (7) Peer leadership: Student leaders of some program activities may be more effective than teacher leaders. Teacher compliance to the social influences model was evaluated under three program and one control condition. Two programs used established social influences curricula; one program involved teachers developing or adapting existing curricula to the social influences model. Schools in the control condition used their existing tobacco use prevention curricula, which were not explicitly based on the social influences model. The programs varied in teacher training, from face-to-face (one- and two-day) to receipt of an instructional manual and videotape. Compliance Results: The results were variable, but overall statistically higher compliance to the social influence model occurred with the established social influences curriculum (as opposed to the teacher developed/adapted curricula), and with the face-to-face training in how to teach the lessons of established curricula (as opposed to an instructional manual and videotape).

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Prince, F. (1995). The relative effectiveness of a peer-led and adult-led smoking intervention program. Adolescence, 30(117), 187-194. This study evaluated the effectiveness of a peer-led tobacco use prevention education program. Ninety-three 11th and 12th grade students from seven high school campuses in Ventura and Los Angeles Counties, California participated in the program. The participant group was made up of 54 males and 46 females, who were assigned to one of three treatment conditions: (1) peer-led group (30 students), (2) an adult-led group (31 students), and (3) a control group (32 students). The tobacco-use prevention education program used in this study was the Tobacco, No Thanks (TNT). The program is taught is six sessions, and was designed with specific directions for involving peer leaders. The peer leaders for this program were recruited from peer leadership programs on their campuses, and they attended a two-day training course before beginning the program instruction. The prevalence of smoking was assessed by self-report at the pretest, posttest, and the one-month follow-up. Results: Students in the peer- and adult-led groups both showed a significant decrease in the number of cigarettes smoked, when compared to the control group (p = < .0001). Smoking reduction continued in both treatment groups at the time of the one-month follow-up assessment. This would suggest that peer-led programs can be just as effect as adult-led programs.

Severson, H. H., Glasgow, R., Writ, R., Brozovsky, P., Zoref, L., Black, C., Biglan, A., Ary, D., & Weissman, W. (1991). Preventing the use of smokeless tobacco and cigarettes by teens: Results of a classroom intervention. Health Education Research: Theory and Practice, 6(1), 109-120. (GR) This study evaluated the impact of adding a smokeless tobacco component to a drug abuse prevention program for middle and high school students. The Project PATH (Programs to Advance Teen Health) intervention focused on sensitizing students to overt and covert pressures to use tobacco, and on teaching effective ways to respond to these pressures. Students practiced skills for dealing with offers of tobacco and also received lessons in decision-making, long-and short-term consequences of using tobacco and alcohol, nicotine addiction, advertising, and smoking and smokeless tobacco use prevalence rates. Students made a public commitment not to use tobacco and conducted interviews with adults about their tobacco habits. Two of the seven sessions specifically addressed smokeless tobacco, and five of the seven lessons included activities that were led by student-nominated peer leaders. Three brochure-like messages were mailed to parents to reinforce refusal skills and the commitment not to smoke or chew, and to encourage parents to discuss with their child their views of tobacco use. Smokeless Tobacco Results: Because of the low rates of smokeless tobacco use by females, these analyses were only conducted on male students. One year after the program middle school program students showed significantly less increase in the use of smokeless tobacco than control students. Among high school students there was a decrease in reported smokeless tobacco use among program students compared with an increase among control students. This result should be interpreted with caution however, because when a statistical correction was applied due to skewed data, the differences in smokeless tobacco use between program and control students were no longer statistically significant. Tobacco Results: There was no difference in smoking rates between program and control students. Students in both conditions increased their rate of smoking by similar amounts. Alcohol Results: There was no difference in smoking rates between program and control students. Marijuana Results: There was no difference in smoking rates between program and control students.

