in44fewerdrugusersand66fewerpolydrugtobacco,alcohol,marijuanausers [60]
. It is concluded from this study that reductions in tobacco and drug use can be achievedbyteachingsocialresistanceandgenerallifeskills,includingatleast2yearsof
boostersessions. Thesecondmajorstudydescribedtheresultsofa15-yearfollow-upofaschool-and
community-basedsmokingpreventionprojectinNorthKarelia,Finland [72]
.Fourinter- ventionschoolsfromthisdistrictandtwocontrolschoolsfromanotherprovincewere
chosenfortheevaluation,beginningin1978with7thgradestudentsandrunningthrough 1980,witha15-yearfollow-up.InNorthKarelia,acommunity-basedsmokingcessation
programmeforadultswasorganisedinaddition.Intheinterventionschools,healtheduca- torsandtrainedpeerleadersled10sessions3inthe7thgrade,5inthe8thgrade,and2in
the9thgrade.In1993,thesubjectscompletedaquestionnaireathomeandatrainednurse carriedoutacardiovascularriskfactorsurveyinalocalhealthcentre.Cohortparticipation
wasstill71after15years.Theprevalenceofallsmokersinthefourinterventionschools wasbetween28and32,whilethatinthecontrolschoolswas36and41.After15
years,cumulativeexposuretotobaccointheinterventiongroupwas22lowerthaninthe
13 15 16 17
21 28
Age [years]
Intervention females
Intervention males
Control females
Control males
200 400
Smoked Cigarette Packs
600 800
1000 1200
Fig. 12.3
Cumulativelifetime cigarettesmoking,inpacks,
amongmaleandfemale studentsintheintervention
andcontrolschoolsinthe NorthKareliaYouthProject
[72] .Atotalof640subjects
71oftheoriginalcohort participatedintheinal
survey.Analysesofvariance: schoolgroup,p=0.027;sex,
p=0.000;schoolandsex interaction,p=0.28
controlgroupp=0.017whenmissingdatapointswereignored.Thepreventiveeffect measuredintermsoflifetimetobaccoconsumptionwasslightlymorepronouncedamong
menthanwomencf.Fig. 12.3
.Mentendedtosmokemoreheavilythanwomen [72]
. Betweentheagesof13and28years,thesmokersintheinterventiongroupsmoked5,500
fewercigarettesthanthoseinthecontrolgroup.Accordingtothisstudy,long-termsmok- ingpreventioneffectscanbeachievedbyaprolongedbutexpensivesocialinluencemodel
incombinationwithcommunityandmassmediainterventions [72]
. The third recently published long-term study
[73] reveals less optimistic results for
school programmes of this type. The Hutchinson Smoking Prevention Project included 8,388studentsfromschoolyears3–12whowerementoredthroughatrainingprogramme
withatotaldurationof2,805min,correspondingto225–435minperacademicyear.In total, 640 teachers from 72 schools were available. The social inluences programme
includeddiscussions,mediaactivitiesTV,videos,socialresistanceskills,avoidingthe temptationtrap,aswellastheaccurateinterpretationofsocialnormsandthedevelopment
ofself-conidence.Thesmokerstatusofthestudentswasveriiedbycotininedetermina- tionsinsalivaorurine.Asshownbytheresultsattheendofthestudy,summarisedinTable
12.3 ,theeffectontheadolescentsoverseveralyearsintermsofsmokingcessationwasnot
successfulwhentheresultswerecomparedwiththoseinaparallelcontrolgroup.Smoking prevalenceatthestudyendwasthesameinallgroupsregardlessofgender.Thisresultgives
pauseforthoughtbecauseexogenousfactorsevidentlydeterminesmokingbehaviourmore stronglythanshort-,medium-orlong-termeducationalortrainingprogrammes
[73] .
