Project Ex-4: The Failure to Utilize Effective Social and Behavioral Approaches to Prevent Smoking Among Adolescents-Kathleen Leahy
Tobacco use among adolescents is a major issue facing public health practitioners today. The majority of young people who begin smoking during adolescence will be addicted by age 20 (1). Although there was a significant decrease in tobacco use among youth between 1997 and 2003, rates have since stabilized and studies indicate that approximately 4,000 young people in the U.S. smoke their first cigarette every day (2,3). According to 2007 YRBS data, 50% of U.S. high school students have tried cigarettes and 20% are daily smokers. These numbers have major implications for the health of U.S. adolescents and effective interventions are needed to reduce rates of smoking in this population. Project EX-4 is a school-based smoking prevention and cessation program adopted from Project EX, a clinic-based smoking cessation program for adolescents. The goal of Project EX-4 was to utilize the classroom setting to reach large numbers of high school students and to implement a program that would prevent smoking in non-smokers, while encouraging current smokers to quit (4,5). The program consists of eights sessions delivered by teachers over a six week period. The sessions provide information regarding the harmful effects of tobacco on the body and the nature of addiction. Discussions about lifestyle and coping mechanisms for stress are also a major component of these sessions. Finally, students are given assertiveness training and anger management, so that they are not tempted to turn to cigarettes or other substances to deal with their problems (4,5). While this program was shown to have short-term effects on smoking related knowledge and decreases in daily smoking, long-term studies showed that Project EX-4 had no effect on smoking initiation rates or daily smoking rates among 12th graders (5-8). This program is largely information based and fails to use many of the social and behavioral approaches that have been shown to be effective in adolescents. The following are three principle critiques of the preventative efforts of Project EX-4.
Critique 1: Assumes Rational Decision Making
Project EX-4 is a lecture-based intervention that draws from the Health Belief Model, providing students with information about the harmful effects of smoking on the body, the biological basis of addition, and alternative methods for coping with problems and daily stress(4). The goal is to increase students’ perceived risk of smoking-related health problems while stressing the benefits of remaining a non-smoker. This approach, which has been criticized by many social scientists, assumes that adolescents will engage in a rational weighing of the risks and benefits of cigarette smoking and fails to take into account the many factors that influence adolescent behavior (9,10).
The adolescent brain is growing and changing, and full maturation of the frontal lobe, the part of the brain responsible for judgement and decision making, does not occur until the mid-twenties (11). The majority of adolescent decision making, particularly in emotionally heightened situations, takes place in the amygdala, the emotional center of the brain (11,12). As a result, adolescents rely primarily on their ‘gut’ for deciding whether to engage in risky behavior and are virtually incapable of fully considering the consequences of their decisions. Furthermore, as adolescents’ bodies change and they acquire new cognitive abilities, they develop a sense of invulnerability that makes them prone to risk-taking and feelings of immunity to the consequences of such behavior(13). The Project EX-4 sessions focus on scare tactics and statistics, information that students are unlikely to consider when offered a cigarette by one of their peers. The intervention inaccurately assumes that avoiding diseases such as lung cancer and emphysema are at the forefront of students' minds and that they will consider these consequences when faced with the opportunity to smoke. In reality, adolescents are influenced by the opinions of their peers and their environment, factors that further impede rational decision making. A survey of adolescents in California indicated that students who smoke or have tried smoking weigh the chance of experiencing a smoking-related social benefit, such as looking cool or gaining popularity much more heavily than the chance that they would experience smoking-related health problems (14), In order to be more effective, smoking prevention programs must appeal to students' desires and provide them with negotiation and refusal skills, thus removing the need for rational decision making(15). An intervention which presumes that simply informing students of the risk of cigarette smoking will discourage them from engaging in this behavior is developmentally inappropriate and bound to fail.
