Case Studies On Health Promotion Initiatives From The Nordic Countries

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Contents
	Introduction
1	Promoting healthy school meals for Norwegian children
2	From control policy to comprehensive family planning: success stories from Finland
3	Everybody is needed - Södra Skaraborg, Sweden
4	The promotion of oral health among Danes
5	Interventions for smoke-free schools. From information deficit to social influence
6	The prevention of night blindness in Bangladesh
7	Health policy development in Costa Rica

Case study #5: Interventions for smoke-free schools. From information deficit to social influence

Name of the person reporting:	Leif Edvard Aarø, Ola Jøsendal, Ingunn Holden Bergh
Address:	Department of Psychosocial Science University of Bergen Christies gt. 12 N-5015 Bergen Norway
Telephone:	+ 47 - 55 58 26 06
Fax No	+ 47 - 55 58 98 79
E-mail:	Leif.Aaro@psych.uib.no

Introduction

According to a comparison across nine European countries and Canada, the prevalence of smokers among 15 year old Norwegian girls is 32 per cent. We are only surpassed by Finland. Among boys the corresponding prevalence is 29 per cent, which means we are number four on the list. In this context smoking has been defined as smoking daily, weekly or even more seldom (King & Coles, 1992). According to figures from the National Council on Smoking and Health, there has been almost no change in the smoking habits of young Norwegians during the last 8-9 years. The need for strengthening anti-smoking efforts targeting adolescents in Norway is obvious.

According to Sussmann et al (1995) school-based programmes tend to be more effective than other options in combating smoking among children and adolescents.

School-based programmes - a brief overview

The first school-based programmes against smoking were developed in the United States by Daniel Horn in the late fifties. Horn tested out five different approaches with various emphasis on messages and educational principles:

Emphasis on short-term consequences
Emphasis on lung cancer
Two-sided argumentation
Authoritative teaching approach
Giving pupils the role of teaching their parents.

The changes in smoking habits among these target groups were compared with those of a control group. It is most surprising to find that the effects in the "emphasis on lung cancer"- condition led to significantly lower recruitment of smokers than in the control group for both boys and girls. All other interventions gave less convincing results.

The history of school-based smoking prevention programmes has been dealt with in a 1994 publication from the U.S. Department of Health and Welfare. The report distinguishes between three models. The Information Deficit Model was built on the assumption that providing knowledge on the health consequences of smoking would lead to less smoking. Comprehensive reviews published at that time concluded that smoking prevention programmes based on the information deficit model were not effective (Thompson, 1978; Goodstadt, 1978).

Alternative approaches that evolved during the 1970s tested out various forms of motivational or affective education (U.S. Department of Health and Welfare, 1994). These approaches, which came to be referred to as the affective education model, sought to increase adolescents' perception of self-worth and to establish or clarify a health-related value-system that would support a young person's decision not to smoke. Reviews have concluded that interventions based on the affective model were no more effective in reducing adolescent smoking than those based on the information deficit model (Kinder, Pape & Walfish, 1980; Schaps et al., 1981; Hansen et al., 1988).

During the eighties and nineties a new generation of interventions has emerged; comprehensive interventions based on the social influence model. Since studies have consistently shown that social influences (like the behaviours and attitudes of parents and peers) play a major role in determining onset of smoking among adolescents (Aarø et al., 1981), it is reasonable to assume that such factors may play a similarly important role in keeping young people smoke-free. In the U.S. Botvin and Dusenbury have demonstrated that onset of smoking may be reduced by as much as 75 per cent by a programme labelled "Life skills training". In Minnesota Perry and associates (1992) have found that two years after the intervention started, the prevalence of smokers was 40 per cent lower in the intervention group compared to the control group.

In Norway interventions which come close to a social influence model were developed and tested out during the late 70s. One evaluation study focused on the short-term effects. Involving parents and utilizing the principle of "induced compliance" led to three times higher short-term reduction in cigarette consumption. A second, intervention (slightly modified) and evaluation study was carried out in another district in order to examine effects after one year. One year after administering the intervention, the use of cigarettes was 21 per cent lower among pupils in the intervention area compared with control schools (Aarø et al., 1983). This was the case for boys as well as for girls.

School-based interventions seem to be effective, provided that they are designed on the basis of a social influence approach.

Be (smoke) free - a school based intervention designed by the Norwegian Cancer Society

Based on experiences from previous interventions and evaluations in the U.S. and Norway, the Norwegian Cancer Society has designed an intervention programme which is currently implemented in a sample of schools in Norway. The programme has been based on experiences from previous studies, and builds largely on a social influence model. An important aim is to have a programme which appeals to those who are particularly at risk of becoming smokers, those who score high on scales for the measurement of sensation seeking, antisocial behaviour and tobacco-related outcome expectancies. The title of the programme is "BE (smoke) FREE".

The intervention started during fall 1994 targeting those who were in grade seven (13 year olds). The same classes (and pupils) are followed during three school years. The intervention consists of 8 sessions during grade seven, 5 in grade eight, and again 5 sessions in grade nine. The model intervention is based on several educational principles:

An important message is that real freedom means not smoking
It is recognized that smoking has a function for those who start smoking. Efforts are made to help the pupils finding alternative ways to obtain the same goals.
The programme emphasizes the development of skills to resist smoking pressure
Although all advertising of tobacco products is banned in Norway, indirect advertising exists. Raising awareness of the impact of indirect advertising and the role of the tobacco industry in promoting smoking among young people worldwide is focused.
Short-term benefits of not smoking are emphasized.
Efforts are made to involve the pupils actively in every session.
Parents are involved. Social support from parents has previously been shown to be an important factor in successful school-based anti-smoking programmes.

