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year's television and radio campaign ran ... best matches from regional pools. Selec- ... Smoking Prevention though Mass Media and School Intervention.
Prevention of Cigarette Smoking

through Mass Media Intervention and School Programs

Brian S. Flynn, ScD, John K Worden, PhD, Roger H. Secker-Walker, MB, BChir, Gary J. Badger, MS, Berta M. Geller, EdD, and Michael C. Costanza, PhD

Introduction Cigarette smoking prevention programs based in middle schools have consistently shown initial reductions in the proportion of students who begin regular smoking.1 However, when students are followed up through grade 12 these effects have been lost.2,3 Thus, these programs may have only delayed the onset of cigarette smoking. Strategies that could be used to broaden and extend the impact of these prevention programs include enhancing their effect by combining them with educational channels outside of the school setting.4-6 This study was designed to test the additional effect that could be achieved by adding a mass media intervention to a school smoking prevention program.

Methods Our hypothesis was that regular cigarette smoking would increase less among adolescents receiving a mass media intervention and a school smoking prevention program that had common educational objectives than among those receiving a school program only. Each treatment group included students from one community in the Northeastern United States and one community in Montana. Five annual in-school surveys were conducted in these four communities. The surveys were linked longitudinally.

Educational Interventions On the basis of theoiy7-12 and research on smoking initiation, we developed four common objectives for the ed-

ucational interventions. As a result of these interventions, young people will have: 1. a more positive view of nonsmok-

ing; 2. a more negative view of smoking; 3. improved skills for refusing ciga-

rettes; 4.

a

better understanding that most

people their age do not smoke cigarettes. Our conceptual approach linked these objectives to mediating and outcome variables (Figure 1).713 Additional objectives concerning cessation skills and awareness of cigarette marketing to young people were added during the common

fourth year as a result of program development research.14 The mass media intervention consisted of radio and television spots designed to accomplish the objectives listed above. Six different producers developed 36 television and 17 radio spots, which were broadcast as paid ads over local media. About 15 different television spots and 8 different radio spots were broadcast during each of the 4 years. Brian S. Flynn, John K. Worden, and Roger H. Secker-Walker are with the Office of Health Promotion Research and the Vermont Cancer Center; GaryJ. Badger iswith the Medical Biostatistics Unit; Berta M. Geller is with the Office of Health Promotion Research; and Michael C. Costanza is with the Medical Biostatistics Unit and the Vermont Cancer Center-all at the College of Medicine, University of Vermont, Burlington, Vt. Requests for reprints should be sent to Brian S. Flynn, ScD, Office of Health Promotion Research, 235 Rowell, College of Medicine, University of Vermont, Burlington, VT 05405. This paper was submitted to the Journal June 13, 1991, and accepted with revisions November 12, 1991.

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munity was so designated because of a need in the other community to avoid contaminating other health promotion studies within reach of the media. In the other community pair, the media-and-school community was so designated because its media served fewer outlying communities

and broadcast costs were lower. A cohort of 5458 students from these four SMSAs was established in grades 4, 5, and 6 in the spring of 1985.

Measurement Pwrclvd Pfr Smoking

Smoking Norm

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FIGURE 1-ilypotheslzed of mass media and school program effects, medang variabes, and behavioral outcomes

The exposure plan for the first intervention yearl4 was modified to match changes in media use as the target cohort matured. From the first to the fourth year, annual paid broadcast television exposures in each market were reduced from 284 to about 98; annual MTV and other cable television channel exposures were reduced from 450 to about 250; and annual paid radio exposures increased from 248 to about 450. In addition, we obtained approximately 50%o further exposure from public service matching in all media. Placement of both paid and public service exposures in specific broadcast programs or viewing periods was guided by survey data. To provide a uniform school smoking prevention program, we developed a program forgrades 5 to 10 that included gradespecific curricular materials, annual teacher training, and monitoring of program implementation. The school program was based on the common educational objectives. Specific units emphasized decision making, skills to resist peer pressures and advertising pressures, social support for nonsmoking, and information about smoking and health. The curriculum was delivered by usual classroom teachers who were trained by project staff in four annual day-long teacher training workshops in each study community. For grades 5 to 8, the curriculum required four class periods peryear; for grades 9 and 10, three periods were required. The school program was linked with the media intervention only at the level of educational objectives. There was no direct programmatic relationship between the two because of the strategic decision to present the interventions as multiple, independent sources of information. The

