Reducing Adolescent Smoking: A Comparison of Peer-led, Teacher-led, and

~

Expert Interventions John H. Clarke, Brian MacPherson, David R. Holmes, Robert Jones

ABSTRACT: To test the effectiveness of a psychosocial strategy of smoking deterence on seventh grade students. the School Health Education Development project implemented peer-led, teacher-led, and expert-led interventions in six Vermont schools. Four additional schools served as control groups. The teacher-led approach reduced the rate of smoking onset and the intention to smoke in the future among highly vulnerable females but not among males. The peer-led approach reduced the behavioral intention to smoke for both sexes but did not affect current smoking behavior. The expert-led approach did not produce favorable effects. Both the peer-led and teacher-led interventions had positive, though not signifcant, effects on student perception of locus of control. In the control schools, females experienced higher levels of smoking onset than males. Generally, the study points toward further development of a teacher-led approach to smoking deterence based on the theory of adolescent psychosocial development and the principle of continuous reinforcement. (J Sch Health 1986;56(3): 102-106)

ptimism about progress to reduce cigarette con- 0 sumption must be tempered by the recognition that certain groups of young people remain particularly vulnerable to smoking onset. A review of experimental studies of early adolescent smoking suggests that smok- ing behavior, measured in various ways, may range widely in that group (between 10% and 50%). It is particularly problematic to estimate the proportion of individuals in only the first stages of developing an infixed nicotine habit.1*2 However, it is clear in studies of smoking onset that smoking prevalence continues to increase rapidly with age through the adolescent years and that young women are more exposed than ever to the smoking habit.

In 1979, teen-age women apparently smoked at a greater rate than their male peers for the first time, with notable increases occurring within the youngest group, ages 12-14, as well as the oldest group, ages 17-18.’ One study suggested that females may be smoking more be- cause of a greater sensitivity both to nicotine and to social pressure in the adolescent years - sensitivities nicely accommodated by available low nicotine ciga- r e t t e ~ . ~ Further success in reducing smoking may now depend on the ability to reduce initiation of the habit among subgroups of adolescents that are both particu- larly vulnerable and particularly resistant t o conven- tional deterrence strategies.

Supported by an increased understanding of adoles- cent psychology, most smoking prevention efforts have

~-

John H. Clarke, EdD, Professional Education/Curriculum Develop- ment, and David R. Holmes, PhD, Organizational, Counseling, and Foundational Studies. College of Education and Social Services, and Brian MacPherson, MS. Biometry Facility, College of Medicine, University of Vermont, Burlington, VT 05405; and Robert Jones, t d D , Vermont Lung Association, Farrell Drive, South Burlington, VT OS401. This study was supported by grant #HL17292 from the National Heart, Lung, and Blood Institute, National Institutes of Health, to the University of Vermont. Burlington. The project represents a cooperative effort between the Medical School and the Instructional Development Center of the University of Vermont and the Vermont Lung Association, Burlington.

moved away from traditional “scare tactics” toward approaches that aim to activate the natural attributes of adolescence in behalf of nonsmoking behavior.6 The more recent approaches have recognized the tendency of adolescents to reject or ignore negative health informa- tion. Indeed, the “risks” associated with smoking may make cigarettes attractive to some adolescents.’ Young people listen with greater favor to messages that also reduce the fear of peer rejection and that interrupt the chain of influence from smoking parents and respected role models.

Within the school setting, most promising programs have attempted to “innoculate” teen-agers against the spread of influence toward smoking - from peers, parents, and the media. The general aim of most suc- cessful programs has been to adjust adolescent culture within the schools so the adolescent yearning to appear “cool,” “tough,” or just older supports resistance rather than vulnerability to smoking.

How can the adult world, concerned about the pro- found health effects of smoking, influence the relatively closed world of the adolescent, where smoking may be valued as an expression of autonomy, peer affiliation, and rebellious nonconformity? Within the general model for smoking deterrence emerging from the social psychology of adolescence, three approaches have shown promise. The expert-led educational approach, represented most notably by the work of Evans,* con- veys health and social information from the world of medical science, through an adolescent interpreter, to a high school or middle school audience. The teacher-led approach, represented by the work of S p i t ~ e r r i , ~ among others, has prepared the teachers to convey health information and shift values within their assigned teaching loads. The peer-led approach best prepares respected young people to act as opinion and trend- setters within their peer groups.lo-12 The work of Luepker et a1 suggested that peer-led interventions may be more successful than an adult-led approach in re- ducing smoking behavior.I2-I4 While all three

102 Journal of School Health March 1986, Vol. 56, No. 3

approaches have shown some effect on adolescent health knowledge, attitude, or behavior, no studies have compared relative effectiveness of peer-led, teacher-led, and expert approaches to adolescent subculture within the school setting.

