Trier University Health Programme Long-Term Studies

in฀44฀fewer฀drug฀users฀and฀66฀fewer฀polydrug฀tobacco,฀alcohol,฀marijuana฀users฀ [60] .฀ It฀ is฀ concluded฀ from฀ this฀ study฀ that฀ reductions฀ in฀ tobacco฀ and฀ drug฀ use฀ can฀ be฀ achieved฀by฀teaching฀social฀resistance฀and฀general฀life฀skills,฀including฀at฀least฀2฀years฀of฀ booster฀sessions. The฀second฀major฀study฀described฀the฀results฀of฀a฀15-year฀follow-up฀of฀a฀school-฀and฀ community-based฀smoking฀prevention฀project฀in฀North฀Karelia,฀Finland฀ [72] .฀Four฀inter- vention฀schools฀from฀this฀district฀and฀two฀control฀schools฀from฀another฀province฀were฀ chosen฀for฀the฀evaluation,฀beginning฀in฀1978฀with฀7th฀grade฀students฀and฀running฀through฀ 1980,฀with฀a฀15-year฀follow-up.฀In฀North฀Karelia,฀a฀community-based฀smoking฀cessation฀ programme฀for฀adults฀was฀organised฀in฀addition.฀In฀the฀intervention฀schools,฀health฀educa- tors฀and฀trained฀peer฀leaders฀led฀10฀sessions฀3฀in฀the฀7th฀grade,฀5฀in฀the฀8th฀grade,฀and฀2฀in฀ the฀9th฀grade.฀In฀1993,฀the฀subjects฀completed฀a฀questionnaire฀at฀home฀and฀a฀trained฀nurse฀ carried฀out฀a฀cardiovascular฀risk฀factor฀survey฀in฀a฀local฀health฀centre.฀Cohort฀participation฀ was฀still฀71฀after฀15฀years.฀The฀prevalence฀of฀all฀smokers฀in฀the฀four฀intervention฀schools฀ was฀between฀28฀and฀32,฀while฀that฀in฀the฀control฀schools฀was฀36฀and฀41.฀After฀15฀ years,฀cumulative฀exposure฀to฀tobacco฀in฀the฀intervention฀group฀was฀22฀lower฀than฀in฀the฀ 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 ฀฀฀Cumulative฀lifetime฀ cigarette฀smoking,฀in฀packs,฀ among฀male฀and฀female฀ students฀in฀the฀intervention฀ and฀control฀schools฀in฀the฀ North฀Karelia฀Youth฀Project฀ [72] .฀A฀total฀of฀640฀subjects฀ 71฀of฀the฀original฀cohort฀ participated฀in฀the฀inal฀ survey.฀Analyses฀of฀variance:฀ school฀group,฀p฀=฀0.027;฀sex,฀ p฀=฀0.000;฀school฀and฀sex฀ interaction,฀p฀=฀0.28 control฀group฀p฀=฀0.017฀when฀missing฀data฀points฀were฀ignored.฀The฀preventive฀effect฀ measured฀in฀terms฀of฀lifetime฀tobacco฀consumption฀was฀slightly฀more฀pronounced฀among฀ men฀than฀women฀cf.฀Fig.฀ 12.3 .฀Men฀tended฀to฀smoke฀more฀heavily฀than฀women฀ [72] .฀ Between฀the฀ages฀of฀13฀and฀28฀years,฀the฀smokers฀in฀the฀intervention฀group฀smoked฀5,500฀ fewer฀cigarettes฀than฀those฀in฀the฀control฀group.฀According฀to฀this฀study,฀long-term฀smok- ing฀prevention฀effects฀can฀be฀achieved฀by฀a฀prolonged฀but฀expensive฀social฀inluence฀model฀ in฀combination฀with฀community฀and฀mass฀media฀interventions฀ [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฀ 8,388฀students฀from฀school฀years฀3–12฀who฀were฀mentored฀through฀a฀training฀programme฀ with฀a฀total฀duration฀of฀2,805฀min,฀corresponding฀to฀225–435฀min฀per฀academic฀year.฀In฀ total,฀ 640฀ teachers฀ from฀ 72฀ schools฀ were฀ available.฀ The฀ social฀ inluences฀ programme฀ included฀discussions,฀media฀activities฀TV,฀videos,฀social฀resistance฀skills,฀avoiding฀the฀ temptation฀trap,฀as฀well฀as฀the฀accurate฀interpretation฀of฀social฀norms฀and฀the฀development฀ of฀self-conidence.฀The฀smoker฀status฀of฀the฀students฀was฀veriied฀by฀cotinine฀determina- tions฀in฀saliva฀or฀urine.฀As฀shown฀by฀the฀results฀at฀the฀end฀of฀the฀study,฀summarised฀in฀Table฀ 12.3 ,฀the฀effect฀on฀the฀adolescents฀over฀several฀years฀in฀terms฀of฀smoking฀cessation฀was฀not฀ successful฀when฀the฀results฀were฀compared฀with฀those฀in฀a฀parallel฀control฀group.฀Smoking฀ prevalence฀at฀the฀study฀end฀was฀the฀same฀in฀all฀groups฀regardless฀of฀gender.฀This฀result฀gives฀ pause฀for฀thought฀because฀exogenous฀factors฀evidently฀determine฀smoking฀behaviour฀more฀ strongly฀than฀short-,฀medium-฀or฀long-term฀educational฀or฀training฀programmes฀ [73] .