A large-scale quantitative evaluation is carried out, with (a) one control group (n=1123) and three interventions (n=1104, 1023, 974). In the first intervention group (b) the model intervention with all its elements and educational principles is administered. The second intervention (c) follows the model intervention with one important exception: The teachers are not trained. The third intervention (d) is also identical to the model intervention, except that in this group the parents are not involved.

Questionnaire surveys are carried out before the first intervention, after six months, and then after 1.5 years, after 2.5 years and after 3.5 years. The questionnaires cover topic like demography, smoking habits, factors known to predict smoking (antisocial behaviour, smoking-related outcome expectancies, parental and peer smoking, sensation seeking etc.), and pupils' perceptions of and reactions to the intervention.

Results from the first follow-up (after 6 months) are available. We have found that the recruitment of new smokers in the control group during the first six months is 8.2 per cent. In the model intervention the recruitment rate is 2.4 per cent. The other interventions seem to be less effective (4.8 per cent when teacher courses are not administered and 6.3 per cent when parents are not involved). A multiple logistic regression analysis controlling for smoking habits at baseline confirms these findings. The difference between control and model intervention is highly significant. The difference between control group and the second intervention (group c) is borderline significant.

The data presented stem from the first follow up. The results are promising. Under the model intervention the recruitment rate has been reduced by approximately 70 per cent. We can not expect similarly strong findings throughout the 3.5 years. However, the results may indicate that we may obtain effects similar to those from the best social influence programmes carried out in the United States.

When interpreting the findings we also have to bear in mind that also those pupils who belong to the control group are exposed to anti smoking education and messages. It would be unethical to prevent these pupils from being exposed to the normal stream of information regarding smoking and health. When comparing intervention and control groups we are therefore underestimating the effects of administering anti-smoking interventions.

I would like to add that preliminary analyses indicate that the Norwegian Cancer Society has been most successful in influencing "high risk" adolescents not to start smoking. By high risk we mean those who obtain high scores on indicators known to predict smoking. More specifically we have found that high sensation seekers, those who obtain high scores on a scale on antisocial behaviours and those with high scores on smoking outcome expectancies benefit more than average from the intervention programme. This will be analysed more thoroughly and elaborated in future publications from this project.

As soon as the final results from the present study are available (perhaps even before), and if the positive results so far receive additional support from the data, a national action for smoke-free schools will be launched by the Norwegian Cancer Society.

I started by referring findings from The American Cancer Society and Daniel Horn's pinoneer study from the end of the fifties. He found that communicating information about the harmful effects of lung cancer proved to be the most effective kind of school-based intervention. This seems to be in conflict with most research carried out during the last 30 years. We have to bear in mind, however, that in 1958-59 the epidemiology of smoking and health was still in its infancy, and the awareness of the connection between smoking and lung cancer was probably low. Later research has shown that stimulating discussion among the target groups is a promising approach to mass mediated health education. It is easy to imagine that the messages regarding the risk of lung cancer led to so much interpersonal discussion that the social influence processes which have proven effective, in fact did get a chance to work.

References

Aarø,L.E., Bruland,E., Hauknes,A. & Løchsen,P.M. (1983): Smoking among Norwegian schoolchildren 1975-80. III. The effect of anti smoking campaigns. Scandinavian Journal of Psychology, 24, 277-283.

Botvin,G.J. & Dusenbury,L. (1989). Substance abuse prevention and the promotion of competence. I L.A.Bond & B.E.Compas (red.). Primary prevention and promotion in the schools. Newbury Park: Sage.

Goodstadt,M.S. (1978). Alcohol and drug education: models and outcomes. Health Education Monographs, 6(3), 263-279.

Hansen,W.B., Johnson,C.A., Flay,B.R., Graham,J.W., Sobel,J. (1988). Affective and social influence approaches to the prevention of multiple substance abuse among seventh grade students: Results from project SMART. Preventive Medicine, 17(2), 135-154.

Horn,D. (1960). Modifying smoking habits in high school students. Children, 7, 63-65.

Kinder,B.N., Pape,N.E. & Walfish,S. (1980). Drug and alcohol education programs: A review of outcome studies. International Journal of the Addictions, 15(7), 1035-1054.

King,A.J. & Coles,B. (1992). The health of Canadas youth. Views and behaviours of 11-, 13- and 15-year-olds from 11 countries. Ottawa: Health and Welfare Canada.

Perry,C.L., Kelder,S.H., Murray,D.M. & Klepp,K.I. (1992). Communitywide smoking prevention: Long-term outcomes of the Minnesota Heart Health Program and the class of 1989 study. American Journal of Public Health, 82(9), 1210-1216.

Schaps,E., Dibartolo,R., Moskowitz,J., Palley,C.S. & Churgin,S. (1981). A review of 127 drug abuse prevention program evaluations. Journal of Drug Issues, 11(1), 17-43.

Sussman,S., Dent,C.W., Burton,D., Stacy,A.W. & Flay,B.R. (1995). Developing school-based tobacco use prevention and cessation programs. Thousand Oaks, California: Sage.

Thompson,E.L. (1978). Smoking education programs 1960-1976. American Journal of Public Health, 68(3), 250-257.

U.S.Department of Health and Welfare (1994). Preventing tobacco use among young people. A report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Center for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

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