12.8 Role of Teachers in Primary Prevention
ComparedwithotherEUcountries,smokinglawsinGermanyareveryliberal [74]
.The rulesforstudentsandteachersconcerningsmokingonschoolgroundsarewidelydis-
crepant [75]
.Smokingoutsidetheclassroomishardlymonitoredatall.Infringementof therulesbystudentsdoesnottriggerdisciplinarymeasuresinallcases.Inthisrespect,
verbalinstructiontostudentsisprovidedintheminorityofschools,butthishasbecome afocalpointofinterestinindividualschools,thankstocampaignssuchas“Besmart–
don’tstart”.Onemajorbarriertoimplementingschoolrulesabouttobaccouseisthe inclusionoftobaccoconsumptionbytheteachingstaff
[76] .Regulationsonsmokingin
schoolsvarywidelyforteachersandstudents,aswellasforstudentsindifferentyear groups.Teachersarepermittedtosmokeinalmosteveryschoolandalsobelievethatthis
Girls Boys
Controlclassesn=20 24.70–41.9
26.714.2–46.3 “Treated”classesn=20
24.415.5–34.2 26.310.3–41.7
Difference 0.25p=0.91
0.33p=0.89
Table 12.3
ResultsoftheHutchinsonsmokerpreventionprogramme
Smokingprevalenceamongadolescentsattheendofthestudy [73]
does not inluence their students’ behaviour. Inconsistency such as this in any single institutioncanonlyhaveanegativeeffectonthecredibilityoftobacco-usepreventionin
the school and may even condemn such programmes to failure [74, 77]
. Ultimately, teachersshouldactasrolemodelsfortheirstudents,andthereforetobaccoconsumption
byteachersinevitablybecomesakeydeterminantofstudentbehaviour [78]
.Manystu- dentsreportthattheirteacherssmokeandthisprovidesthemwithanalibifortheirown
smokingbehaviour.
12.9 Prevention by Restricting Sales of Tobacco Products to Minors
Inadditiontohealtheducationforstudents,anotherpossibilityofdelayingsmokinginitia- tionamongminorsisthestatutoryregulationofcigarettesalestoyoungpeoplebelowthe
ageof16yearsbytheenforcementofyouth-protectionlegislation.Campaignsusingpost- erssuchasthosedepictedinFigs.
12.4 and
12.5 canalsobeeffectiveinaschoolsetting.
Atthesametime,thenumerouscigarettevendingmachinessitedclosetoschoolsshould beremovedand,inconjunctionwithnewlegislation,retailersshouldbe“educated”to
recognisethatthesaleofcigarettestochildrenandadolescents16yearsofageisboth illegalandimmoral.Suchactioncouldultimatelybringaboutchangesinadolescentsmok-
ingbehaviour.StudiesexaminingthisissuehavebeenreviewedintheUSA [79]
.Incon- nectionwiththesaleoftobaccoproducts,theUSstudiesshowedthatthreequestionswere
important:1whether,inresponsetoappropriateinterventions,retailerscomplywiththe requestnolongertosellcigarettestoadolescents;2whetheradolescentsquitcigarette
smokingoratleastcutdowntosomeextent;and3whethersuchinterventionsproducea declineinsmokingprevalenceamongadolescents.
Overall,attemptstoinluenceretailersbyverballyadvisingthemofthelegalsituation havebeenminimallyeffective
[80,81] .Availabilityfromothersourcesmaybeadeci-
sivefactor,asdemonstratedbyastudyin700communitiesinMassachusetts [81]
.More favourableresultswereonlyachievedwhentheinterventionsincludedpersonalvisitsto
theretailersandmobilisationofassistancefromthecommunity [82]
.Onlyapermanent warningtoretailerswasfoundtobeeffective,andeficacywasreducedwhen4–6checks
yearweremade [83]
.Penaltieshaveanimportantparttoplaywhereviolationsarefound but these must be set at the right level because excessive leniency merely serves to
hardenretailerstotheissue.Thethreatenedwithdrawaloftobaccosaleslicenceswould carrymoreweightifretailercomplianceweretobemonitoredcontinually
[84] .Where
legalcircumstancespermit,agraduatedsystemofwarningsandinesthroughtolicence withdrawalwouldbeeffective.Similarly,awarningsystemwithgraduatedinestargeted
atsmokingadolescentsinWoodridgewashighlyeffectivebutdidnotmeetwithvery wideacceptance
[85] .Thesanctionsdirectedatoffendingtobaccoretailersonlyhithome
whereauniformpolicyexistedinthestatessurroundingWoodridge [86]
.Likewise,ado- lescentlockoutdevicesoncigarettevendingmachines,suchasarecurrentlyalsobeing
testedinGermany,havebeenlesseffectivethanremovalofthevendingmachinesalto- gether
[87] .