DESCRIPTION OF THE TREATMENT Curriculum

Within six schools selected for experimental treat- ment, a multicomponent program lasting four days, one hour each day, was conducted for all seventh grade stu- dents. Each four-hour instruction block focused on a separate source of smoking pressure: the desire to look older; the desire to be accepted by a group; the desire to look “cool” and “free;” and the desire to assert independent decisions. Each day consisted of a four- part instructional sequence, aiming in each case toward a public affirmation of free choice in the last phase of the class.

Peer, teacher, and expert leaders all used the same structure of activity: introduction to the problem; a videotape focused on the problem; role playing or ques- tion period; and development of resistance strategies. Finally, all students were encouraged to affirm that position to their group, leader, or class.

leadership Approaches A basic curriculum and tapes provided a framework

for alternative leadership approaches in three treatment situations.

Peer-led Approach: Within peer-led schools, school administrators selected ninth grade students who pre- sumably reflected the natural leadership in the school. In selecting peer leaders, school administrators were asked to avoid one-sided representation of a particular social class, gender, or student type. Rather, an attempt was made to select athletes, college preparatory stu- dents, “good kids,” and “wise guys” in a loosely structured collection of student types. Each school team had five or six student members, all of whom worked together to teach a class. The teams received a full day of training from two project staff who also supervised the team teaching and provided support to the team.

Expert-led Approach: The “expert” in the expert- led schools was a professional health educator from the Vermont Lung Association. In adapting this approach to the curriculum, the expert enforced an expert-center- ed interaction with the seventh grade students. In order, the expert spoke to them as a group, played the tape, questioned them individually on their skits or exercise sheets, and encouraged them separately to affirm deci- sions. The approach was deliberately designed to dimin- ish the level of interaction among students and make the expert’s presence the dominant influence in the room.

Teacher-led Approach: In teacher-led schools, the instructor was the health teacher assigned to the seventh grade class. With minimal training, the teachers were able to adapt their style to the requirements of the cur- riculum package. The teachers in both schools were able to introduce the four-day smoking curriculum into the regular curriculum sequence without violating the gen- eral intent of their regular courses. Like the outside “ex-

pert,” the teachers were trained to skillfully implement the four-part sequence of each day’s activity.

METHOD A cohort of 1,321 entering seventh grade students

representing ten junior/senior high schools from Ver- mont were selected to participate in the study. The two criteria that determined whether or not a school would be eligible for inclusion in the study were that each school must have a seventh-12th grade structure so that all entering seventh grade students would be exposed to a new and challenging environment and that each school have sufficient enrollment to provide adequate statisti- cal power in evaluating the effectiveness of the inter- ventions.

Schools were randomized into various treatment modalities after school administrators agreed to par- ticipate. The design scheme involved assigning two schools to each of the three treatment interventions and four schools to a control setting.

All entering seventh grade students were targeted for survey in October 1980 prior to any intervention. Special educational interventions occurred in November 1980 with some follow-up in April 1981 and again in April 1982. Observations were obtained from study subjects in May 1981, October 1981, and June 1982.

Behavioral outcomes were elicited by self-report questionnaire items similar to those used by Evans et a1.* Specifically, subjects were asked whether they smoked last month, last week, or yesterday. An addi-

Figure 1 Prevalence of Cigarette Smoking (Yesterday)

Among Females by Time and Treatment

I

P 1 R 20 { E

L Control / Expert

4

0 2 4 6 8

F S A P L R L I

N I G 9 8 1 0 9

8 10/80 1

\ Teacher

10 1 2 1 4

F A L L

1 9 8 1

10/81

- 16 18 20

S P R I N G

1 9 8 2

Journal of School Health March 1986, Vol. 56, No. 3 103

tional multilevel item involving self-reported cigarette smoking frequency was dichotomized into smokes one or more cigarettes each day versus smokes less than one cigarette each day or is a nonsmoker. Behavioral inten- tion was measured as intends to start or continue versus never intends to begin or intends to discontinue. The internal-external locus of control perception was mea- sured using the Nowicki-Strickland abbreviated instru- ment designed for use with populations of seventh-12th grade students.lJ Behavioral items were collected at all four observations while locus of control perception was measured only at the October 1980 baseline and the June 1982 follow-up.

