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Activism more than lectures prompts teen smokers to cut back on cigarettes
A novel approach showed that teens reduced their own smoking while trying to persuade others to quit


Scare tactics and lectures don’t persuade teenage smokers to change their habits, but engaging them as anti-smoking activists does, say School of Medicine researchers.

A study involving 10 Bay Area continuation, or alternative, high schools found that among students who were regular smokers, those who engaged in anti-tobacco advocacy efforts significantly reduced their own cigarette use compared with teens in traditional drug abuse prevention classes. What the researchers found even more encouraging was that the decrease continued six months later – a rarity in the efforts to reduce cigarette use among teens.

“The real, sustained change we saw is different from most other studies on teenage smoking. In past studies where smoking behaviors changed, the effect was very transitory,” said Marilyn Winkleby, PhD, associate professor of medicine at the Stanford Prevention Research Center and senior author of the paper published in the March issue of the Archives of Pediatrics and Adolescent Medicine.

Smoking remains the leading cause of illness, disability and death in the United States, with adolescents being the most likely to begin using tobacco, Winkleby said. In 2001, 36 percent of high school students reported smoking cigarettes within the past 30 days. That rate is closer to 70 percent at continuation high schools, which serve students who are at risk of failing or dropping out of regular school or have been removed from their school for other reasons.

In comparing teen smokers in traditional prevention classes to those who were part of an anti-tobacco advocacy program, researchers found that cigarette use dropped dramatically for those in the advocacy program. The first panel shows the number of students who smoked a pack or more a week before beginning each program, while the second and third panels show the changes at the end of the training and again six months later. Graphic: Amy Feldman

Ten continuation high schools in the San Francisco/San Jose area were selected for the study, with five randomly assigned to a new anti-tobacco advocacy curriculum and the other five to an existing curriculum on drug and alcohol abuse prevention. Juniors and seniors were recruited during each of four semesters to attend a weekly class for which they received credit.

Students were surveyed to determine their tobacco use at the beginning of each semester. Roughly 35 percent were non-smokers (never or former smokers), 40 percent were light smokers (less than a pack a week) and 25 percent were regular smokers (a pack or more a week). Students breathed into a carbon-monoxide monitor to confirm their reported level of smoking. At the end of the semesters and again six months later, they were re-surveyed about their tobacco use.

For students in the advocacy curriculum the most significant change was among regular smokers, whose smoking decreased by 3.8 percent at the end of the semester and an additional 1 percent six months later. By comparison, the rate among regular smokers in the drug and alcohol prevention curriculum increased by 1.5 percent at the end of the semester. “Without any intervention, you would expect to see even larger increases in smoking during a period of six months to a year,” Winkleby said. “The fact that the regular smokers in the advocacy curriculum made a significant decrease in their usage and sustained that behavior for another six months is very encouraging.”

The goal of the advocacy program was to heighten students’ awareness of the cues in their school and community environments that promote cigarette use, Winkleby said. “It’s not the traditional approach of providing individuals with information to get them to change their own behavior. It’s an indirect way to bring about behavior change by making students aware of the social context of smoking behavior.”

Students learned about tobacco availability and advertising strategies, and assessed tobacco promotion in their communities. “Most of them were surprised and then angry when they realized how extensive it was,” Winkleby said. “Teenagers don’t like it when other people try to influence them.”

The students then developed, implemented and evaluated advocacy projects that included: forming a task force to enforce campus smoking bans; increasing store compliance with laws limiting tobacco ads on building exteriors; eliminating magazines with cigarette ads from medical and dental offices; and convincing city council members to decline campaign contributions from tobacco companies.

The drug and alcohol prevention classes for the five other schools were adapted from a highly regarded curriculum that had proved effective among continuation students, Winkleby said. It focused on health motivation, social skills and decision-making regarding drug and alcohol use.

The success of the advocacy approach in changing smoking behavior makes it a strategy worth evaluating for other health-related issues, such as helping teens make better food and exercise choices, Winkleby said.

Other co-authors of the study include statistical computer analyst David Ahn, PhD, and Joel Killen, PhD, professor (research) of medicine at the Stanford Prevention Research Center. The study was funded by a grant from the National Institute on Drug Abuse.

Packard residents fight Hollywood puffing

Junior pediatric residents at Lucile Packard Children’s Hospital are setting their sights on teen smoking, taking aim at a big target: Hollywood.

A study that appeared in The Lancet last June said that adolescents who see movie characters smoking are more likely to pick up the habit themselves than are adolescents without the exposure. Other research has shown that the number of movies portraying smoking is on the rise. The residents are working with the Campaign for Tobacco-Free Kids and the national Smoke Free Movies organization to address the problem.

“Smoking in movies is a significant health threat to children,” said Lisa Chamberlain, MD, who supervises Packard’s advocacy training course for residents and is one of the Smoke Free Movies project leaders. “We want Hollywood to take notice.”

Packard residents are meeting with community leaders, school boards and health-care providers to gather signatures on letters and petitions along with empty cigarette cartons as part of an aggressive education and awareness plan. In June, the residents will deliver these signatures to some of Hollywood’s most influential moviemakers.

The hope? Filmmakers will reduce smoking in movies and voluntarily assign R-ratings for movies that contain smoking scenes.

The Packard residents are also educating area students on the dangers of youth smoking and how tobacco companies benefit from smoking in movies. “The community is learning that movie smoking is a serious health issue,” said Seth Ammerman, MD, assistant professor in pediatrics and co-leader of the project with Chamberlain. “It’s clear that children who are exposed to smoking and smoking marketing in movies are more likely to try it themselves, and the residents are doing something about it.” – Robert Dicks

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