5.23 School-based interventions

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5.1 Introduction

5.2 Stages in the uptake of smoking

5.3 Factors influencing uptake by young people—overview

5.4 Physiological aspects

5.5 Individual personality traits and psychiatric influences

5.6 Intentions, attitudes and beliefs

5.7 The home environment

5.8 The smoking behaviour of peers, and peer attitudes and norms

5.9 The educational environment: achievements, aspirations and 'school connectedness'

5.10 Other drug use

5.11 Accessibility of tobacco products to young smokers

5.12 Affordability of tobacco products

5.13 Opportunity to smoke

5.14 Cultural background

5.15 Tobacco advertising and promotion targeted at young people

5.16 Products and packaging created to appeal to new users

5.17 Factors influencing uptake of smoking later in life

5.18 Uptake—a concluding note

5.19 What is meant by prevention?

5.20 Approaches to youth smoking prevention

5.21 Mass media strategies/campaigns

5.22 Interactive technology and multimedia

5.23 School-based interventions

5.24 Peer influence and education

5.25 Parent/family/home targeted interventions

5.26 Reducing tobacco access and supply

5.27 Reducing product appeal

5.28 Promotion and visibility of tobacco

5.29 Denormalising smoking

5.30 Taxation and pricing of tobacco products

5.31 Harnessing predictors of uptake to prevent smoking

5.32 Preventing smoking in more 'at risk' groups

Acknowledgments

References

School-based interventions have been the traditional cornerstone of efforts to prevent the adoption of health-compromising behaviours by young people, including smoking. Lynagh et al267 identify some of the major premises underlying the use of schools to promote health:

• children spend a large proportion of their waking life in school, including the developmental years, in which health risk behaviours are often formed;
• schools are recognised places of learning, and have existing structures and systems into which 'health education' can be integrated;
• the school environment, and the messages and cues it communicates, can influence student attitudes and behaviours by either reinforcing or undermining what is taught in the classroom;
• schools provide a prime access point as nearly all young people attend school, including disadvantaged and 'at risk' groups; and
• schools also provide access to important secondary target groups such as parents, families and the broader community.

The most common types of school-based smoking prevention interventions are described in programs with the main methods outlined in Table 5.5.268 An evaluation summary of the approaches is presented in the following section.

5.23.1 Are school-based programs effective?

There is mixed evidence regarding the effectiveness of school-based smoking interventions225, 238, 268, 274 and few studies have evaluated their long-term impact.275 Programs providing information only have limited, if any, effect268 and are generally viewed as dated and too narrow a form of health education. Several reviews of tobacco-specific interventions have concluded that interventions based on social reinforcement, developmental stages and social norm orientations appear to be more effective in modifying attitudes and behaviour than programs that focus on more rational information delivery.232, 276 Programs that focus more generally on self-esteem and reducing alienation, but with less or little smoking specific content may be effective, but to a lesser extent.232

The most widely used school-based interventions draw on social influence models with 50% of such interventions evaluated through randomised trials reporting positive, significant results.268 Some studies support the effectiveness of school prevention efforts focusing on social influence and resistance skills.232, 276, 277 However, the Hutchinson Smoking Prevention Project, considered one of the most rigorous and largest tests of a social influences model, found no evidence of a sustained effect on smoking prevalence.278

School-based programs that have not been backed up by comprehensive community programs and policies have generally had only modest or nil effect.279 Congruency between the health messages promoted in schools and the health related attitudes and behaviours which prevail in the broader school environment and community is critical.267, 280 One of the single most inexpensive actions a school can take to reduce smoking is to introduce and enforce a no-smoking policy.281, 282 An analysis of smoking and policy at 55 schools demonstrated an association between policy strength, policy enforcement, and the prevalence of smoking among pupils.283 Bans on smoking in schools need to be diligently enforced, however, to have most impact on adolescent smoking rates.78

In Australia, although all states and territories have had smokefree school buildings under workplace laws since 1988, some have been slow to extend this to all school grounds. Western Australia's Department of Education and Training only extended its policy to all outside areas in 2005,284 and the Northern Territory still allows smoking in designated areas on school grounds under the proviso that it is out of sight of children.285 In Victoria, the Smoke-free Schools – Tobacco Prevention and Management Guidelines recommend that schools operate as non-smoking environments.286

Quality multi-modal approaches that complement school-based interventions with broader community campaigns and strategies are most likely to have a positive effect,268 but are relatively rare in practice and in the literature. The successful and often-cited smoking interventions in North Karelia287 and Minnesota288 that reported positive long-term outcomes for school-based programs were complemented by broader community campaigns.