Critique 2: Failure to Consider Environmental Influences
In addition to it's focus on rational decision making, the failure of Project EX-4 to account for environmental influences is a second reason this intervention fails to be successful in preventing adolescent smoking. Many studies have indicated that factors such as socioeconomic status, gender, developmental status, and race have an effect on smoking initiation rates and this intervention neither identifies a target population among high-risk groups nor does it tailor its approach to vulnerable students (16,17). There is no indication in the literature that Project EX-4 is designed to be implemented in urban vs rural schools or with minority vs. non-hispanic white students;this generalized approach rarely works, especially with adolescents. Perhaps the most important environmental influence that Project EX-4 fails to address is the social norms regarding smoking in the adolescents populations targeted by this intervention. Adolescents are highly concerned with the approval of their peers and often gage how 'normal' they are by the actions or presumed actions of their classmates and friends (13). There have been numerous studies that have investigated the effect of perceived social norms on the prevalence of drinking, drug use, and smoking in different adolescent populations and the results are extremely convincing. Young people almost universally overestimate the degree to which their peers are engaging in risky behaviors and this perception has a profound affect on their behavior (18-20). With regards to smoking specifically, studies suggest that students are influence by how 'normal' is is to smoke in their community. For example, one paper showed that students who attended schools that strictly enforced anti-smoking policies were less likely to begin smoking than their counterparts at schools where these policies were not heavily enforced (21). In addition, there have been several studies that have suggested that students are more likely to smoke when they perceive it to be an acceptable or common behavior among their peers (22,23). The Social Norms and Social Expectations Theories, as well as the Social Ecological Theory take these environmental factors into account when considering behavior (24-26). Project EX-4, however, failed to utilize any of these theories in their prevention efforts. The classroom sessions do not include any discussion of school norms around smoking or students' perceptions regarding the acceptability of this behavior among their peers. In addition, there is no discussion of a school anti-smoking policy, s0 there is no aspect of this intervention that attempts to portray smoking as a socially unacceptable behavior among educators or peers. Once again, in order to be effective, an intervention that aims to prevent smoking among adolescents must take into account all of the influences that affect their decision to engage in this behavior. By focusing solely on the harmful and addictive effects of smoking and disregarding the strong environmental and social pressures that influence behavior, Project EX-4 falls short in its efforts to prevent smoking among students.
Critique 3: Failure to Consult Adolescents in the Design and Implementation of Intervention
Adolescence is a time of truth-seeking and of searching for a sense of belonging (13). These developmental aspects of adolescents can prove extremely useful when planning successful interventions aimed at this population. The most successful campaigns to prevent smoking in young people have been mindful of these developmental traits and involved students in the formulation of an intervention. Campaigns such as the 'Truth' Campaign to prevent smoking formed focus groups of students and surveyed youth in order to understand their values and aspirations (27, 28). Project EX-4 did not use any of these approaches in their smoking prevention intervention. Project EX-4 did not involve any of the students at test schools in the planning of this intervention. In addition, there were no focus groups in which to test the efficacy of the message or delivery before school-wide implementation. In failing to utilize student input, the Project EX-4 initiative did not successfully 'brand' the anti-smoking message or market this message to adolescents. This school-based intervention assumed that adolescents aspire to health and a long life above all else, and therefore focused on the harmful effects smoking have on the body and smokers' increased risk for disease. However, had they taken the time to survey students, they would have found that most young people most strongly desire freedom and independence above all else. If Project EX-4 had tied non-smoking to these ideals, this intervention could have been more successful. In addition to promoting the wrong values, Project EX-4 failed to effectively market the anti-smoking message to students. The sessions provided to students focused on informational lectures in which students were provided with facts and statistics. The students were not exposed to any slogans or images and there was no use of media, which is a highly effective way to reach adolescents today (27). Had students been consulted, organizers of Project EX-4 could have found more appropriate ways to deliver the anti-smoking message.
Branding and marketing are aspects of Social Marketing Theory, an approach to interventions that is gaining popularity among public health practitioners. These concepts are highly dependent on the involvement of the population targeted for intervention(28-30). By determining the values and aspirations of adolescents, for example, an intervention can create an ideal or group that young people will long to be a part of. Project EX-4 did not empower students or make them feel like they belonged to something special by not smoking. It also failed to appeal to the hopes and dreams of adolescents, instead relying on a catch-all approach to smoking prevention. This final critique is one the most important reasons why Project EX-4, and other programs based solely on the Health Belief Model are largely ineffective in preventing smoking among adolescents.
I propose an alternative intervention to Project EX-4, one that is comprehensive rather than school-based, and is based primarily on the principles of three theories: Social Marketing Theory, Social Networking Theory, and Social Cognitive Theory. The intervention also includes components from Maslow's Hierarchy of Neeeds and Labeling Theory.