12.8 Role of Teachers in Primary Prevention

Compared฀with฀other฀EU฀countries,฀smoking฀laws฀in฀Germany฀are฀very฀liberal฀ [74] .฀The฀ rules฀for฀students฀and฀teachers฀concerning฀smoking฀on฀school฀grounds฀are฀widely฀dis- crepant฀ [75] .฀Smoking฀outside฀the฀classroom฀is฀hardly฀monitored฀at฀all.฀Infringement฀of฀ the฀rules฀by฀students฀does฀not฀trigger฀disciplinary฀measures฀in฀all฀cases.฀In฀this฀respect,฀ verbal฀instruction฀to฀students฀is฀provided฀in฀the฀minority฀of฀schools,฀but฀this฀has฀become฀ a฀focal฀point฀of฀interest฀in฀individual฀schools,฀thanks฀to฀campaigns฀such฀as฀“Be฀smart฀–฀ don’t฀start”.฀One฀major฀barrier฀to฀implementing฀school฀rules฀about฀tobacco฀use฀is฀the฀ inclusion฀of฀tobacco฀consumption฀by฀the฀teaching฀staff฀ [76] .฀Regulations฀on฀smoking฀in฀ schools฀vary฀widely฀for฀teachers฀and฀students,฀as฀well฀as฀for฀students฀in฀different฀year฀ groups.฀Teachers฀are฀permitted฀to฀smoke฀in฀almost฀every฀school฀and฀also฀believe฀that฀this฀ Girls Boys Control฀classes฀n฀=฀20 24.7฀0–41.9 26.7฀14.2–46.3 “Treated”฀classes฀n฀=฀20 24.4฀15.5–34.2 26.3฀10.3–41.7 Difference 0.25฀p฀=฀0.91 0.33฀p฀=฀0.89 Table 12.3 ฀฀฀Results฀of฀the฀Hutchinson฀smoker฀prevention฀programme Smoking฀prevalence฀among฀adolescents฀at฀the฀end฀of฀the฀study฀ [73] does฀ not฀ inluence฀ their฀ students’฀ behaviour.฀ Inconsistency฀ such฀ as฀ this฀ in฀ any฀ single฀ institution฀can฀only฀have฀a฀negative฀effect฀on฀the฀credibility฀of฀tobacco-use฀prevention฀in฀ the฀ school฀ and฀ may฀ even฀ condemn฀ such฀ programmes฀ to฀ failure฀ [74,฀ 77] .฀ Ultimately,฀ teachers฀should฀act฀as฀role฀฀models฀for฀their฀students,฀and฀therefore฀tobacco฀consumption฀ by฀teachers฀inevitably฀becomes฀a฀key฀determinant฀of฀student฀behaviour฀ [78] .฀Many฀stu- dents฀report฀that฀their฀teachers฀smoke฀and฀this฀provides฀them฀with฀an฀alibi฀for฀their฀own฀ smoking฀behaviour.