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first school curriculum units were completed during the fall of 1985. The first year's television and radio campaign ran from January through May 1986; the campaign then continued at decreased intensity through the summer on radio only, with a short surge on both television and radio at the beginning of school in the fall. This pattern was repeated for 3 additional years. (Information about a videotape of selected media messages and about the school curriculum can be obtained from the authors.)

Study Sample Two pairs of standard metropolitan statistical areas (SMSAs) were selected as best matches from regional pools. Selection criteria included being an independent media market; having a population between 50 000 and 400 000; and having matched demographic characteristics including education, income, and ethnicity. The regions were originally selected for demographic similarity to a Vermont SMSA. One pair of SMSAs was located in the Northeastern United States (Vermont and south-central New York State) and the other was located in Montana (Table 1). Study samples were matched more closely through selection of specific school districts and feeder school units within these four SMSAs on the basis of demographic data from census tracts for the localities serving as catchment areas for the schools. Selection at this level focused on higher risk populations as indicated by adult educational attainment and household income. Initial consent to participate was obtained at the school-district level; no school refused. Within one community pair, the media-and-school com-

Measures for each construct depicted in Figure 1 were included in each survey with the exception of refusal skills, which are difficult to measure effectively and efficiently in a questionnaire format. All measures were coded such that higher scores reflected increased levels of smoking behavior or risk. The Smoking Behavior Index (SBI) consisted of three items that were weighted to the equivalent number of cigarettes smoked per week, then averaged.'5 The internal consistency reliability coefficient (Cronbach's alpha'6) for this scale averaged .87 over five surveys. These self-reports were collected at the same time that a saliva sample was obtained. The students were told that the samples were taken to verify their selfreports; this procedure has been shown to enhance the validity of self-reports.'7 "Intention to smoke" was measured by a single item. "Attitude toward smoking" was measured by a three-item scale'8 (a = .84). "Advantages of smoking" was measured by a seven-item scale'9 (a = .75). "Disadvantages of smoking" was measured by four items combined as an index. "Smoking norm" was measured by a three-item scale20 (a= .72). "Perceived smoking by peers" was measured by a three-item scale (a = .70). Measures of risk factors for smoking that were not targets of the intervention program were included to provide tests of the specificity of intervention effects.

Analysis The results for the outcome measures are presented here in terms of means

(proportions for dichotomous measures), with their 95% confidence intervals, for the subset of participants who took part in all five school surveys. The unit of analysis for these presentations is the individual, according to the original design of the experiment. A supplemental analysis is presented in which the community is the unit, although the original design was not intended to support this analytic strategy. June 1992, Vol. 82, No. 6

Smoking Prevention though Mass Media and School Intervention

Results

Less than one percent of the parents requested that their children not take part, and nearly all absentees were surveyed through later visits to schools. In this report we focus on the students who participated in all four additional surveys. Forty-seven percent (2540) of the cohort was present for all surveys (50%o in the schooland-media group and 43% in the schoolonly group). Of those not included in the five-survey study sample, 82% moved out of the community or transferred to private schools, 15% missed one or more intermediate surveys, and the remainder were refusals, nearly all from one district that changed its consent procedures midway through the study.

Comparison with Other Baseline Participants To assess differences between those who participated in all five surveys and the 2918 who did not, we compared baseline characteristics. Students in the fivesurvey sample were slightly younger (10.7 vs 10.9 years; P = .001) and included more girls (49.6% vs 46.4%; P = .02). They reported less smoking among family members, with fewer reporting any older brothers who smoked (13.8% vs 21.0%; P < .001), any older sisters who smoked (14.7% vs 24.9%; P < .001), and smoking by either parent (53.2% vs 65.3%; P < .001). These students also reported less smoking behavior than did those in the other group, as measured by the SBI (0.06 vs 0.53 cigarettes per week; P < .001), smoking yesterday (0.6% vs 3.0%; P < .001), and smoking in the past week (1.4% vs 5.6%; P < .001).

