The risk of smoking in relation to engagement with a school-based smoking intervention
Introduction
A classic approach to smoking prevention is to use epidemiological methods to determine risk factors for smoking, such as social influences. Then, using this knowledge, the opposite and hopefully at least equal force is applied to adolescents to stop them becoming smokers, e.g. Peterson, Kealey, Mann, Marek, and Sarason (2000). Whether the social influences or alternative paradigms are chosen, the common element is the passive pupil in the middle of these opposing forces (Michell, 1994). In 1997 we started a cluster randomised trial using methods based on the transtheoretical model (TTM) (Prochaska & Diclemente, 1983; Pallonen, Prochaska, Velicer, Prokhorov, & Smith, 1998) to prevent smoking in non-smoking adolescents, and to assist stopping adolescent smokers (Sherratt & Almond, 1999; Aveyard et al. (2001), Aveyard et al., 2 (1999)). The TTM proposes that adolescents are in one of nine stages ranging from acquisition precontemplation (not intending to commence smoking in the next 6 months), to cessation maintenance (stopped smoking at least 6 months ago) (Pallonen et al., 1998). According to the model, the other concepts of the TTM—temptations, decisional balance, and processes are the driving forces that move individuals through the stages (Prochaska, Diclemente, & Norcross, 1992). This trial used the classic approach outlined above to reverse the seemingly inexorable transition to smoking that occurs throughout adolescence, by moving adolescents in the opposite direction through the stages. For example, participants in acquisition preparation could be told “To be more like others who were thinking about trying it [smoking], but have chosen to stay smoke free, think more about the cons of smoking”, and some of these were then listed. Participants may well have asked why they should do this. The only reason to do so would be to avoid becoming a smoker, which, it is assumed, is as important to the adolescent as it is to the health educator.
The assumption underpinning this approach, that individuals do not actively want to become smokers is common to many different theoretical perspectives. It is inherent in the social influences approach (Flay, 1985), for example, which suggests that, as West & Michell (1999) characterise it, some adolescents will be cajoled into smoking against their will. This assumption explains why the same young people who at the start of adolescence are fiercely anti-smoking have become smokers by the end of adolescence (Chassin, Presson, Sherman, & McGrew, 1987). Nevertheless, this remains an assumption, and, to our knowledge, an untested assumption. In this report, we derive a variable, engagement, which recorded whether individuals felt the TTM intervention in the trial was interesting and useful. Clearly, no intervention could ever be thought interesting and useful by every adolescent. However, non-smokers who thought the intervention was either uninteresting or not useful should be no more likely to become smokers in the future than young people who thought it was interesting and useful. Alternatively, if disengagement with the intervention reflected desire to smoke, then disengagement from the intervention would act as a risk factor for later smoking. However, controlling for smoking behaviour and intention to smoke, indicated by stage of change, should abolish the apparent risk of becoming a smoker in future arising from disengagement with the intervention. This is because in this paradigm, experimentation with smoking, intention to smoke, and disengagement have the same meaning: a wish to smoke in the future, but smoking behaviour and intention to smoke are more direct measures of this than is disengagement from the intervention. The aims of this study, therefore, were to examine whether disengagement from the intervention was associated with smoking at 1 and 2 years follow-up in the trial, and to show whether the effect of disengagement was independent of smoking status or intention to smoke.
Section snippets
Method
The data are taken from a previously reported trial, and the full report is freely available at www.bmj.com/cgi/reprint/319/7215/948 (Aveyard et al., 1999), and updated results are also published (Aveyard et al., 2001). Briefly, 89 West Midlands schools were selected randomly with probability proportional to size, and were approached to participate in a randomised trial of smoking prevention and cessation. Fifty-two (58.4%) schools agreed and these schools were randomised into intervention and
Results
Table 1 shows the intervention was deemed interesting and useful by most participants on each of the three computer sessions, which accords with our sense that it was popular when we delivered it (Sherratt & Almond, 1999). (Feedback from the teachers about the whole class lessons suggested they were also popular (Aveyard et al., 1999).) This, however, did not make the intervention work. The percentage smoking in those followed up at 1 year was 18.8% in the TTM arm and 17.5% in the control arm:
Discussion
These results show that both non-attendance at school and non-engagement with an anti-smoking intervention were risk factors for smoking, independently of other established risk factors. The strongest risk factor was non-engagement. Sensitivity analysis showed that these results could not be explained by reverse causation: smoking causing disengagement. Disengagement preceded smoking uptake. The influence of disengagement was largest for never-smokers, though there was limited evidence to
Acknowledgements
This trial was funded by the health authorities of the West Midlands. The computerised intervention described is copyright of Pro-Change. Professor Prochaska and his colleagues and Public Management Associates, UK, designed the intervention and we are grateful to them for their help.
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