“Be Smart: Don’t Start”

Early฀elementary฀school Later฀elementary฀school Knowledge:฀students฀will฀learn฀that Knowledge:฀students฀will฀learn฀that A฀drug฀is฀a฀chemical฀that฀changes฀how฀the฀ body฀works Stopping฀tobacco฀use฀has฀short-฀and฀long-term฀ beneits All฀forms฀of฀tobacco฀contain฀a฀drug฀ called฀nicotine Environmental฀tobacco฀smoke฀is฀dangerous฀to฀ health Tobacco฀use฀includes฀cigarettes฀and฀ smokeless฀tobacco Most฀young฀persons฀and฀adults฀do฀not฀use฀ tobacco Tobacco฀use฀is฀harmful฀to฀health Nicotine,฀contained฀in฀all฀forms฀of฀tobacco,฀is฀ an฀addictive฀drug Stopping฀tobacco฀use฀has฀short-term฀and฀ long-term฀beneits Tobacco฀use฀has฀short-term฀and฀long-term฀ physiologic฀and฀cosmetic฀consequences Many฀persons฀who฀use฀tobacco฀have฀ trouble฀stopping Personal฀feelings,฀family,฀peers,฀and฀the฀media฀ inluence฀decisions฀about฀tobacco฀use Tobacco฀smoke฀in฀the฀air฀is฀dangerous฀to฀ anyone฀who฀breathes฀it Tobacco฀advertising฀is฀often฀directed฀toward฀ young฀persons Many฀ires฀are฀caused฀by฀persons฀who฀smoke Young฀persons฀can฀resist฀pressure฀to฀use฀tobacco Some฀advertisements฀try฀to฀persuade฀ persons฀to฀use฀tobacco Laws,฀rules,฀and฀policies฀regulate฀the฀sale฀and฀ use฀of฀tobacco Most฀young฀persons฀and฀adults฀do฀not฀use฀ tobacco Persons฀who฀choose฀to฀use฀tobacco฀are฀not฀ bad฀persons Attitudes:฀students฀will฀demonstrate Attitudes:฀students฀will฀demonstrate A฀personal฀commitment฀not฀to฀use฀tobacco A฀personal฀commitment฀not฀to฀use฀tobacco Pride฀about฀choosing฀not฀to฀use฀tobacco Pride฀about฀choosing฀not฀to฀use฀tobacco Support฀for฀others’฀decisions฀not฀to฀use฀tobacco Responsibility฀for฀personal฀health Skills:฀students฀will฀be฀able฀to Skills:฀students฀will฀be฀able฀to Communicate฀knowledge฀and฀personal฀ attitudes฀about฀tobacco฀use Communicate฀knowledge฀and฀personal฀attitudes฀ about฀tobacco฀use Encourage฀other฀persons฀not฀to฀use฀tobacco Encourage฀other฀persons฀not฀to฀use฀tobacco Demonstrate฀skills฀to฀resist฀tobacco฀use State฀the฀beneits฀of฀a฀smoke-free฀environment Develop฀counterarguments฀to฀tobacco฀advertise- ments฀and฀other฀promotional฀materials Support฀persons฀who฀are฀trying฀to฀stop฀using฀ tobacco Middle฀schooljunior฀high฀School฀ knowledge:฀students฀will฀learn฀that Senior฀high฀school฀knowledge:฀students฀will฀ learn฀that Most฀young฀persons฀and฀adults฀do฀not฀ smoke Most฀young฀persons฀and฀adults฀do฀not฀smoke Laws,฀rules,฀and฀policies฀regulate฀the฀sale฀ and฀use฀of฀tobacco Tobacco฀use฀has฀short-฀and฀long-term฀physi- ologic,฀cosmetic,฀social,฀and฀economic฀ consequences Tobacco฀manufacturers฀use฀various฀ strategies฀to฀direct฀advertisements฀ toward฀young฀persons,฀such฀as฀ “image”advertising Cigarette฀smoking฀and฀smokeless฀tobacco฀use฀ have฀direct฀health฀consequences Table 12.2 ฀฀฀Instructional฀concepts฀kindergarten฀through฀grade฀12฀for฀school฀health฀programmes฀to฀ prevent฀tobacco฀use฀and฀addiction฀ [43] Table 12.2 ฀฀฀continued Early฀elementary฀school Later฀elementary฀school Knowledge:฀students฀will฀learn฀that Knowledge:฀students฀will฀learn฀that Tobacco฀use฀has฀short-฀and฀long฀term฀ physiologic,฀cosmetic,฀social,฀and฀ economic฀consequences Community฀organizations฀have฀information฀ about฀tobacco฀use฀and฀can฀help฀persons฀stop฀ using฀tobacco Cigarette฀smoking฀and฀smokeless฀tobacco฀ use฀have฀direct฀health฀consequences Smoking฀cessation฀programs฀can฀be฀successful Maintaining฀a฀tobacco-free฀environment฀ has฀health฀beneits Tobacco฀use฀is฀an฀unhealthy฀way฀to฀manage฀ stress฀or฀weight Tobacco฀use฀is฀an฀unhealthy฀way฀to฀manage฀ stress฀or฀weight Tobacco฀use฀during฀pregnancy฀has฀harmful฀ effects฀an฀the฀foetus Community฀organizations฀have฀information฀ about฀tobacco฀use฀and฀can฀help฀persons฀ stop฀using฀tobacco Schools฀and฀community฀organizations฀can฀ promote฀a฀smoke-free฀environment Smoking฀cessation฀programs฀can฀be฀ successful Many฀persons฀ind฀it฀hard฀to฀stop฀using฀tobacco,฀ despite฀knowledge฀about฀the฀health฀hazards฀ of฀tobacco฀use Tobacco฀contains฀other฀harmful฀substances฀ in฀addition฀to฀nicotine Attitudes:฀students฀will฀demonstrate Attitudes:฀students฀will฀demonstrate A฀personal฀commitment฀not฀to฀use฀tobacco A฀personal฀commitment฀not฀to฀use฀tobacco Pride฀about฀choosing฀not฀to฀use฀tobacco Pride฀about฀choosing฀not฀to฀use฀tobacco Responsibility฀for฀personal฀health Responsibility฀for฀personal฀health Support฀for฀others’฀decisions฀not฀to฀use฀ tobacco Support฀for฀others’฀decisions฀not฀to฀use฀ tobacco Conidence฀in฀personal฀ability฀to฀resist฀ tobacco฀use Conidence฀in฀personal฀ability฀to฀resist฀tobacco฀ use Willingness฀to฀use฀school฀and฀community฀ resources฀for฀information฀about,฀and฀help฀ with,฀resisting฀or฀quitting฀tobacco฀use Skills:฀students฀will฀be฀able฀to Skills:฀students฀will฀be฀able฀to Encourage฀other฀persons฀not฀to฀use฀tobacco Encourage฀other฀persons฀not฀to฀use฀tobacco Support฀persons฀who฀are฀trying฀to฀stop฀ using฀tobacco Support฀persons฀who฀are฀trying฀to฀stop฀using฀ tobacco Communicate฀knowledge฀and฀personal฀ attitudes฀about฀tobacco฀use Communicate฀knowledge฀and฀personal฀attitudes฀ about฀tobacco฀use Demonstrate฀skills฀to฀resist฀tobacco฀use Demonstrate฀skills฀to฀resist฀tobacco฀use Identify฀and฀counter฀strategies฀used฀in฀ tobacco฀advertisements฀and฀other฀ promotional฀materials Identify฀and฀counter฀strategies฀used฀in฀tobacco฀ advertisements฀and฀other฀promotional฀ materials Develop฀methods฀for฀coping฀with฀tobacco฀ use฀by฀parents฀and฀with฀other฀dificult฀ personal฀situations,฀such฀as฀peer฀ pressure฀to฀use฀tobacco Develop฀methods฀for฀coping฀with฀tobacco฀use฀ by฀parents฀and฀with฀other฀dificult฀personal฀ situations,฀such฀as฀peer฀pressure฀to฀use฀ tobacco Request฀a฀smoke-free฀environment Use฀school฀and฀community฀resources฀for฀ information฀about฀and฀help฀with,฀resisting฀or฀ quitting฀tobacco฀use Initiate฀school฀and฀community฀action฀to฀support฀ a฀smoke-free฀environment These฀concepts฀reinforce฀content฀introduced฀during฀earlier฀grades. subjects฀“Smoking”฀and฀“Taking฀a฀stand”฀are฀not฀covered฀in฀years฀12.฀The฀following฀life฀ skill฀areas฀are฀covered฀in฀a฀manner฀commensurate฀with฀the฀children’s฀age:฀self-image฀and฀ ability฀to฀understand฀the฀situation,฀handling฀stress,฀communication฀issues,฀critical฀think- ing฀and฀taking฀a฀stand,฀problem-solving฀and฀health-related฀knowledge.฀From฀school฀year฀ 3฀ onwards,฀ students฀ learn฀ about฀ the฀ harmful฀ constituents฀ of฀ tobacco฀ smoke฀ and฀ their฀ implications฀for฀health฀are฀presented.฀Extensive฀and฀varied฀study฀and฀exercise฀materials฀ are฀made฀available฀to฀the฀students.฀The฀programme’s฀mascot฀is฀“Igor฀the฀Hedgehog”฀who฀ says฀“No”฀to฀cigarettes฀ [65] . The฀ study฀ was฀ conducted฀ in฀ particular฀ to฀ establish฀ whether฀ students฀ show฀ positive฀ changes฀in฀terms฀of฀smoking฀behaviour฀and฀whether฀they฀also฀show฀positive฀development฀ in฀terms฀of฀expectations,฀attitudes฀and฀knowledge฀with฀regard฀to฀smoking.฀On฀the฀basis฀of฀ a฀questionnaire฀score,฀the฀students฀were฀assessed฀for฀smoking฀behaviour฀and฀for฀its฀per- sonal฀consequences฀on฀them.฀Since฀the฀teaching฀activities฀were฀easy฀to฀implement,฀the฀ programme฀was฀very฀positively฀assessed฀by฀students฀and฀teachers฀ [65] .฀A฀positive฀inlu- ence฀has฀been฀assumed฀on฀the฀psychosocial฀behaviour฀of฀the฀students:฀aggressive฀behav- iour฀among฀the฀younger฀students฀was฀reduced฀and฀there฀was฀a฀decline฀in฀social฀problems฀ among฀the฀older฀students฀in฀terms฀of฀delinquent฀and฀anxious,฀aggressive฀behaviour฀pat- terns฀ [65] .฀However,฀it฀is฀important฀to฀note฀that฀only฀the฀short-term฀effects฀of฀the฀interven- tion฀ were฀ studied฀ and฀ that฀ consequently฀ no฀ conclusions฀ can฀ be฀ drawn฀ concerning฀ the฀ permanence฀of฀the฀resulting฀behaviour฀patterns฀self-worth,฀strength฀of฀resistance,฀par- ticularly฀since฀the฀frequency฀of฀tobacco฀consumption฀will฀increase฀ [34] .

