A randomized controlled trial of two primary school intervention strategies to prevent early onset tobacco smoking

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Abstract

In this article, we examine the impact of two universal, grade 1 preventive interventions on the onset of tobacco smoking as assessed in early adolescence. The classroom-centered (CC) intervention was designed to reduce the risk for tobacco smoking by enhancing teachers’ behavior management skills in first grade and, thereby, reducing child attention problems and aggressive and shy behavior—known risk behaviors for later substance use. The family–school partnership (FSP) intervention targeted these early risk behaviors via improvements in parent–teacher communication and parents’ child behavior management strategies. A cohort of 678 urban, predominately African–American, public school students were randomly assigned to one of three Grade 1 classrooms at entrance to primary school (age 6). One classroom featured the CC intervention, a second the FSP intervention, and the third served as a control classroom. Six years later, 81% of the students completed audio computer-assisted self-interviews. Relative to controls, a modest attenuation in the risk of smoking initiation was found for students who had been assigned to either the CC or FSP intervention classrooms (26% versus 33%) (adjusted relative risk for CC/control contrast=0.57, 95% confidence interval (CI), 0.34–0.96; adjusted relative risk for FSP/control contrast=0.69, 95% CI, 0.50–0.97). Results lend support to targeting the early antecedent risk behaviors for tobacco smoking.

Introduction

The aim of this study is to estimate the efficacy of two primary school preventive interventions designed to ameliorate malleable early antecedents of smoking. The study was organized as a group-randomized controlled trial with intervention and control arms. The conceptual background for this research includes an array of complimentary conceptual models that link early aggression and rule-breaking behaviors with early emergence of youthful drug-taking (e.g. see Kellam and Rebok, 1992, Patterson et al., 1992). The research represents a shift in focus for drug prevention programs. For about 30 years, the field of smoking prevention has been dominated by a ‘school-based’ drug education paradigm. Before the 1970s, drug education consisted mainly of scare tactics and informational programs that seem to have promoted awareness of tobacco-related harms, but did little or nothing to affect the incidence of teen tobacco smoking (Ennett et al., 1994, Flay, 2000). More recently, social psychological concepts and principles have been used to promote resistance to peer pressure to smoke and to build social skills that might help young people refrain from starting to smoke. Some forms of peer resistance and social skills programs for secondary school students have seen limited success in the delay of adolescent tobacco smoking, at least through follow-up intervals of up to multiple years duration (Ellickson and Bell, 1990, Botvin et al., 1995, Peterson et al., 2000). Nonetheless, even when these programs have short-term beneficial impact, they do not seem to work for adolescents who started to smoke before the program (Ellickson and Bell, 1990, Jackson et al., 1997). The goal of ‘tobacco-free cohorts’ will require early interventions in place before the pre-teen years.

In complement with secondary school intervention programs, there are some already-developed smoking prevention programs for primary school pupils. Some of these interventions are based upon the proposition that tobacco smoking has identifiable causal antecedents, observable in the early years of primary school, or before school entry. These primary school programs target these early antecedents, seek to modify the antecedents, and thereby aim to delay the onset or prevent the occurrence of tobacco smoking and related behavior. Our research group has described one recent example of this type of intervention, as well as initial evidence of beneficial preventive impact through early adolescence (Kellam and Anthony, 1998). In brief, we targeted early rule-breaking and other socially maladaptive behavior in primary school, previously found to help account for tobacco and other drug involvement of teenage boys. At their entry onto the first year of school, children were assigned at random to classrooms where the teachers had been trained in the use of the ‘good behavior game’ (GBG) or to classrooms where the GBG intervention was not in place. The GBG curriculum is designed to improve behavior and reduce rule-breaking. We held these GBG versus ‘no GBG’ assignments in place for 2 academic years (Grades 1 and 2), with no subsequent booster sessions. Follow-up evidence through age 14 was balanced in favor of beneficial program impact, with reduced risk and delayed onset of tobacco smoking of boys exposed to the GBG intervention (Kellam and Anthony, 1998).

From the early days of the GBG study, our research team has been asked whether the same impact could be achieved with just 1 year of GBG programming (during grade 1 of primary school), and whether we might see a greater impact if family resources were brought into play with those of the classroom teacher. A separate randomized controlled trial was designed to address these issues. The goal of this report is to evaluate the impact of a shortened GBG program (Grade 1 only) and a family–school partnership (FSP) intervention on delayed onset of tobacco smoking 6 years after the intervention ended.

As described in detail in Ialongo et al. (1999), the conceptual basis for the interventions was derived from the life course/social fields framework (Kellam and Rebok, 1992) and its integration with Patterson et al.'s (1992) model of the development of antisocial behavior and substance use. Briefly, the CC and FSP interventions were hypothesized to reduce the early antecedent risk behaviors of aggressive and shy behaviors and their distal correlates, such as tobacco smoking, by improving teachers’ and parents’ disciplinary practices, respectively, and through the enhancement of parent–teacher communication in the case of the FSP intervention (see Henderson, 1987, Sattes, 1985). The reductions in the early antecedent risk behaviors were hypothesized, in turn, to lower the risk for antisocial behavior and substance use in adolescence and young adulthood. As reported in Ialongo et al., the CC and FSP interventions had significant impact on the early risk behaviors of attention/concentration problems and aggressive and shy behavior through the Grade 2 follow-up (Ialongo et al., 1999).

Section snippets

Study participants

In Fall of 1993, a total of 678 pupils started grade 1 in the nine participating Baltimore City public primary schools (Fig. 1). Among eligible pupils, 53% were male, 86% were African–American, with 14% of Euro-American heritage. The students ranged in age from 5.3 to 7.7 years with a mean age of 5.7 years (S.D.=0.5). Nearly two-thirds of the children (62%) received free or reduced lunch—a proxy for low family income. Three percent of the parents or guardians refused to participate in the

Sample characteristics at randomization

Table 1 characterizes children assigned at random to the CC and FSP intervention conditions and the control group. Children in the control group were somewhat less likely to be male and to be of African–American heritage, as compared with children in the CC and FSP conditions. They were somewhat more likely to come from two-parent households. The teacher ratings of problem behavior (TOCA-R summary score) is modestly larger for CC children. We speculate that training of the CC teachers might

Discussion

Evidence from the study's main analyses is consistent with the hypothesized program impact on children's risk of starting to smoke tobacco during the primary school years. The magnitude of program associated attenuation of risk is modest but noteworthy. It may be remarkable that a single year of preventive effort of this type is associated with even a modest attenuation of risk. The risk attenuation associated with the study's FSP intervention was almost as great as the attenuation associated

Acknowledgements

This research is supported by the National Institute of Mental Health (R01MH57005) and the National Institute on Drug Abuse (R01DA11796). Dr Storr was supported by a National Institute on Drug Abuse Institutional Training Grant (DA07292). Special thanks are due to the Baltimore City Public Schools for their continuing collaborative efforts, and the parents, children, teachers, principals and school psychologists/social workers who participated. We thank Scott Hubbard for data management support

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