Rise Morgenstern Arkin Helen F. Roemhild

C. Anderson Johnson Russell V. Luepker

David M. Murray

The Minnesota Smoking Prevention Program:

A Seventh-Grade Health Curriculum Supplement

A seventh-grade program based on social psychological theories attempted to prevent non-smokers from starting to smoke. Two competing strategies, a Short-Term Influences Curriculum and a Long- Term Influences Curriculum were compared. Within these broad strategies, several other variables were also tested: the use of same age peer opinion leaders or health educators as teachers, the use of media supplements and the elicitation of a public commitment not to become a regular smoker. Program effectiveness was evaluated using seu-report measures confirmed by saliva thiocyanate analyses. The treatment groups were compared to a standard curriculum comparison group.

INTRODUCTION efforts have used auite different imdementation Recent reports indicate that the prevalence of

cigarette smoking among teenagers remains high. I In view of the substantial increase in the risk of coronary heart disease, cancer and premature death attributed to cigarette smoking and the low success rates reported in adult cessation programs, the need to develop more effective smoking prevention programs for youth is underscored.

Over the years, such programs have focused on the long-term health risks of smoking.' Although they occasionally produced changes in knowledge and attitudes, they have rarely been effective in changing b e h a ~ i o r . ~ . ~ More recent attempts have addressed the social influences which encourage smoking onset, and these programs appear to have had considerably greater success.5.1z

In spite of their conceptual similarities, these recent

procedures. McAliste; et al, for exampie, used older peer leaders as the intervention agents and relied on highly participatory classroom s e s s i o n ~ . ~ J ~ . ~ ~ Evans et al, on the other hand, used media very heavily with little active participation on the part of the students.s.6

This study compared two approaches to smoking pre- vention. The first approach initially was referred to as the Social Pressures Curriculum,' although it would be more descriptive to label it the Short-Term Influences Curriculum. This approach focused on the immediate consequences of smoking, both social and psysiological, and on the immediate social influences which encourage smoking. Within this curriculum, the effectiveness of same-age peer leaders to professional health educators as teachers was compared. Some students were also exposed to a media supplemented program while others had no special media materials.

The second amroach. which focused on the long- term health risks- of smoking, was labeled the Long- T~~~ ~ ~ f l ~ ~ ~ ~ ~ ~ curriculum. This approach differed from the standard smoking education curriculum in two

This work was supported in part by funds from NICHD Research Grant ROI HD12801, NIH Biomedical Research Support Grant S07RR05448. and NHLBI Training Grant T32HL07328 (DMM).

NOVEMBER 1981 THE JOURNAL OF SCHOOL HEALTH 61 1

ways. I t did not rely heavily upon either fear arousal or a didactic teaching style; rather, it presented factual information and encouraged students to actively participate in the learning process. This paper presents these curricula and our preliminary findings.

METHODS During the 1979-80 school year, the entire seventh

grade population in each of eight suburban Twin Cities junior high schools participated. As a prior condition to participation, each school accepted the random assign- ment of schools to one of four educational programs. For the September, 1979 pretest, 3,206 seventh graders were present. Students provided saliva samples for thiocyanate analysis and smoking self-reports. Saliva thiocyanate provides an objective measure of smoking among adolescents; in addition, collection of the saliva samples prior to the self-reports increases the validity of the self-report i t ~ e l f . l ~ - ~ ~ The eight schools were ranked based on the baseline prevalence of weekly smoking. They were randomly assigned to the four treatment con- ditions from the upper and lower halves of the weekly smoking distribution.

This eight-school design permitted adequate evaluation of between-treatment differences; however, it did not allow comparisons of any of the programs to a standard smoking education curiculum. Such a group was formed utilizing data collected from two of these

TREATMENT GROUP

Long Term Influences

schools, which had served as a standard curriculum comparison group in a pilot study.*s9 The complete design is depicted in Table 1.

A detailed description of the Short-Term and Long- Term Influences Curricula is presented below. Since the three versions of the Short-Term Influences Curriculum differed only in their use of peer leaders, health educators and media supplements, only the peer-led, media supplemented version is presented here. Please note that in Group 11, a professional health educator led all activities attributed to peer leaders in the descriptions below. Similarly in Group IV, the media supplements were not used. In each experimental program, five inter- vention sessions took place between October 1979 and April 1980.