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Baseline Equivalence of Treatment Grouns We compared the characteristics of those completing five surveys in the school-and-media group and in the school-only group. The school-and-media group was slightly younger (10.7 years vs 10.8 years; P = .002) and included more females (51.8% vs 47.0%; P = .02). The school-and-media group was somewhat more likely to report having an older brother who smoked (15.8% vs 11.3%; P = .06), but there were no other differences in family smoking. Measures of behavioral and psychosocial impact were examined to assess baseline equivalence. None of these characteristics differed significantly for the two groups, except that the school-only group reported perceiving more peer smoking (see Year 1 data in Table 2).

Impact on Cigarete Smoking Behaviors Figure 2 depicts the SBI with 95% confidence intervals for the two study groups over 5 years. These data show a consistent trend toward less smoking by the school-and-media group, with significant differences appearing in the final 2 years. In the fifth year the school-andmedia group reported smoking an average of 2.6 cigarettes per week, compared with 4.4 cigarettes per week for the school-only group, a relative difference of 41%. SBI measures for each of the four study communities are shown in Figure 3; the smoking patterns were similar within each pair of study communities. Examination of responses to individual items in this scale, indicating whether the respondent smoked any cigarettes yesterday or in the past week, showed sim-

ilar patterns (Table 3). In the fifth year, smoking yesterday was reported by 8.6% ofthe school-and-media group and 13.1% of the school-only group, a relative difference of 34%; the percentages reporting smoking in the past weekwere 12.8% and 19.8%, respectively, a relative difference of 35%. As an alternate approach to assessment of smoking behavior changes, a repeated measures analysis of variance was done using the community as the unit of analysis and blocking on geographic area (east, west). This analysis showed a significant difference between treatment groups in the trends observed over time for the SBI scores (P < .01).

Impact on Targeted Mediating

Vanables The impact of the interventions on hypothesized mediating variables (see Figure 1) is shown in Figure 4 and Table 2.

The pattem was similar for each measure. The groups were equivalent at baseline, then showed a significant difference in the second year, which persisted through the fifth year. Results from each community for three key mediating variables (Table 4) indicated similar patterns of effect within each community pair.

Impact on Varables that Were Not Taigeted Use of two substances not targeted by the interventions, smokeless tobacco and alcohol, was measured in each survey (Table 5). In smokeless tobacco behavior,

reported as any use in the past week, the two groups did not differ significantly except in the fourth year, when the schoolonly group was more likely to report use. The groups showed no difference in alcohol use (having had beer more than once)

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until higher levels of use were observed

among the school-only group in the fifth year. The groups did not differ over 5 years on a psychosocial stress scale, and differed in perceived adult smoking only in year 3.

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Recall of Exposure to the School Pmgram Items measuring recall of grade-specific elements of the school curriculum were included in the surveys foryears 2 to 5. Scores were added and converted to percentages of elements recalled (Table

6). Three of the four communities produced index scores that were generally in the same range. The fourth community had somewhat lower scores.

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830 American Journal of Public Health

Consistent pattems of effect favoring the school-and-media group were found for smoking behaviors and mediators of these behaviors that were targeted by the educational interventions. Behavioral and mediating variables not targeted by the interventions generally failed to show any June 1992, Vol. 82, No. 6

Smoking Prevention though Mass Media and School Interventon trend for higher levels of risk in the schoolonly group. Thus, the interventions appeared to have consistent effects only on those variables it had targeted, which suggests that the effects were independent of any possible underlying general differences in study group characteristics. The consstency of the impact of the program also can be seen clearly for smoking behavior when the two pairs of communities were viewed as four separate communities (Figure 3). The two school-and-media communities showed a clear separation fron the two school-on communities in the third through the fifth surveys. Simiar pattems are also seen in the data from all four conmnunities for mediating variables (Table 4). These data also tend to support the conclusion that the effects observed were due to the interventions. Further evidence for the internal consistency of these results can be seen by comparing the temporal ordering ofthe appearance of differences among the various targetedvariables. In keepingwith theoretical expectations, differences generally appear sooner in mediating variables (Figure 4 and Table 2) and later in smoking behavior variables (Figure 2 and Table 3). The media-and-school group was slightly younger than the school-only group and contained a larger proportion of females. Younger age and greater female representation may offset one another as risk factors for adoption of cigarette smoking. Begining at about grade 8, girls in this study were more likely to report that they were smokers. Separate analyses done within gender and grade-level categories (not shown here) showed patterns of effect similar to those seen in the aggregated data. Baseline comparisons of behavioral and psychosocial variables showed no differences (Table 2) except for

