J. Allan Best

Are Social-Psychological Smoking Prevention Programs Effective? The Waterloo Study

Recent evaluations of smoking prevention programs have suggested considerable promise for curricula emphasizing resistance of social influences. The present study extends these evaluations by addressing key methodological limitations in previous work. Twenty-two matched schools were randomized to experimental and control conditions. Grade 6 students received a 6-week core curriculum, plus additional sessions through Grades 7 and 8. Questionnaires, and saliva samples to validate self-reported smoking behavior, were collected at five times over the 2-year study period. Cross-sectional and longitudinal analyses examined program impact for five levels of initial smoking experience, ranging from “never smoker” through regular, weekly smoker. Significant program effects were documented, most clearly for those having some experience with smoking before the program began and for those with smoking peer and family models. This study provides the methodologically most rigorous test to date of social influence programs for smoking prevention and documents for the first time significant effects for those at high risk for smoking.

A situation-specific model for smoking behavior.

Abstract Ratings of common cigarette smoking situations were analyzed to develop a model of smoking behavior consistent with behavioral intervention techniques. Mean intensity of urge was rated for each of 63 smoking situations by 177 males and 154 females drawn from the general population. Multivariate analyses of the data revealed distinct response patterns for males and females. Factor analyses for each sex yielded a relatively large number of homogeneous factors. In general, the results suggest a more varied and differentiated pattern of smoking than has been suggested previously. It is argued that this model of smoking behavior may be able to provide a basis for tailoring smoking modification procedures to individual reasons for smoking.

Aversive and cognitive factors in the modification of smoking behaviour.

Abstract This study investigated the role of verbalization and behavioural rehearsal procedures in an aversive conditioning behaviour therapy for smokers. Experimental conditions, contrasted with an insight control condition, featured combinations of overt or covert verbalizations describing the smoking act and the use or omission of behavioural rehearsal of the smoking act concomitant to an avoidance conditioning procedure. Substantial improvement was obtained, and continued in the follow-up, from a particular combination of behavioural rehearsal and covert verbalization. In this condition S s were trained to smoke a cigarette while imagining themselves to be in a social situation, and while making a sub-voca description of their smoking behaviour. These results have led to the speculation that the manipulation of covert events and behavioural rehearsal of the deviant act may be important adjuncts of the aversive paradigm by virtue of the greater generalizability of the self-generated cues to extra-therapy situations.

Tracking and attrition in longitudinal school-based smoking prevention research☆

Research in the development of school-based smoking prevention programs has resulted in a set of approaches of known short-term efficacy. Further evaluation of these approaches now requires long-term follow-up of participants. To minimize the problems caused by attrition in these longitudinal studies, investigators have developed techniques for tracking study participants. Based primarily on the use of the telephone, mail, and public documents, these methods require good background information on both the study participants and their parents. This article summarizes the experience of three teams of researchers engaged in such follow-up studies. These investigators have identified the types of background information most useful in long-term follow-up of participants, have developed a set of strategies to obtain such background information, and have developed methods for successfully tracking participants after a lapse of several years.

Smoking modification procedures tailored to subject characteristics

Explanations of treatment were devised to capitalize on the individual differences of smoking clinic clientele volunteering for a standard aversive conditioning treatment. The experimental design permitted study of the interactions of specially tailored explanations and the individual difference dimensions from which the commentaries were derived. The primary goal of the study was to contrast the utility of an internalized “willpower”-oriented approach to smoking control with an externalized environmentbased approach to self-control and to analyze the relative worth of these procedures for clients falling at the high and low end of the Rotter LOC scale. Also, procedures designed to induce dissonance gave an opportunity to test the application of a dissonance model and, in post hoc analyses, to study the interaction of the dissonance-inducing procedure with pretreatment levels of dissonance as measured by Keutzers ECD scale. The results failed to show promise for the control manipulation or its interaction with LOC scores, but the dissonance procedure alone and in interaction with the ECD scores produced positive findings. It was noticed that greater levels of induced dissonance produced greater reductions in smoking, and that the best improvements occurred in subjects with high natural dissonance scores who received the low dissonance procedures, and low dissonance score subjects who received the strong dissonance induction.

Overcoming design problems in evaluating health behavior programs.

The increasing importance of high-quality evaluative research on health lifestyle change programs is established. Failure to ask the right evaluative research questions and problems of research design are identified as two major reasons for the dearth of well-controlled, interpretable evaluations in this area. Thirteen issues of research design that need to be considered if interpretable answers to evaluative research questions are to be obtained are identified and discussed. Solutions to these problems and design recommendations are offered.

Dispositional risk factors for smoking-stage transitions: A social influences program as an effect modifier

A cognitive-developmental model postulates three predominant adolescent dispositions (self-definition, social compliance, and affect regulation) which may impede or facilitate transitions in stages of smoking. The purpose of the present prospective study was to build on the findings supporting this model. One hundred schools were randomly assigned to either receive or not receive a social influences smoking prevention program. A baseline survey, including smoking behavior and dispositional items, was administered in the sixth grade in 1990, interventions were delivered in the sixth and seventh grades, and a survey was administered following the seventh grade intervention. Principal component patterns, based on dispositional items, were very similar for grades 6 and 7, did not vary by gender, and the components (rebelliousness, rejection of adult authority, personal dissatisfaction, and peer approval) were correlated. All smoking-stage transitions were positively related to rebelliousness for boys. The relationship of the dispositional scores with smoking-stage transitions was more complex for girls. Receiving the program modified the effects of the dispositional risk scores, particularly for girls.

Promoting adherence to health behavior change interventions: Recent findings from behavioral research

Abstract This paper provides an overview of adherence issues as they relate to health behavior change programs. A selective review of the weight loss, smoking cessation, and exercise literatures was conducted to illustrate basic principles and the current state of knowledge. The review suggested that the current literature lacks coherence and direction. There is a need for greater theoretical organization, standardization of interventions, examination of specific manoeuvres in relation to process and setting variables, and more systematic evaluation of intermediate as well as ultimate outcomes of adherence enhancement manoeuvres.

Smoking cessation in family practice: The effects of advice and nicotine chewing gum prescription

The efficacy of physician anti-smoking intervention with 289 patients in a family practice setting was assessed. The design included two treatment conditions, physician advice and physician advice plus the offer of nicotine chewing gum (NCG) prescription. A no-advice group permitted assessment of the effects of repeated testing. The NCG group had higher rates of abstinence at all follow-up points, but the difference approached statistical significance at 3 months only (p less than .10). Comparison of those who actually used NCG to all other groups revealed significantly more users were abstinent at 1- and 3-month follow-up. A similar pattern occurred for proportion attempting cessation and smoking reduction. A dose-response relationship of gum use to outcome was identified. Long-term users (greater than 20 days) had 86% abstinence at 3 months versus 18% for short-term users. Thus, NCG does appear to have a role in family practice for promoting short-term cessation.

Intervention Perspectives on School Health Promotion Research

J. Allan Best is with Department of Health Studies at the University of Waterloo. Address reprint requests to J. Allan Best, PhD, Department of Health Studies, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1. School health research has moved rapidly over the past decade to integrate social science advances and develop an empirical science of health promotion. However, studies differ in their theoretical underpinnings, intervention methods, and research aims. Four interlocking conceptual frameworks are useful in reviewing progress. They characterize ( 1 ) the determinants of youth health behavior and the behavior change process, (2) factors determining the impact of health promotion interventions, (3) a model of stages through which program development research progresses, and (4) the diffusion process. This article briefly reviews each framework and issues which arise in assessing recent research findings. Recommendations are made to facilitate future school health promotion research.