12.9 Prevention by Restricting Sales of Tobacco Products to Minors

In฀addition฀to฀health฀education฀for฀students,฀another฀possibility฀of฀delaying฀smoking฀initia- tion฀among฀minors฀is฀the฀statutory฀regulation฀of฀cigarette฀sales฀to฀young฀people฀below฀the฀ age฀of฀16฀years฀by฀the฀enforcement฀of฀youth-protection฀legislation.฀Campaigns฀using฀post- ers฀such฀as฀those฀depicted฀in฀Figs.฀ 12.4 ฀and฀ 12.5 ฀can฀also฀be฀effective฀in฀a฀school฀setting.฀ At฀the฀same฀time,฀the฀numerous฀cigarette฀vending฀machines฀sited฀close฀to฀schools฀should฀ be฀removed฀and,฀in฀conjunction฀with฀new฀legislation,฀retailers฀should฀be฀“educated”฀to฀ recognise฀that฀the฀sale฀of฀cigarettes฀to฀children฀and฀adolescents฀16฀years฀of฀age฀is฀both฀ illegal฀and฀immoral.฀Such฀action฀could฀ultimately฀bring฀about฀changes฀in฀adolescent฀smok- ing฀behaviour.฀Studies฀examining฀this฀issue฀have฀been฀reviewed฀in฀the฀USA฀ [79] .฀In฀con- nection฀with฀the฀sale฀of฀tobacco฀products,฀the฀US฀studies฀showed฀that฀three฀questions฀were฀ important:฀1฀whether,฀in฀response฀to฀appropriate฀interventions,฀retailers฀comply฀with฀the฀ request฀no฀longer฀to฀sell฀cigarettes฀to฀adolescents;฀2฀whether฀adolescents฀quit฀cigarette฀ smoking฀or฀at฀least฀cut฀down฀to฀some฀extent;฀and฀3฀whether฀such฀interventions฀produce฀a฀ decline฀in฀smoking฀prevalence฀among฀adolescents. Overall,฀attempts฀to฀inluence฀retailers฀by฀verbally฀advising฀them฀of฀the฀legal฀situation฀ have฀been฀minimally฀effective฀ [80,฀81] .฀Availability฀from฀other฀sources฀may฀be฀a฀deci- sive฀factor,฀as฀demonstrated฀by฀a฀study฀in฀700฀communities฀in฀Massachusetts฀ [81] .฀More฀ favourable฀results฀were฀only฀achieved฀when฀the฀interventions฀included฀personal฀visits฀to฀ the฀retailers฀and฀mobilisation฀of฀assistance฀from฀the฀community฀ [82] .฀Only฀a฀permanent฀ warning฀to฀retailers฀was฀found฀to฀be฀effective,฀and฀eficacy฀was฀reduced฀when฀4–6฀checks year฀were฀made฀ [83] .฀Penalties฀have฀an฀important฀part฀to฀play฀where฀violations฀are฀found฀ but฀ these฀ must฀ be฀ set฀ at฀ the฀ right฀ level฀ because฀ excessive฀ leniency฀ merely฀ serves฀ to฀ harden฀retailers฀to฀the฀issue.฀The฀threatened฀withdrawal฀of฀tobacco฀sales฀licences฀would฀ carry฀more฀weight฀if฀retailer฀compliance฀were฀to฀be฀monitored฀continually฀ [84] .฀Where฀ legal฀circumstances฀permit,฀a฀graduated฀system฀of฀warnings฀and฀ines฀through฀to฀licence฀ withdrawal฀would฀be฀effective.฀Similarly,฀a฀warning฀system฀with฀graduated฀ines฀targeted฀ at฀smoking฀adolescents฀in฀Woodridge฀was฀highly฀effective฀but฀did฀not฀meet฀with฀very฀ wide฀acceptance฀ [85] .฀The฀sanctions฀directed฀at฀offending฀tobacco฀retailers฀only฀hit฀home฀ where฀a฀uniform฀policy฀existed฀in฀the฀states฀surrounding฀Woodridge฀ [86] .฀Likewise,฀ado- lescent฀lockout฀devices฀on฀cigarette฀vending฀machines,฀such฀as฀are฀currently฀also฀being฀ tested฀in฀Germany,฀have฀been฀less฀effective฀than฀removal฀of฀the฀vending฀machines฀alto- gether฀ [87] .