Students were assured of anonymity both to protect confidentiality of responses and to enhance truthful reporting. Saliva thiosalinatic tests were included in the evaluation procedure, though not with reliable results. The evaluation compared the four treatment conditions with respect to rate of change over time for each of the binary behavioral outcomes as well as the continuous locus of control variate. These treatment comparisons were conducted using 5 % simultaneous tests. In particu- lar, the authors tested for equality of slopes of these trend lines, using analysis of covariance procedure, implemented by the BMDP statistical package.l6.l7

RESULTS Nonresponse ranged from 1 % to 5 % within study

schools at each of the four observations; most loss was

due to routine absenteeism rather than refusal. The prevalence of daily smoking among females by

time and intervention is displayed in Figure 1. The rate of daily smoking onset among teacher-led female stu- dents was significantly less than the rate of change for control students; the rate actually decreased for this group (simultaneous p = 0.05). Similarly, with respect to behavioral intention among female students, both teacher-led and peer-led approaches were observed to be more effective than the control situation (simultaneous p =0.05). For example, the rate at which the prevalence of intention to use cigarettes changed during the time of the study was less favorable in the control groups than in the teacher-led and peer-led strategies (Figure 2).

While the peer-led intervention also had encouraging implications for male students with respect to behavior- al intention, the difference was not statistically signifi- cant (Figure 3). The information reported in Figures 1-3 is more compactly displayed in Table 1 for all outcome measures considered. The rates of change reported in Table 1 correspond to the least-squares slope estimates of the trend lines seen in the Figures. For instance, with respect to Figure 3, the rate at which daily smoking decreased among teacher-led female students amounted to 0.24 percentage points per month. The negative sign indicates a declining slope. In general, for each of the behavioral outcome measures in Table 1, a negative slope can be associated with a favorable outcome, indi- cating that the prevalence of a faulty health practice is

Figure 2 Prevalence of Cigarette Smoking Intention Among Females by Time and Treatment

P

E v A L E N C E

R 1 0

A T E

%

R 10

F A L L

1 9 8 0

10/80

S P R I N G

1 9 8 1

F A L L

1 9 8 1

10181

S P R I N G

1 9 8 2

5/81 6/82

P R 2 0

E v A L E N C E

R l o

A T E

%

1 1

Control

/ Exoert

/ Teacher

Figure 3 Prevalence of Cigarette Smoking Intention

Among Males by Time and Treatment

~ l t l l l 1--l. 1

F S F S A P A P L R L R L I L I

N N 1 G 1 G 9 9 8 1 8 1 0 9 1 9

8 8 10180 1 10/81 2

0 2 4 6 8 10 1 2 1 4 16 18 IQ

5/81 6/82

104 Journal of School Health March 1986, Vol. 56, No. 3

declining over time. Several important observations can be made after

examining Table 1. The natural history of smoking on- set can be examined for males and females by restricting attention only to the control schools. For each behavior- al measure, females deteriorated more rapidly during the study than their male counterparts.

The intervention activity appeared to have had a greater impact on female subjects. It already has been pointed out that the teacher-led and peer-led interven- tions significantly arrested the rate at which negative be- havioral intentions were adopted among females (sim- ultaneous p =0.05). Also, in the teacher-led intervention only, the rate at which females adopted the daily smok- ing habit was significantly reduced relative to the con- trol setting. While these three findings were statistically significant, other trends were observed to be sizeable and are worth noting.

Among the female cohort, both teacher-led and peer-led subjects consistently experienced a better out- come over the course of the study than did the controls for all outcome measures examined. For male subjects, none of the treatment interventions were significantly efficacious from a statistical perspective, but some en- couraging observations can be made. For all behavioral outcome measures considered, male subjects in the expert-led and peer-led treatments had more positive experiences than their counterparts in the control groups. An especially large effect, albeit not statistically significant, was seen with respect to positive behavioral intentions among male students who participated in the peer-led program.