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Sussman, S., Dent, C. W., Stacy, A. W., Hodgson, C. S., Burton, D., & Flay, B. R. (1993). Project Towards No Tobacco Use: Implementation, process and post-test knowledge evaluation. Health Education Research: Theory and Practice, 8(1), 109-123. (GR) This study describes the curricular contents and process evaluation of four curricula developed to counteract the effects of three different types of tobacco use factors typically addressed in social influences programs: (1) peer approval for using tobacco (normative social influence), (2) incorrect social information provided about tobacco use (information social influence), and (3) lack of knowledge or misperceptions about physical consequences resulting from tobacco use. The article provides detailed descriptions of the curricular components. It also provides student, health educator, and teacher ratings of the curriculum implementation and process including adherence, delivery, attendance and homework rates. All conditions were rated favorably, with students rating the physical consequences condition and the normative social influences condition more and less favorably, respectively. Health educators and teachers generally rated all conditions more equally.

Sussman, S., Dent, C. W., Stacy, A. W., Sun, P., Craig, S., Simon, T. R., Burton, D., & Flay, B. R. (1993). Project Towards No Tobacco Use: 1-year behavior outcomes. American Journal of Public Health, 83(9), 1245-1250. (GR) This experimental study reports the one-year behavioral impact of school-based tobacco-use prevention programs presented to 7th grade students. Three main learning activity components of a social influence approach were evaluated separately and in combination: (1) activities that counteract Normative Social Influence to use tobacco, especially refusal assertion skills, (2) activities that counteract Informational Social Influence to use tobacco, including information about modeling and advertising tactics, and correction of inflated tobacco use prevalence estimates, and (3) activities that counteract misperceptions or a lack of knowledge regarding the Physical Consequences of tobacco use. Trained health educators delivered the curricula over 10 consecutive school days. The study examined the program effects on changes in cigarette and smokeless tobacco use behavior compared to control schools one-year post-program. Results: For both cigarette and smokeless tobacco use, the Combined Program (Normative and Informational Social Influence, plus Physical Consequences) consistently demonstrated significantly lower student tobacco use (four of four analyses) than the control condition. The learning activity components taught separately demonstrated variable results. For cigarette use, the Informational Social Influence and Physical Consequences components taught separately both showed significantly lower rates than the control condition (two of two analyses each). For smokeless tobacco use, none of the components taught separately showed consistent impact compared to the control condition (two of six analyses).

Sussman, S., Dent, C.W. & Stacy, A.W. (2002). Project Towards No Drug Abuse: A review of the findings and future directions. American Journal of Health Behavior, 26, 354-365. This study reviewed evidence from 3 Project Towards No Drug Abuse (TND) experimental studies. Outcomes were assessed using student questionnaires at baseline and 1 year follow up. Telephone surveys were used to collect data from students who were no longer enrolled in the high school at 1 year follow up. Student questionnaire items and responses were derived from the national Monitoring the Future survey. Unless a gender is specified, results were found for the combined (male and female) student data. The first study was conducted in 21 continuation high schools. Schools received either the standard care control, a 9-session TND program, or a 9-session TND program plus a school-as-community program. When schools receiving Project TND and Project TND plus the school-as-community program were compared to standard care schools at 1 year follow-up, there was a 25% relative reduction in the prevalence of hard drug use, 7% relative reduction in alcohol use for those using alcohol at baseline, 21% relative reduction in weapon carrying in males, and 23% relative reduction in victimization in males. There were no significant behavior differences between students who received the TND program and the TND plus community program. The second study was conducted in 3 traditional high schools. Twenty-six classrooms were randomly assigned to receive the 9-session TND program or the standard care control. At 1 year follow up, the students in Project TND classrooms showed a 25% relative reduction in the prevalence of hard drug use, 12% relative reduction in alcohol use among baseline users, 19% relative reduction in weapon carrying in males, and 17% relative reduction in victimization in males. The third study was conducted in 18 continuation high schools randomly assigned to receive the 12-session TND program, the 12-session self-instructional version of TND, or standard care control. Only the health educator-led condition provided a reduction in problem behavior rates relative to the other conditions. There was a 26% relative reduction in hard drug use, 9% relative reduction in alcohol use among baseline users, 6% relative reduction in victimization among males, 37% relative reduction in weapon-carrying among baseline non-weapon carriers, 27% relative reduction in cigarette smoking, and 22% relative reduction in marijuana use.