There is some evidence of a synergistic effect on smoking behaviour from the dovetailing of school programs with mass media and other interventions targeting young people.289 The experiences of Western Australia's long running Smarter than Smoking project support this contention, with an active schools component complementing mass media and other strategies.224 As noted by Flay,290 however, existing multi-modal studies often do not define or are not able to disentangle the relative impact of school curricula-based, school-wide environmental change, parent training, mass media or community-wide interventions.

Reid et al232 caution that some of the more successful school-based smoking interventions have occurred as pilot research projects, and that their effectiveness is considerably reduced under 'real life conditions'. In seeking to explain the disappointing evaluation of two multifaceted school-based programs in the UK that were modelled on a successfully trialled program (in the US), Nutbeam et al291 also query the efficacy of school interventions in real life settings.

On the basis of existing and evaluated school-based youth smoking programs, it has been argued that at best, existing school based interventions appear to be able to delay the onset of smoking.279, 292 While prevention is obviously the preferred outcome, delayed onset is still a positive public health outcome because mortality is lower and quitting rates are higher among smokers who commence smoking at a later age.238, 292 The most critical window of opportunity for prevention programs in school settings appears to be in the late primary to early secondary school years.293

5.23.2 School-based smoking interventions in Australia

All states and territories in Australia have developed or have access to some form of school-based smoking prevention activity (see Table 5.6), with information on many of these programs easily accessible online. These programs vary in their delivery technique, content and target group, but many cover similar topics. Jointly developed initiatives such as The Critics' Choice, which have been used by a number of states and territories, are an example of a more strategic and cost effective approach.

As noted in the literature, evaluation of school-based smoking interventions is generally patchy, and information on effectiveness is not readily available for many Australian interventions. Exceptions are interventions that have received research grant funding. For example, a randomised controlled trial of the Smoking Cessation for Youth Project (SCYP) found that the project was successful in both reducing regular cigarette smoking (five days per week or more) and preventing greater uptake of cigarette smoking in students who had not smoked.213 Another Australian study targeting high school students was not as successful, and while the intervention improved smoking knowledge, it had no success in improving smoking behaviour.294

5.23.3 Making school-based interventions more effective

Despite the mixed evidence of effectiveness to date, school settings do have the potential to influence the health-related beliefs, attitudes, knowledge and behaviour of young people in relation to smoking, and are an important complement to other tobacco control measures.

Effectiveness would be enhanced if school-based interventions were more strategically based around the evidence of factors influencing smoking uptake. For example, the increasing recognition of the importance of the social context of smoking supports programs that explore and address social influences, particularly programs that allow students to explore these issues themselves, either individually or in groups.295 School programs have effectively helped to impart awareness of the long-term health effects of smoking, but young people tend to disassociate themselves from these consequences,98 as they lack personal salience to their lives in the here and now. Focusing on the shorter term consequences of smoking is far more relevant to young people than longer term health effects,296, 297 a finding reiterated repeatedly in focus group research with adolescents in Australia54, 98 Findings from the National Youth Tobacco Prevention Research Project also suggest that there is potential for smoking to be incorporated into teaching as a 'factual study' of a social change phenomenon,98 rather than being confined to the health curriculum.

There is considerable scope also to improve the content, design and delivery of behaviourally based interventions in schools to enhance their relevance, appeal and effectiveness with young people.276, 291 Classroom-based activities and lessons need to be framed around current and evidence-based pedagogy and not outdated health education or didactic learning approaches. Young people today are exposed both in and out of school to a range of stimulating mediums and activities that set a high benchmark in terms of interest and creativity. Smoking in particular runs the risk of being viewed as a 'tired' issue, and so innovative and creative ways to address it need to be found.239

Moreover, teachers and school curricula often struggle within a crowded timetable to accommodate the silo approach to health risk factors (that is to say, lessons focused on tobacco only). It is artificial always to treat each health issue independently, as there are underlying determinants, issues and skills relevant across health behaviour areas. The clustering of tobacco use with other risk behaviour is indeed well-documented245, 298, 299 (see Section 5.5 above). Reid also argues that coupling smoking with other health issues is beneficial because on its own, it is often ranked below other topics in terms of teacher priority.232 Others concur that teachers may be more prepared to devote valuable curriculum time to more comprehensive rather than single issue programs.238