Studies have shown that comprehensive programs to prevent smoking in adolescents are the most effective (31,32). By involving the community, local media stations, and other local organizations, students are able to receive the anti-smoking message frequently and consistently. My program would begin with a task force that is comprised of members from the community, including teachers, students, local business owners, law enforcement, and local journalists. Together they would produce effective and feasible ways to make the entire community 'smoke-free'. In addition, several focus groups of students from middle school and high school would be heavily involved in the formulation of an anti-smoking message that will 'speak' to adolescents and in the design of posters, ad campaigns, and slogans. The school component of the intervention would also be very different, consisting of six sessions per school year, starting in seventh grade and continuing throughout ninth grade, since data suggests that there is a greater effect with interventions that are continuous and have several sessions (16). The sessions will be interactive and include a variety of approaches to educate and empower students. While much of the information included in Project EX-4 will still be included in the intervention, this information will be coupled with negotiation skills, education about social norms, and a comprehensive anti-smoking media campaign. The following is a detailed explanation of how this alternative campaign addresses the three main problems with the Project EX-4 campaign. Answer to Critique 1:Recognizes Connection between Behavior, Self Efficacy, and Environment
This alternative intervention does not rely on the rational decision making of adolescents to prevent smoking. While information regarding the health risks of cigarettes will be included in the intervention, this is not the focus of the program. Taking a social learning approach, this intervention will seek to empower students and promote self esteem and then surround them with a community, both inside and outside the school, that models anti-smoking behavior (33).
The first step in building self efficacy is promoting self-esteem and a sense of belonging, and providing students with negotiation skills. Part of the school-based aspect of this intervention will involve choosing a community service program that students will participate in throughout the three year intervention. Community service builds self esteem and by choosing the program, students can take ownership of this project and develop a sense of social belonging within this small group(34). In addition to community service, intervention sessions will include role-playing to build refusal and negotiation skills that students can use when faced with any risky behavior, such as smoking, drugs, or alcohol. These role-playing activities have been shown to increase self-efficacy and have a positive effect on students' ability to refuse tobacco (35).
Finally, the commitment of both the school and the larger community to be 'smoke-free' will provide an environment that promotes anti-smoking behavior. Teachers and students will not be able to smoke outside the school and local businesses will ban smoking on their premises. Even parks and playgrounds will be declared smoke-free zones. In every aspect of students' lives, smoking will be viewed as socially unacceptable, which leads into the answer to the second critique. Answer to Critique 2: Takes a Social Networking Approach to Smoking Prevention
Project EX-4 relies heavily on the principles of the Health Belief Model, which assumes that once individuals are provided with the information regarding the risks of a certain behavior, they will weigh those risks versus the benefits of not doing the behavior and make the right decision. However, this model is not appropriate to prevent smoking among adolescents, as they are highly susceptible to environmental influences, particularly the behaviors of their peers(13). This alternative intervention takes into account the importance of social influences and uses social networking theory to correct inaccurate perceptions about the prevalence of smoking in the school community and to create a new, anti-smoking social norm. As part of the planning stages of this intervention, the students in the focus group will help survey peers regarding their tobacco use and their perceived notions about tobacco use among their peers. As with most risky behaviors, it is likely that perceived norms will be greater than actual norms (18-21). A major part of the media and advertising aspect of this campaign will be devoted to promoting actual norms in the school and community. This approach was highly successful in a Montana campaign aimed at teens, entitled 'MOST of US (70%) Are Tobacco Free'. This campaign, like our intervention, involved students in the media campaign that promoted the actual norms and resulted in a 41% difference in teen smoking rates between test and comparison counties (36,37).