Short-Term Influences Curriculum This program focused on the covert and overt social

pressures to smoke. Teenage cigarette smoking was presented as a psychosocial phenomenon encouraged by influences from peers, family members and media. Skills training sessions taught students to recognize the pressures to smoke and to resist them using a variety of techniques. Only immediate social and physiological effects of smoking were considered.

In the peer-led program, the students in each class nominated persons in that class whom they admired and respected. The three persons receiving the most votes

Schools Public

N o

Yes 2

TABLE I Study Design

Adult Led With Media

Short

Term

Influ- With Media Peer Led

ences

Peer Led Without Media

Standard Curriculum

I No

1 Yes

I No

2 I- 2 k I Yes

Pretest

September

1979

September 1977

Treatment

October I979

through

April

1980

Postest

May

1980

May 1980

612 THE JOURNAL OF SCHOOL HEALTH NOVEMBER 1981

were identified as peer opinion leaders. Twice during the school year, the peer opinion leaders attended a half- day training seminar to become familar with their responsibilities in the program. Workshop sessions included group dynamics, leadership skills and a re- hearsal for the activities of the intervention sessions. The peer opinion leader then assumed full responsibility for each classroom intervention. The health educator, although present in the classroom at all times, acted only as an observer and general supervisor. To ensure consistency among peer leaders and their groups, the peer opinion leaders received an outline for each day’s activities. A detailed description of the five sessions follows.

In Session 1, the peer opinion leader directed a discus- sion session where students listed, categorized and dis- cussed negative aspects of smoking and gave reasons why seventh graders begin to smoke. The peer opinion leaders also instructed the members of their group to estimate the number of regular smokers in the seventh grade at their school. The estimates were collected, averaged and utilized during the second session. Finally the students briefly role-played situations where they effectively resisted pressures to smoke. Following the role playing, the first videotape of the Minnesota Smoking Series, “Why Do People Smoke?,” was shown at the media-supplemented schools. This tape identified and gave examples of peer pressures and effective resistance techniques. It also reviewed the short-term physiological effects of smoking. At schools where the media materials were not used, the role playing was extended.

In Session 2, the peer opinion leaders provided feed- back on the actual number of seventh graders who smoked and compared this figure to the estimates from Session 1. Without exception, the students had over- estimated the number of smokers. Afterwards the class discussed reasons for this overestimation, and the students realized that nonsmokers were in the majority. Each group also brainstormed situations in which their friends encouraged them to smoke and role-played strategies to resist such encouragement. Following the role-playing activity, students viewed another tape in the Minnesota Smoking Series, “If Your Friends Smoke, Do You Have To?’’ This film provided situa- tions where positive role models effectively refused offers of cigarettes.

Session 3 encouraged students to develop counter- arguments for smoking by first assuming the role of an individual offering cigarettes and then the role of an individual rejecting cigarettes. In this way, each student debated the pros and cons of cigarette smoking. Social psychological research has indicated that persons who develop and verbalize counterarguments to a persuasive

NOVEMBER 1981

attempt will be more lik& to resist that persuasive attempt in the future.15 No videotape was shown in this session.

In Session 4, students focused on media and family smoking models. Activities included constructing anti- smoking collages using cigarette advertisments. The stu- dents posted these collages in prominent places around the school. They also watched the last tape in the Minnesota Smoking Series, “Aren’t We Smarter Than That?,” which reviewed the types of messages found in cigarette advertisements and the ways that family smoking can influence adolescents.

In Session 5 , the students composed and were video- taped delivering a public commitment not to smoke. The tape was replayed to the class to reinforce this commitment. Data from our earlier work indicated the importance of such a public ~ommi tmen t .~ To isolate and more fully test this effect, half of the seventh graders in each treatment condition participated in the public commitment. Long-Term Influences Curriculum

The Long-Term Influences program also consisted of five one-hour sessions in which students identified and discussed the long-term physiological effects of cigarette smoking. All sessions were led by a professional health educator.

The theme of Session 1 was the long-term effects of cigarette smoking on the lung. The students viewed the American Cancer Society’s film, “Breath of Air.” After the film, the class discussed the effects of smoking on the lungs.

During Session 2, cardiovascular damage from smoking provided the focus. The health educator related the effects of smoking on blood pressure, the heart and blood cholesterol levels. Students measured their own pulse and viewed “Smoking: A Report on the Nation’s Habit” (Pelican Films). For the third session, the students played a smoking and health-related version of the game “Password.”