Locus of control perception was hypothesized a priori by the investigators to be potentially important as an intermediate outcome. Previous studies indicated

Table 1 Rate of Change Estimates During the 20-Month Study

Period by Treatment Modality, Outcome criterion, and Gender

E q u a w OI Rate of Change Outcome Changa

P-Value Gender Crltarlon R a t w Teacher Expert Peer Control

~~ - .____ - _ _ _ ~ ~ ~ - - _ _ -~ Females Yesterdaya 002 0 24’ 0 76 0 31 0 64 Smoking Last weeka 075 0 09 0 86 0 34 0 63

Last monlha 034 0 23 1 23 0 45 0 76 1 t /daya 096 0 04 0 60 0 37 0 52 With intentiona 001 0 25’ 0 80 0 16’ 0 56 to continue or begin

LCb 327 0 3 1 0 0 5 - 0 1 3 0 1 2 Males Smoking Yesterdaya 223 0 6 1 0 0 5 0 1 7 0 2 5

Lasl weeka 235 0 5 1 0 0 3 0 0 1 0 3 1 Lasl montha 375 0 45 0 20 0 18 0 59 1 + /Daya 234 0 50 0 08 0 03 0 20 Wilh intentiona 203 0 1 0 0 0 2 0 1 9 0 3 0 to continue or begin

LCb 416 0 22 0 0 4 0 15 0 02

a A binary outcome measure at each observational point the characteristic under consideration was either present or absent Group rates 01 change expressed as Percentage pointsirnonth

DLocus of Conlrol perception (LC) was translormed linearly to a scale ranging from 0 (most internal) to 100 (most external) Group rales 0 1 change expressed as LC uniis/month