In addition to this social norms campaign, each school will encourage students leaders, such as team captains, student council members, and other well-likes members of the student body to promote the new social norm of not smoking. These students can perpetuate this anti-smoking norm within their networks and before long, not smoking will become engrained in the culture of the school. Throughout the discussion of this alternative intervention there has been an emphasis on student involvement, which leads to the third and final critique of Project EX-4. Answer to Critique 3: Using Student Input to Brand Anti-Smoking Behavior and Effectively Market to Adolescents Project EX-4 did not involve students in the formulation of the intervention and thus the message and delivery of the program did not resonate with the target population. This alternative intervention relies heavily on input from students and is modeled in part after the 'Truth' Campaign to prevent smoking in adolescents. The 'Truth' Campaign involved students in every aspect of planning and implementation and appealed to many of the fundamental developmental aspects of adolescents (38). In our intervention, classroom sessions will include a dissection of the tobacco industry and activities where students find and criticize tobacco advertisements aimed at adolescents. By exposing the manipulation displayed by tobacco companies, students will feel empowered and display reactance that will lead them to reject tobacco. In addition, students will have the opportunity to pledge to remain part of the smoke-free group, thereby labeling themselves as non-smokers. This feeling of ownership over their status as smoke-free will help promote the anti-smoking 'brand'. Finally, students will be involved in the design and implementation of a slogan and media campaign, involving posters, a Facebook page, and possibly even local television PSA's. The slogan and images will all be designed to empower students and appeal to their desire to be free and independent, as opposed to being puppets for the tobacco industry. This social marketing approach has been very successful, not only as part of the 'Truth' campaign, but in many other public health interventions as well (39,40).
Smoking is a serious threat to the health of adolescents and there is a great need for effective interventions to prevent tobacco use in this population. Many current school-based interventions, such as Project EX-4, are based on theories that are developmentally inappropriate for adolescents and the effects of such programs do not extend outside the classroom. Schools and communities must work together to provide comprehensive anti-smoking interventions to adolescents that are based in more contemporary and appropriate social and behavioral theories. By appealing to the core values and aspirations of adolescents, while also taking into account developmental and environmental influences, it is possible that we will someday be able to celebrate a generation of young people that are truly smoke-free.
1)Lewis PC, Harrell JS, Bradley C, Deng S. Cigarette Use in Adolescents: The Cardiovascular Health in Children and Youth Study. Research in Nursing & Health 2001;24:27-37 2)Center For Disease Control. Tobacco Statistics: Highlights HYPERLINK "http://www.cdc.gov/tobacco" http://www.cdc.gov/tobacco 3)Massachusetts Youth Risk and Behavior Survey 4)Sun P, Miyano J, Rohrbach LA, Dent CW, Sussman S. Short-term effects of Project Ex-4: A classroom-based smoking prevention and cessation intervention program. Addictive Behaviors 2007; 32:342-350 5)Sussman S, Miyano J, Rohrbach LA, Dent CW, Sun P. Six-month and one-year effects of Project EX-4: A classroom-based smoking prevention and cessation intervention program. Addictive Behaviors 2007;32:3005-3014. 6)Wiehe SE, Garrison MM, Christakis DA, Ebel BE, Rivara FP. A systematic review of school-based smoking prevention trials with long-term follow-up. Journal of Adolescent Health 2005;36:162-169. 7)Flay BR. The Promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews. Tobacco Induced Diseases 2009;5:1-12. 8)Thomas RE, Perrera R. School-based programs for preventing smoking (Review). The Cochrane Collaboration 2008;4:1-185. 9)Poss JE. Developing a New Model for Cross Cultural Research: Synthesizing the Health Belief Model and the Theory of Reasoned Action. Advances in Nursing 2001;23:1-15. 10)Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995;11:246-252 11)Steinberg L. Cognitive and affective development in adolescence. TRENDS in Cognitive Sciences 2005;9:69-74. 12)Giedd JN. The Teen Brain: Insights from Neuroimaging. Journal of Adolescent Health 2008;42:335-343. 