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FIGURE 3-Smoidng Beaior Index values (mean number of gares ked per Week, by four IndMdhul stidy communities The schoololy communitie (SO) are Indked by filled symbols and the No t communities are Indicatd by square symbols

perceived peer smoking. This difference was likely due to the slightly older age and greater male representation in the schoolonly group. Males were more likely to report smoking in the younger grade levels surveyed at baseline. With respect to the school program, it should be noted that its length, starting point, and content rank it as a relatively intensive smoking prevention intervention.1 Although differences among communities in levels of school program exposure were reported, these differences were small in relation to the differences

observed in smoking behavior. Differences in reported exposure generally did not coincide with changes in smoking behavior (Figure 3 and Table 6) or mediating variables (Figure 4 and Table 4); this is especially apparent when data for the two school-only communities are compared. It is possible that these differences in level of implementation had little or no effect on smoking behavior because the lowest level of reported school program implementation exceeded a ceiling above which no further effect could have been attained.1,4,21,22

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absentees at the time of the main surveys subsequently surveyed. It seems likely that those excluded from these analyses live in less stable family environments; this likelihood reduces the generalizability of these results for a part of the adolescent population that is at somewhat higher risk for adoption of smoking.23 We are following up the entire cohort to assess the sustained impact of the program. A second factor that limits the generalizability of the study is the lack of racial and ethnic diversity in the study population. This feature of the study is a result of a matching process that began in a relatively homogeneous area. The challenge for researchers is to adapt the strategies used here to devise equally effective campaigns for other major population groups and for more heterogeneous populations. were

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FIGURE 4-Percentage of St rporting tht they Intend to smoke a cgarette If offered by a friend, for th schoolonly group (SO) and the media-andschool group (MS) over 5 years, with 95% cnence Intervals

The study was designed with individual participants as the unit of analysis. However, because of the need to apply the educational programs to larger aggregates rather than to randomly selected individuals, participants were allocated to treatment conditions by communities. We have carried out the analyses according to the original design, using individuals as the primary analytic unit. An additional analysis was conducted with the community as the analytic unit, although the original 832 American Journal of Public Health

design did not anticipate this approach. This supplementary analysis produced results similar to those of the main analysis, providing confirmation at the community level of the impact of the mass media intervention. The results reported in this paper were for students who participated in all surveys. Most of the other students left the school systems after the first survey. Very few parents or students refused to participate in any survey, and nearly all

Interpretation of Mass Media Effect Aside from the fact that it shared objectives with a school program, the impact of this mass media intervention may be attributed to several features that set it apart from previous efforts using mass media in health promotion12,14: the intervention had sufficient duration; it used multiple channels; it was presented at times and places when young people reported their highest use of media; it used a variety of message styles; it used appeals to age- and gender-specific motives determined through surveys and focus groups; and it used messages portraying perceived social support with attractive age- and gender-relevant models providing appropriate behavioral skills, alternatives, and reinforcement. This intervention also avoided the use of exhortations; the spokespersons were credible young models saying "I don't smoke," letting each youngster make his or her own decision. Program formats that appealed to young people were used for these messages: situation comedies, cartoons, rock videos, and testimonials. Because young people at higher risk for smoking also tend to shun authority, the messages were not "tagged" with a logo or name of a sponsoring agency; the sponsor was identified only in an unobtrusive copyright notice. Lastly, rather than presenting only a few spots in each "flight" (6- to 15-week period) in an effort to ensure awareness of specific content, we presented 12 to 18 different spots in each fight to establish a perception of a common

nonsmoking lifestyle; more popular spots repeated annualy.