‘Rale of change significantly different from lhat 01 the control group at the two-sided 5% simultaneous level 01 significance

~~~ ~ _ _ - ______-______-- -~ -

that individuals having externally-oriented loci of control are more apt to be cigarette users.5 It may be important if programs are effective in displacing the locus of control orientation toward internality. To this end, treatment-control comparisons were made with respect to this potentially important construct. While none of these differences were statistically significant, the point estimates for locus of control changes were most favorable for both males and females who partici- pated in the teacher-led and peer-led interventions.

DISC USSl ON If the experience of the control groups in this study

reflect the natural history of smoking onset among ado- lescents, grades seven-nine, female students express a greater vulnerability to influence toward smoking than do male students. While the causes of increased vulner- ability remain obscure, developmental differences be- tween males and females, cultural differences between male and female adolescent subgroups, and increased pressure toward “liberation” from the larger social environment all could play a role.

However, to the extent that females in the control group proved vulnerable to smoking onset, they also showed a greater responsiveness to treatment. The find- ings of this study suggest that the teacher-led approach may be capable of effecting a significant behavior modi- fication among females. Conceivably, a psychosocial educational approach led by a person who remains relatively permanent in a young woman’s experience and who may represent an influential role model for that student may provide a countervaling force to the pressures of smoking behavior. The teacher’s influence over perceptions of control may play some part in reducing the vulnerability of young women.

The behavioral intention to refrain from smoking, an important predictor of health behavior, also im- proved significantly among female participants in the teacher-led groups as well as for female participants in the peer-led groups. Assuming that cigarette consump- tion has not become an infixed habit among most middle school students, and assuming that adolescents generally are given to some experimentation with cig- arettes, the expression of intention not to smoke among teacher-led and peer-led women may be the most impor- tant finding of this study.

Locus of control perception was favorably though not significantly modified both for male and female students having the teacher-led experience and for male students in the peer-led intervention.

The most disappointing result of the study was the failure of the expert-led approach to generate any indi- cation of positive effect. It also is somewhat disappoint- ing that the psychosocial model of smoking interven- tion, represented by the three approaches together, pro- duced no significant changes in smoking behavior. The failure to find results in the expert-led interventions and the failure of the general model to produce results point to a similar conclusion: relatively light, short-term inter- ventions may have little effect in an environment which is bombarded with powerful, incessant prosmoking messages from the media, older peers, and adult role models. The two interventions that succeeded in affect-

Journal of School Health * March 1986, Vol. 56, No. 3 * 105

ing smoking onset - teacher-led and peer-led approach- es - had the advantage of being built into the school environment. They had their greatest effect on female students whose smoking behavior was inclining sharply against the norm. Shifting adolescent culture against cigarettes may require the active involvement of people w h o inhabit the adolescent world.

The results of this study are not entirely inconsistent with the findings of Luepker'* whose peer-led curricu- lum had greater effect on smoking behavior than the adult-led curriculum. In 60th studies, leadership from within the school setting was necessary to promote change. The young men in this study seemed to respond

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to a peer-led approach while the women responded to the teachers. This difference may reflect cultural or sexual differences in the process of smoking onset.

Possibly, because all schools in this study reflect their rural culture, the teacher-led approach showed the most promise. Teachers are relatively nonintrusive par- ticipants in the lives of rural adolescents. Teachers hold a role that may allow them to mediate effectively be- tween the adult world, with its concern for long-term health effects, and the adolescent world, with its emphasis on short-term pleasures such as social accept- ance, peer respect, and symbolic autonomy. In addi- tion, compared to expert-led and peer-led interventions, the teacher-led approach is inexpensive and easy to accomplish. Teachers do not need additional training to teach this approach. They need some well-designed materials and a clear mandate to work in behalf of smoking prevention. Future studies should consider em- powering teachers as well as peers to use their skill and influence to increase the feeling of self-efficacy among their female students and to diminish the pressures toward adolescent smoking. 0

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ette smoking among adolescents: The Muscatine Study. Prev Med 1982;11:417-428.

2. Mittelmark MB, Murray DM, Luepker RV, Pecharek T: Cigar- ette smoking among adolescents: Is the rate declining? Prev Med

3. Survey of teenage smokers , United States. MMH'K 1979;28:206.

4. Silverstein B, Feld S, Kozlowski L: The availability of low nico- tine cigarettes as a cause of cigarette smoking among teen-age females. J Health Soc Behav 1980;21:383-388.

5 . Clarke J H , MacPherson B, Holmes D: Cigarette smoking and external locus of control among young adolescents. J Health Soc Behav 1983;23:253-259.

6 . McAlister A, Perry C, Maccoby N: Adolescent smoking: Onset and prevention. Pediatr 1979;63:650-658.

7. Williams AF: Personality and other characteristics associated with cigarette smoking among young teenagers. J Health Soc Behov 1974;14:374-381.

8. Evans RI, Rozelle RM, Mittelmark MB, Hanson LB. et al: Deterring the onset of smoking in children: Knowledge of immediate psychological effects and coping with peer pressure, media pressure, and parent modeling. J Apl Soc Psycho/ 1978;8:126-135.

9. Spitzerri F, Jason L: Prevention and treatment of smoking in school-age children. J Drug Educ 1979;9:285-296.

10. McAlister A, Perry C, Killen J , Maccoby LA: Pilot study of smoking, alcohol, and drug abuse prevention. A m J Public Healrh l980;70:7 19-722.

I I . Perry C , Killen J , Telch M, Slinkard LA, et al: Long-term follow-up of a pilot project on smoking prevention with adolescents. J Behav Med 1982;5:1-8.

12. Luepker RV, Johnson C , Murray D, Pechacek T: Prevention of cigarette smoking: Three-year follow-up of a n educational program for youth. J Behav Med 1983;6:53-62.

13. Hurd P D , Johnson C, Pechacek T , Bast L, et al: Prevention o f cigarette smoking in seventh grade students. J Behav Med

14. Murray DM, Luepker RV, Johnson CA, Mittelmark MB: The prevention of cigarette smoking in children: A comparison o f two strategies. J Appl Soc Psychol 1984;14(3):274-288.

IS. Nowicki S Jr , Strickland B: A locus of control scale for chil- dren. J Clin Consul Psychol 1973;40: 148-1 54.

16. Dixon WJ: BMDP Biomedical Programs. Berkeley and 1.0s Angeles. Calif, University of California Press, 1975.

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1982;11:708-712.

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106 Journal of School Health March 1986, Vol. 56. No. 3