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Sussman, S., Lichtman, K., Ritt, A., & Pallonen, U. (1999). Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Substance Use and Misuse. (GR) This article reviews the last two and a half decades of research on tobacco cessation and prevention program impact on adolescent tobacco users. Cessation Results: Seventeen tobacco cessation studies were included. More than half of the studies used less rigorous single-group research designs. One study presented data on both cigarette smoking and smokeless tobacco use, four studies pertain only to smokeless tobacco use, and 12 studies examined only smoking cessation. Ten different theories "or hunches" guided the programs. Programs focused on immediate consequences (affective/values, physical or social) and instruction in coping skills. Twelve programs were based in school clinics, one in the classroom, the rest out of school. The mean number of sessions was 6.3 (range from 1 to 20 sessions). No study reported fewer than 50% white participants, although ethnicity was not reported in 13 of 17 studies. Recruitment ranged from 6 to 100%, with a mean of 62%. Retention ranged from 46 to 100% with a mean of 77%. Mean quit rate (reported by 13 studies) post-program was 20.7% (range = 0 to 36%). Quit rate at followup dropped to a mean of 13%. Program quit rates were compared to naturally occurring quite rates among adolescent tobacco users vary from agout 0 to 11%. In addition, four of the six studies reported greater than 49% reduction in smoking. Prevention Results: The results of seventeen prevention studies including adolescent tobacco users were reviewed. All programs included some physical consequences information. All but two of the programs used some form of social influences model; two programs used social-cognitive approaches. Fourteen of 17 programs were school-based. The mean number of sessions was 14.4 (including booster sessions (range = three to 30 sessions). The prevention studies tended to use either quasi-experimental or experimental designs with control groups, biochemical validation, and large subject populations increasing the reliability and validity of results. Five to 15% of research participants were baseline tobacco users. No Studies reported less than 50% white participants. Recruitment was 80 to 90%. Average retention rate was 64% (range = 40 to 94%). Average reduction rate was 6% (range = 1 to 11%). Conclusion: Researchers conclude that prevention appears to be efficacious among younger, less frequent tobacco users, and cessation appears to be appropriate for older, heavier users who are further along in the stages of change. The cite the promise of one study evaluating a combined prevention and cessation high school program, and the need for more sophisticated program development and research designs for cessation programs.

Thomas, S. M., Fick, A. C., & Henderson, J. A. (1992). Meeting the needs of special populations: A formative evaluation of a school-based smoking prevention program. Journal of the Louisiana State Medical Society, 144(4), 157-161. The National Cancer Institute recommends three minimum components for school-based tobacco-use prevention programs: (1) knowledge of short term physiological effects, (2) social consequences, and (3) training in refusal skills. The authors of this study were interested in whether or not these minimum recommended elements address the needs of special populations.

The authors describe the results of a 7-day, teacher-led smoking prevention class that was offered in 9th-grade health education classes. The 300 participating students attended an urban junior high in the Orleans Parish public school system. The students were 99% African-American. Fifty-four percent were males, and 44% females. The median age was 14.67 years old. Students knowledge of health hazards was assessed prior to beginning the program (using a measure of 27 true-false items), and their evaluations of the program were assessed after its completion. Results: Assessment of the students initial knowledge of the health hazards and consequences of tobacco use revealed that 77% of the students received a "D" or lower on the test. Clearly, they had little information about the long-term effects of smoking. The authors point out that this finding is consistent with that of other researchers who suggest African-Americans may be less knowledgeable about the harmful effects tobacco use, than are members of other ethnic groups. However, African-American are disproportionately at risk for a number of cancers for which tobacco use is a risk factor, (e.g., pancreas, esophagus, stomach, lung, and larynx cancers). The authors of this study highlight the need to provide students of some population groups with more than the minimum recommended components of a tobacco-use prevention education program. Evidently, there are students who need information about the long-term health hazards of tobacco-use as a part of an effective intervention program as well.