In Session 4, the students examined the effects of a woman’s smoking habits on her unborn child. After watching the film, “I’m Sorry, Baby” (Pelican Films), the classes discussed this problem and the long-term effects maternal smoking can have for the child.

Session 5 consisted of the public commitment pro- cedure described previously. Classes not involved in the public commitment constructed collages emphasizing the long-term effects of cigarette smoking. Reactions to the Curriculum Supplements

Teachers and principals in the eight experimental schools were quite cooperative. Scheduling school visits and coordinating the program activities with the other school programs presented no problem, for teachers

THE JOURNAL OF SCHOOL HEALTH 61 3

and principals viewed the programs as strong supple- ments to their health and science programs.

Students also responded in a positive manner. There was generally a high level of activity and movement during each of the programs. The students seemed to look forward to the days when the program staff came to the buildings.

Reactions did vary somewhat by program. Teachers, principals and students generally had more trouble adjusting to the peer-led programs than to the health educator-led programs. This was attributed to the sharp differences between the peer-led classroom style and the more traditional didactic teaching style characteristic of the health educator program. For similar reasons, the Short-Term Influences program was more difficult to adjust to than the more traditional Long-Term Influences program.

RESULTS Of the 3,206 students present for the May, 1979

pretest, 2,848 were also present for the post-test. An additional 691 students from the 1977-78 study formed the standard curriculum comparison group. Of the combined total, 3,466 (97.9%) responded fully to the questions of interest.

The baseline smoking patterns for the five conditions are presented in Table 2. In spite of the randomized block design, several differences between groups were

present at baseline. This is, in part, attributable to the small number of schools available for assignment. No differences were apparent for the prevalence of weekly smoking.

The purpose of each of the experimental programs was to prevent the onset of smoking. The students directly targeted by these programs were those who began the year as nonsmokers. Table 3 presents the posttest smoking patterns for these students in each of the five conditions.

Students in the standard curriculum comparison group moved out of the nonsmoking category at a higher rate than any of the four experimental groups (X2 = 5.11, df = 1, p e .05). The standard curriculum comparison group also has a higher experimental (X2 = 13.03, df = 1 , p e .01)and weekly(X2 = 5.81, df = 1, p .05) smoking onset rate than any of the other groups. In addition, the Long-Term Influences Curriculum significantly (X2 = 6.97, df = 1 , p e .01) reduced the experimental smoking onset rate even beyond the reduction achieved by the Short-Term In- fluences program. The Adult-Led Short-Term Influ- ences program similarly (X2 = 3.5, df = 1 , p 4 .lo) reduced the weekly smoking onset rate beyond the reduction achieved by the other treatment conditions. No significant differences were observed for the rate at which baseline nonsmokers took up smoking and quit by the time of the posttest. On the average, the experimental programs reduced the experimental

TABLE 2 Baseline smoking pattern by treatment group for students responding to both

the baseline and posttest surveys.