12.5 Class 2000 Health Promotion Programme

This฀ programme฀ also฀ aims฀ at฀ the฀ primary฀ prevention฀ of฀ addiction฀ during฀ the฀ early฀ school฀years.฀Its฀objectives฀are฀to฀promote฀a฀positive฀attitude฀to฀health฀at฀an฀early฀stage฀ and,฀by฀strengthening฀life฀skills,฀to฀exert฀an฀addiction-preventing฀inluence฀on฀the฀chil- dren’s฀behaviour฀ [66] ,฀with฀teaching฀in฀school฀focusing฀primarily฀on฀feelings฀of฀self- worth,฀ communication฀ of฀ positive฀ body฀ awareness,฀ and฀ a฀ critical฀ appraisal฀ of฀ legal฀ drugs฀and฀substances฀that฀are฀harmful฀to฀health.฀The฀ability฀to฀say฀“No”฀in฀tempting฀ situations฀is฀the฀key฀point.฀In฀order฀for฀this฀ability฀to฀be฀in฀place,฀knowledge฀has฀to฀be฀ imparted฀before฀the฀irst฀contact฀with฀the฀addictive฀substance,฀and฀the฀children฀and฀ado- lescents฀also฀have฀to฀be฀mentored฀over฀a฀longer฀period.฀Teachers฀take฀5–10฀h฀and฀spe- cialist฀health฀educators฀2–3฀h฀in฀each฀of฀the฀irst฀four฀academic฀years;฀the฀students฀are฀ given฀study฀iles,฀and฀the฀teachers฀and฀specialist฀health฀educators฀are฀issued฀with฀pre- pared฀lesson฀outlines฀ [66] .฀The฀year฀groups฀are฀mentored฀continuously฀by฀a฀member฀of฀ the฀teaching฀staff฀and฀parents฀are฀encouraged฀to฀become฀involved฀in฀the฀work฀of฀the฀ school;฀this฀results฀in฀greater฀health฀awareness฀and฀this฀is฀of฀beneit฀to฀the฀children.฀The฀ programme฀is฀inanced฀through฀sponsorship.฀These฀“Say฀No”฀effects฀are฀reinforced฀dur- ing฀information฀sessions฀designed฀to฀prevent฀addiction฀“advertising฀and฀happiness”,฀ and฀advertising฀agencies฀have฀not฀succeeded฀in฀breaking฀down฀this฀attitude฀on฀the฀part฀ of฀the฀students฀ [67] .