Vartiainen, E., Fallonen, U., McAlister, A., & Puska, P. (1990). Eight-year follow-up results of an adolescent smoking prevention program: The North Karelia Youth Project. American Journal of Public Health, 80(1), 78-79. This study described the long-term effects of an educational program designed to reduce the cardiovascular risk factors of 897, 13-year-old students in the province of North Karelia, Finland. One of the main goals of the program was to delay the onset of smoking in the students. Three pairs of matched schools were chosen for the project. In two schools, students received a "direct" program; of 10 classroom sessions during a two-year period facilitated by a health educator and trained peer leaders. Two other schools received "county-wide" programs, which involved 5 "persuasive behavioral" sessions that concentrated on the social pressures that lead to smoking and techniques to deal with them. Older peer leaders assisted in the program, which also included short- and long-term effects of tobacco-use. The final two schools were used as matched controls. Results: At the post-test, students in both treatment groups reported significantly less smoking than did those in the control group. A similar finding occurred at the 4-year follow-up assessment. At the follow-up assessment, eight years after the completion of the intervention programs, there was similar, consistent evidence of possible preventive effects among those intervention participants who had been nonsmokers when the programs began.

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Wang, M. Q., Fitzhugh, E. C., Eddy, J. M., Fu, Q., & Turner, L. (1997). Social influences on adolescents' smoking progress: A longitudinal analysis. American Journal of Health Behavior, 21(2), 111-117. The researchers for this study were interested in examining the social factors that predict increases in the rate of adolescent smoking over a three-year period. They specifically examined the influence of parents, siblings, and best friends' smoking behaviors using a social learning theory model. Participants in the study were adolescents who were interviewed for the 1989 and 1993 Teenage Attitudes and Practices Survey (TAPS I and TAPS II, respectively). The total number of adolescents who participated in both surveys was 7,960. The age of the TAPS I and TAPS II participants ranged from 15 to 22 years old. The telephone survey included information about smoking behaviors and smoking models in the participants' social environment. The results showed that the smoking behavior of best friends was the only statistically significant factor in predicting whether or not an adolescent would move on to more "advanced stages" of smoking behavior (e.g., a nonsmoker's onset of tobacco use, or occasional smoker's increasing rate of cigarette smoking). The authors report that the ability of social factors (parents, siblings, and friends) to predict adolescent smoking progress was weak by the time of the TAP II survey. They suggest that the age of the adolescents at the end of the program may have made them less impressionable to the effects of social influences in their environment.

Weinrich, S., Hardin, S., Valois, R. F. Gleaton, J., Weinrich, M., & Garrison, C. Z. (1996). Psychological correlated of adolescent smoking in response to stress. American Journal of Health Behavior, 20(1), 52-60. This study examined the role of psychological distress and social support in adolescent smoking. Participants for this study had been recruited to take part in a larger study that assessed adolescents' reactions to a natural disaster (Hurricane Hugo in South Carolina). The researchers selected three high schools from the south that had been effected by the hurricane. These schools were situated in three different areas (rural, suburban, and urban). A total of 1,168, sophomore and junior high school students chose to participate. Forty-three percent were White and 57% African American. Fifty-two percent of the sample were girls, and 48% were boys. Students completed Derogatis' Brief Symptom Inventory, Spielberger's Anger Expression Scale, and a revised version of Coppel's Index of Social Support. Results: The researchers found that 19% of the students reported having smoked in reaction to stress. Those teens with higher scores for anger-control and somatization (e.g., the expression of anxiety through somatic or physiological symptoms) and those with lower reported social support were more likely to smoke when under stress. White students were more likely than African American students to engage in smoking as a reaction to stress. The authors suggest that students who engage in stress-related smoking may be more responsive to programs that teach behavioral strategies for stress reduction.