13)Catalano RF, Hawkins, JD, Berglund ML, et al. Prevention science and positive youth development: competitive or cooperative frameworks? Journal of Adolescent Health 2002; 31(6 Suppl): 230-239. 14)Halpern-Felsher BL, Biehl M, Rubenstein ML. Perceived Risks and Benefits of Smoking: Differences Between Adolescents Who Have and Have Not Smoked. Journal of Adolescent Health 2008;32:147-148. 15)Dobbins M, DeCorby K, Manske S, Goldblatt E. Effective Practices for school-based tobacco use prevention. Preventive Medicine 2008;46:289-297. 16)Harrell JS, Bangdiwala SI, Deng S, Webb JP, Bradley C. Smoking Initiation in Youth: The Roles of Gender, Race, Socioeconomics, and Developmental Status. Journal of Adolescent Health 1998;23:271-279. 17)Anderson C, Burns DM. Patterns of Adolescent Smoking Inititation Rates by Ethnicity and Sex. Tobacco Control 2009;9:4-8. 18) Perkins, H. W. & Berkowitz, A. D. (1986). "Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming." International Journal of the Addictions, 21, 961-976. 19)Martens M, Page J, Mowry E, Damann K, Taylor K, Cimini MD. Differences between Actual and Perceived Student Norms: An Examination of Alcohol Use, Drug Use, and Sexual Behavior. Journal of American College Health, 54(5), 295-300. 20)Albarracin D, Kumkale GT, Johnson BT. Influences of social power and normative support on condom use decisions: a research synthesis. AIDS Care, 2004. 16(6); 700-723 21)Lipperman-Kreda S, Grube JW. Students' perception of community disapproval, perceived enforcement of school antismoking policies, personal beliefs, and their cigarette smoking behaviors: Results from a structural equation modeling analysis. Nicotine and Tobacco Research 2009;11:531-539. 22)Glantz SA, Jamieson P. Attitudes Toward Secondhand Smoke, Smoking, and Quitting Among Young People. Pediatrics 2000;106:1-3. 23)Brown AK, Moodie C, Hastings G, Mackintosh AM, Hassan L, Thrasher J. The Association of Normative Perceptions with Adolescent Smoking Intentions. Journal of Adolescence 2010:1-12. 24)Berkowitz, A. D. The Social Norms Approach: Theory, Research and
Annotated Bibliography. Available at http://www.edc.org/hec/socialnorms/theory.html
25)Berkowitz, A. D. Applications of Social Norms Theory to Other Health and Social Justice Issues. In H. Wesley Perkins, (Ed.), The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, and Clinicians. San Francisco: Jossey Bass. 26).McArthur, Leslie Z.; Baron, Reuben M.Psychological Review. Toward an ecological theory of social perception. (1993);90:215-238. 27) Brown, J. (Ed). (2008). Managing the Media Monster: The Influence of Media (From Television to Text Messages) on Teen Sexual Behavior and Attitudes. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy. 28)Evans DW, Hastings G. Public Health Branding: Recognition, Promise, and Delivery of Healthy Lifestyles (pp.1-24). In: Evans DW, Hastings G. Public Health Branding, Oxford 2008. 29)Blistein JL, Evans WD, Driscoll DL. What is a Public Health Brand? In:Evans DW, Hastings G. Public Health Branding, Oxford 2008. 30) Marketing Social Change-An Opportunity for the Public Health Practitioner (pp. 45-71). In:Evans DW, Hastings G. Public Health Branding, Oxford 2008. 31) Wakefield, M, Chaloupka F. Effectiveness of comprehensive tobacco control programs in reducing teenage smoking in the USA. Tobacco Control 2009;9:177-186. 32)Glantz SA, Mandel LL. Since School-based tobacco prevention programs do not work, what should we do? Journal of Adolescent Health 2005;36:157-159. 33) Redding CA, Rossi JS, Rossi SR, Vellicer WF, Prochaska JO. Health Behavior Models. The International Journal of Health Education 2000;3:180-193. 34)Conrad D, Hedin D. School-based Community Service: What We Know From Research and Theory. Journal of Adolescent Health 1999;10:743-749 35)Nichols TR, Graber JA, Brooks-Gunn J, Botvin GJ. Ways to Say No: Refusal Skill Strategies Among Urban Adolescents. American Journal of Health Behaviors 2006;30:227-236 36) MOST of Us Are Tobacco Free "http://www.mostofus.org/projectdetail.php?id=4" http://www.mostofus.org/projectdetail.php?id=4 37)Martino-McAllister J, Wessel MT. An Evaluation of a social norms marketing project for tobavvo prevention with middle, high, and college students; use of funds from the Tobacco Master Settlement. J Drug Educ., 2005, 35(3): 185-200. 38) Niederdeppe J, Farrelly MC, Havilnd L. Confirming 'Truth':More Evidence of a Successful Tobacco Countermarketing Campaign in Florida. American Journal of Public Health 2004;94:255-257. 39) Friend K, Levy DT. Reductions in smoking prevalence and cigarette consumption associated with mass-media campaigns. Health Education Research 2002;17:85-98. 40)Evans DW, McCormack L. Applying Social Marketing in Health Care: Communicating Evidence to Change Consumer Behavior. Medical Decision Making 2008;28:781-792.