were

It is important to underscore the role that the media play in the socialization of

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Smoking Prevention through Mass Media and School Intervenon

young people. Television has been considered to be a major agent of socialization through which children learn the definitions and expectations underlying the rules and norms of their culture.2 Parents and teachers witness this process every day as new trends seen in the media become the new behaviors to be adopted in the realworld. Because the messages used in this intervention had no unifying tag or logo, and because they appeared to come from many sources simultaneously, it is possible that the young people in our intervention communities thought that these messages were being receied by young people across the nation and perceived them as redefining norms for youth smoking.

Other Mass Media and Smoking Prevention Studies The present study is one of three research projects that were funded by the National Cancer Institute in 1984 to evaluate mass media smoking prevention approaches. The others involved school and family participation with evening newscast coverage25 and television and radio spot messages with sweepstakes participation.26 Bauman et al.27 reported that the media-sweepstakes program produced changes in some mediating variables.

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A media and school-based campaign conducted in Australia, in which an uncontrolled evaluation design was used, resulted in reductions in adolescent smoking.28 Pentz et al. reported the impact on adolescent smoking of a multicomponent prevention program,29 but mass media effects were not assessed independently. These two apparently successful programs combined mass media with school programs and other channels of influence foryoung people. They provide additional evidence that carefully targeted mass media interventions can have a favorable impact on adoption of cigarette smoking when the media interventions are combined with school programs or other powerful channels of interpersonal influence.

Larger Scale Replication The design and implementation proused for this program could be replicated on a larger scale at a reasonable level of investment. In this study the mass media intervention was implemented in cess

two widely separated locations, using sim-

ilar techniques with similar effectiveness. The media tastes of young people in both communities were almost identical. To mount such a campaign on a larger scale would require agreement between media and school program planners on common objectives; access to small student samples for assistance with media intervention development; resources to produce media spots designed to appeal to specific target groups; and money to buy enough American Journal of Public Health 833

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broadcast time in selected markets to ensure high levels of exposure. The average cost of producing a finished television message for this study, including development costs, was $10 369. Average broadcast costs in two small-to-medium markets from 1986 to 1989 were $25 000 per market annually. Several factors work in favor of achieving consistency between school program objectives and mass media objectives in a larger scale replication. The school program used in this study was explicitly designed in 1984 to represent a good smoking prevention program for the future. Continued strengthening of school health education curricula has occurred since then,m with many programs based on objectives similar to those used here. These changes set the stage for more effective collaboration between schoolbased and mass media interventions.

Conclusion The interventions for this study were based on three main strategies: (1) common educational objectives for concurrent mass media and school-based interventions, (2) careful targeting of interventions, and (3) maintenance of interventions at high levels of intensity and diversity throughout the critical years for smoking adoption. Those responsible for directing media interventions should understand the objectives and content of school-based programs being conducted in the broadcast area so that they can reinforce these activities. Media planners also should use diagnostic and formative research to learn about message styles appealing to young people at different developmental stages. Messages should be presented with adequate frequency and variety to promote a lifestyle with positive nonsmoking norms. The strength of this approach is in the promotion of a lifestyle, rather than a product or a service. There are examples from advertising in which selling a product also promotes a lifestyle, most notably in beer advertising. Taken one at a time, beer commercials sell a product; taken together, they promote an easygoing, highly social lifestyle. The media and school interventions in this study accomplished a similar goal by presenting messages that appeared to come from different sources but had the same educational objectives. With their appeal to young people, especially those at highest risk for smoking, mass media provide a particularly ef-

834 American Journal of Public Health

fective way to deliver smoking prevention messages. The approach developed in this study apparently tapped the power of the media to influence smoking norms among this highly impressionable age group, and prevented significant proportions of them from starting to smoke cigarettes. L

Acknowledgments This study was supported by research grants CA38395 and CA22435 awarded by the National Cancer Institute and research grant HL17292 awarded by the National Heart, Lung, and Blood Institute.

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