T R E A T M E N T G R O U P

~~~ ~

Long Term Influences

Adult Led Short With Media

_____

Peer Led With Media

Term

Influ-

ences Peer Led Without Media

Standard Curriculum

aA nonsmoker has never smoked even part of a cigarette. An experimental smoker has tried smoking once or twice. A weekly smoker smokes at least once a week. An exsmoker used to smoke regularly, but has quit.

614 THE JOURNAL OF SCHOOL HEALTH NOVEMBER 1981

TABLE 3 Posttest smoking pattern for students who were nonsmokers at baseline

smoking onset rate by 37.3% and the weekly smoking onset rate by 58.8% for baseline nonsmokers.

DISCUSSION The results of a series of preliminary studies which

have attempted to prevent cigarette smoking among adolescents have been positive and encouraging. The conceptual similarities and practical differences among these independent efforts have offered further encour- agement that progress has finally been made in this important area. Indeed, Fisher has suggested that we are now at the point of having prevention programs which do work.16

The results of this study support this conclusion, at the same time raising questions about how these programs influence smoking onset. The earlier work at Houston, Palo Alto, Boston, Minnesota and New York compared a social model to a standard, fear arousal model, or to a no-treatment condition. This study included a Long-Term Influences model as well. Surprisingly, the Long-Term Influences model fared better in some ways than the standard curriculum group. Although nonsmokers left that category at essentially equal rates for both models, they moved in smaller numbers to experimental smoking under the Long-Term Influences Curriculum and in smaller numbers to weekly smoking under the Adult-Led version of the Short-Term Influences Curriculum. After collapsing the three Short-Term Influences programs, no benefit remained for the weekly smoking onset rate.

Several possibilities exist to explain these findings. I t is possible for example that none of the new educational approaches are better than any other. Perhaps the mere presence of university staff in the schools created a Hawthorne effect. Given the continued positive findings from the initial studies at Palo Alto and Minnesota, however, this appears unlikely. A second possibility is that the increased benefits from the Long-Term Influences program is a temporary effect and will not hold over time. A third possibility is that the Long-Term Influences curriculum, which the authors developed, really is better. Only continued follow-up of these students will provide an answer for this question.

Early analyses suggest no clear benefit from the use of same-age peer leaders rather than specially trained adult health educators or from the use of the media supple- ments. Whether peer leaders might be more effective than actual classroom teachers or whether media materials might help standardize such a program outside a carefully controlled experimental setting are questions which we cannot yet answer. Our continuing efforts, together with those of others around the country, promise to resolve many of these important questions in the next several years.

1 . Harris JE: Cigarette smoking in the United States, 1950-78 in Smoking and Health: Report of the Surgeon General. US Department of Health, Education and Welfare, Public Health Service, 1979.

2. Thompson EL: Smoking education programs, 1960-1976. Am J Pub Health 68:250-257, 1978.

3. Piper GW, Jones JA, Mathews VL: The Saskatoon smoking

NOVEMBER 1981 THE JOURNAL OF SCHOOL HEALTH 61 5

project: Results of the second year. Can J Pub Health 65:127-129, 1974.

4 . Jones JA, Piper GW, Matthews VL: A student-directed program in smoking education. Can J Pub Health 61:253-258, 1970.

5 . Evans RI, Rozelle RM. Mittelmark MB. et al: Deterring the onset of smoking in children: knowledge of immediate physiological effects and coping with peer pressure, media pressure and parent modeling. J Appl Soc Psych 8:126-135. 1978.

6. Evans RI: Smoking in children and adolescents. Psychological determinants and prevention strategies, in Smoking and Health: Report of the Surgeon General, Washington, Government Printing Office, 1979.

7. McAlister A, Perry C, Maccoby N: Adolescent smoking: Onset and prevention. Pediatrics 63:650-658, 1979.

8. Hurd PD, Johnson CA, Pechacek T, et al: Prevention of cigarette smoking in seventh grade students. J Behav Med 3:15-27. 1980.

9. Murray DM, Johnson CA, Luepker RV, et al: Social factors in the prevention of smoking in seventh grade students: A followup experience of one year. Presented at the 87th Annual Meeting of the American Psychological Association, New York, Sept. 1-5, 1979.

10. Botvin GJ, Eng A, Williams CL: Preventing the onset of cigarette smoking through life skills training. Preventive Med 9:130, 1980. I I . Perry C: Stanford heart disease prevention program: Project

C.L.A.S.P. Presented at the Fourth World Conference on Smoking and Health. Stockholm, Sweden, June, 1979.

12. McAlister A, Perry CL, Kilden, et al: Pilot study of smoking,

alcohol and drug abuse prevention. Am J Pub Health 70:719-721, 1980. 13. Evans RI, Hansen WB, Mittelmark M: Increasing the validity of

self reports of smoking behavior in children. J Appl Pxychol

14. Luepker RV, Pechacek TF, Murray D, et al: Saliva thiocyanate: a chemical indicator of cigarette smoking in adolescents. Am J Pub Health In press, 1981.

IS. McGuire WJ: The nature of attitudes and attitude change, in Lindzey G , Aronson E (ed): Handbook of Social Psychology. Reading, Addison-Wesley Publishing Co. Inc.. pp 136-314. 1969.

16. Fisher EB: Progress in reducing adolescent smoking. Am J Pub Health 70:678-679, 1980.

62:521-523, 1977.

Rise Morgenstern Arkin. MEd, Helen F. Roemhild, BS, Russell V.Leupker, MD and David M. Murray, PhD (Corresponding author) are all at the University of Minnesota Laboratory of Physiological Hygiene, School of Public Health, Stadium Gate 27, 611 Beacon Street SE, Minneapolis, MN 55455. C. Anderson Johnson, PhD, is in the Laboratory for Health Behavior Studies, School of Pharmacy, John Stau ffer Pharmaceutical Sciences Center, University of Southern California, 1985 Zonal Avenue, Los Agneles, CA 90033.

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616 THE JOURNAL OF SCHOOL HEALTH NOVEMBER 1981