12.6 Trier University Health Programme

For฀the฀past฀3฀years,฀a฀programme฀designed฀to฀prevent฀cigarette฀smoking฀has฀been฀imple- mented฀in฀year฀6฀students฀aged฀11–12฀years฀from฀various฀secondary฀schools฀in฀the฀Trier฀ region.฀In฀eight฀teaching฀sessions,฀the฀prime฀objective฀is฀to฀motivate฀the฀students฀not฀to฀ start฀smoking฀at฀all.฀At฀the฀same฀time,฀social฀and฀personal฀determinants฀of฀early฀smoking฀ initiation฀are฀identiied฀so฀that฀consequences฀can฀be฀drawn฀for฀the฀programme฀content,฀ which฀is฀constantly฀reined฀in฀the฀light฀of฀new฀data.฀The฀programme฀has฀already฀been฀ described฀in฀various฀publications฀ [39,฀40,฀68,฀69] ฀and฀is฀based฀on฀the฀most฀up-to-date฀ social฀skills฀approaches฀designed฀primarily฀to฀modify฀speciic฀social฀behavioural฀patterns฀ of฀children฀and฀adolescents฀with฀regard฀to฀smoking.฀The฀programme฀has฀been฀integrated฀ into฀the฀school฀curriculum฀and฀it฀comprises฀complementary฀scientiic฀research฀as฀well฀as฀ parental฀collaboration฀and฀public฀relations฀work.฀The฀teaching฀sessions฀have฀revealed฀that฀ students฀with฀smoking฀experience฀are฀more฀prepared฀to฀take฀risks฀than฀non-smokers฀of฀the฀ same฀age.฀They฀also฀have฀a฀considerably฀more฀positive฀image฀of฀smokers. Alongside฀encouraging฀results,฀however,฀this฀study฀also฀revealed฀a฀fall฀in฀the฀number฀of฀ non-smokers,฀although฀no฀educational฀or฀scare฀programme฀was฀used฀for฀which฀such฀an฀ effect฀has฀been฀demonstrated.฀It฀may฀be฀that฀this฀relects฀a฀development฀effect฀in฀as฀much฀ as฀the฀developmental฀tasks฀facing฀adolescents฀e.g.฀leaving฀the฀parental฀home,฀peer฀orien- tation฀coincide฀with฀trial฀consumption฀exploratory฀behaviour฀ [70,฀71] .฀Clues฀to฀this฀may฀ be฀early฀smoking฀initiation,฀and฀the฀connections฀between฀smoking฀behaviour฀and฀a฀ten- dency฀towards฀risky฀forbidden฀activities฀ [42] .

12.7 Long-Term Studies

Within฀the฀past฀8฀years,฀three฀large-scale฀studies฀have฀been฀performed฀to฀investigate฀the฀ prevention฀of฀smoking฀initiation฀among฀adolescents:฀a฀drug฀abuse฀prevention฀trial฀in฀a฀ middle-class฀ population฀ [60] ,฀ a฀ follow-up฀ of฀ smoking฀ prevention฀ effects฀ in฀ the฀ North฀ Karelia฀project฀ [72] ฀and฀the฀Hutchinson฀Smoking฀Prevention฀Project฀ [73] .฀The฀irst฀of฀ these฀studies฀was฀a฀randomised฀trial฀involving฀56฀public฀schools฀3,597฀predominantly฀ white,฀12th฀grade฀students฀who฀represented฀60.4฀of฀the฀initial฀7th฀grade฀sample.฀The฀ schools฀received฀the฀prevention฀programme฀with฀annual฀provider฀training฀workshops฀and฀ ongoing฀consultation,฀the฀prevention฀programme฀with฀videotaped฀training฀and฀no฀consul- tation,฀or฀“treatment฀as฀usual”฀i.e.฀controls.฀The฀intervention฀consisted฀of฀15฀classes฀in฀ 7th฀grade,฀10฀booster฀sessions฀in฀8th฀grade,฀and฀5฀booster฀sessions฀in฀9th฀grade.฀The฀pro- gramme฀taught฀general฀“life฀skills”฀and฀skills฀for฀resisting฀social฀inluences฀to฀use฀drugs.฀ The฀ follow-up฀ data฀ were฀ collected฀ 6฀ years฀ after฀ baseline฀ using฀ school,฀ telephone฀ and฀ mailed฀surveys.฀Six฀tobacco,฀alcohol฀and฀marijuana฀use฀self-report฀scales฀were฀recorded.฀ Reductions฀in฀drug฀and฀polydrug฀use฀were฀found,฀and฀the฀strongest฀effects฀were฀produced฀ for฀individuals฀who฀received฀a฀reasonably฀complete฀version฀of฀the฀intervention,฀resulting฀