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Worden, J. K.,Flynn, B. S., Solomon, L. J., Secker-Walder, R. H., Badger, G. J., & Carpenter, J. H. (1996). Using mass media to prevent cigarette smoking among adolescent girls. Health Education Quarterly, 23(4), 453-468. (GR) This study experimental compared the impact of a four-year combined mass media/school-based smoking prevention intervention versus a four-year school-based program alone. Students received either the media/school program or school-only program for four years beginning in grades 5-8 and ending in grades 7-10. The school and mass media programs were based on social learning theory and related behavior change theories. Four primary educational objectives encouraged young people to (a) have a positive view of nonsmoking, (b) have a negative view of smoking, (c) have skills for refusing cigarettes, and (d) have the perception that most people their own age to not smoke. Additional objectives concerned with cessation skills and awareness of tobacco marketing to youth were also included. A mass media program of 36 television and 17 radio spots was developed by six different media producers. It was designed to specifically target at-risk youth (especially girls) and the spots were revised and changed over time to keep pace with the maturing tastes of the target groups. An average of 190 broadcast TV, 350 cable TV, and 350 radio exposures were purchased in each of the four program years . These were supplemented by time donated by media outlets increasing the total number of spot broadcasts by acout 50%. The school smoking prevention program included grade-specific curricular materials, annual teacher training, and monitoring of program implementation. It was delivered by regular classroom teachers and required either three or four class periods per year over four years. Formative Results: Classroom surveys and focus groups were conducted during the four years of the program to guide the development of the media intervention. These data were used to develop a set of guidelines for the media intervention. Formative data indicated that in leisure activities younger students tended to prefer more athletic and physical activities and the older students tended to prefer more social activities. Across developmental levels, for television programs, girls generally preferred programs focused on social relationships while boys preferred action-oriented programs. The guidelines included the following: For the prepuberty grouping (grades 5-6) provide information supporting decisions to become a nonsmoker, model ways to refuse cigarettes, model coping with social pressures without smoking, and model feeling mature and independent without smoking. For grade 7 and 8, emphasize that girls in this age group want to look older and more attractive to older boys, and they want to feel like they were on their own, coping successfully with social stressors. These guidelines suggested message concepts highlighting social influences and featuring positive female role models. There were few differences between grades 7 & 8 and 9 & 10, with the exception that time spent in cars, particularly on weekends, became prominent at this time, translating into less time spent watching television. This information suggested a reduction of weekend spot placements on television for students in these grades and an increase in placements on radio. Summative Results: The summative data were analyzed for only those students who participated fully in the four-year program. There were no significant differences between the media-school and school-only program for boys (zero of five analyses). There were significant differences between the media-school and school-only program on all measures for girls (five of five analyses). At the end of the fourth year of the intervention, girls participating in the media-school program had significantly lower beliefs in the advantages of smoking cigarettes, lower positive attitudes toward smoking, lower perceptions of peer smoking and lower intentions to smoke cigarettes than girls in the school-only condition. Similarly, girls participating in the media-school program reported lower smoking rates than girls in the school-only program.

Young, R. L., Elder, J., P., Green, M., de Moor, C., & Wildey, M. B. (1988). Tobacco use prevention and health facilitator effectiveness. Journal of School Health, 58(9), 370-373. This program evaluated the effectiveness of college-age, peer facilitators in a tobacco-use prevention education program. Student and peer facilitator participants in this study were part of Project S.H.O.U.T., a school-based smoking prevention program in 11 junior high schools in San Diego County. Eleven undergraduates and one graduate student were recruited to act as peer facilitators. The college students were 19-21 years old, and the group included nine females and three males. These students were from health science and psychology departments and received university credit for their work in the program. They had six hours of training before being sent in pairs to six of the participating junior high schools. The peer-facilitators conducted five program sessions with the younger students in the fall of 1987 and three booster sessions in the spring of 1988. Outside observers evaluated the peer facilitators in seven categories: being prepared, maintaining class control, keeping students' attention, encouraging participation, communication, relating to students, and working well in a team. The results indicate that highly rated peer facilitators were more effective in reducing tobacco use in the participating junior high school students, than were poorly rated peer facilitators. The most effective facilitators were those who were well prepared, related well to students, and who worked well in a team. This article highlights the influence that facilitator quality can have on a tobacco-use prevention program, and lends support to the use of cross-age and peer-leaders.

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Summary of Research Supported TUPE Strategies

TUPE Empirical Evidence Chart

Reviewed TUPE Materials for Research Supported Strategies

TUPE Research by RFA Strategy

Date: 09/07/2010