Affiliations of authors: A. V. Peterson, Jr., Cancer Prevention Research Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, and Department of Biostatistics, University of Washington, Seattle; K. A. Kealey, S. L. Mann, P. M. Marek, Cancer Prevention Research Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center; I. G. Sarason, Cancer Prevention Research Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, and Department of Psychology, University of Washington.
Correspondence to: Arthur V. Peterson, Jr., Ph.D., Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, MP-603, 1100 Fairview Ave., N., P.O. Box 19024, Seattle, WA 981091024 (e-mail: avpeters{at}fhcrc.org).
The comments and questions regarding the Hutchinson Smoking Prevention Project (HSPP) trial raised by Sussman et al., Cameron et al., and Bliss address four main issues: 1) the scientific question addressed by the HSPP trial, 2) appropriate conclusions to be drawn from the trial results, 3) comparison of HSPP results with those of other studies, and 4) implications for the future.
1) The HSPP scientific question.
The HSPP trial was designed to determine to what extent a comprehensive grade 310 social-influences curriculum could deter smoking in youth at the end of the age period of child/adolescent smoking acquisition. The HSPP results pertain only to the intervention approach tested in the HSPP trialthe social-influences approach [e.g., (1)]and not to the life skills training approach [e.g., (2)], brought up by Sussman et al. and by Bliss, or to school-plus-community-wide intervention (i.e., "system-wide programming"), brought up by Sussman et al.
In accordance with the trial's goal, its main endpoints were smoking at 12th grade and at 2 years after high school. So, it is appropriate that the report of trial results focused on these long-term endpoints, on which the answer to the scientific questionthe success or failure of the intervention in deterring smoking at the end of the period of child/adolescent smoking acquisitionrests, rather than on data at younger ages, before the end of the intervention period, for indication of delayed onset (as suggested by Sussman et al.). Analyses of the latter data are planned as part of the trial's secondary analysis of smoking acquisition during the period from grades 3 to 12.
2) Appropriate conclusions to be drawn from the HSPP trial.
Because of the high rates of implementation and follow-up and other achievements related to scientific integrity, alternative explanations for the findings were ruled out. In response to Sussman et al.'s question about students' interest in the curriculum, both the teachers (via post-implementation interviews and a self-report questionnaire) and HSPP staff (via classroom observations) reported that the youth were engaged by and interested in the classroom activities [e.g., (3)].
We agree with Sussman et al. that, because the HSPP trial was not performed in urban areas or in predominately minority populations, the trial itself can make no conclusion specifically about these populations. Nevertheless, the study population was demographically and geographically diverse, covering 40 different rural and suburban communities with a wide range of socioeconomic status, smoking prevalence, and percent of minorities (4).
3) Comparison of HSPP results with other studies.
Sussman et al. are concerned about how the HSPP trial results compare with those of other trials reported in a recent meta-analysis by Tobler and colleagues. But the appropriate comparison for the HSPP trial is with trials that investigated the same scientific question. In contrast to the many studies included in the meta-analysis, which included a variety of different intervention approaches, a number of different targeted substances (alcohol, illegal drugs, and cigarettes), and studies with short-term endpoints, only four trials [HSPP and those in (57)] evaluated the long-term impact of the social-influences approach for the prevention of smoking. In none of these trials was there any evidence of long-term impact of the intervention. Thus, the null results from the HSPP trial are consistent with the relevant literature.
4) Implications for the future.
Our findings have implications for both research and public health practice. Concerning implications for research, future work is needed in the following areas: (a) additional analyses of data from long-term trials and longitudinal studies, both to investigate why the social-influences approach hasn't worked and to obtain information on process and risk factors to inform future intervention development. In particular, related to comments by Sussman et al., (i) preliminary analysis of variables targeted by the HSPP intervention (e.g., knowledge, beliefs, self-efficacy, and perception of smoking norms) reveals that the HSPP intervention did impact these variables (as we reported at the March 2001 meeting of the Society of Behavioral Medicine) and (ii) analyses are planned to evaluate various aspects of the process of smoking acquisition among the HSPP cohort, including comparisons of smoking prevalence early in the smoking acquisition process. Also needed are (b) additional theory development for smok-ing acquisition, informed and guided by data, and (c) future trials, once promising new approaches have been identified. In this context, we agree with Cameron et al. that one should not assume that interventions will necessarily work in all environments. As they point out, for example, the characteristics of the schools (e.g., high-risk versus low-risk) and of youth (e.g., rebellious versus not rebellious) would need to be considered, first in theory development and then in sharpened scientific questions for intervention research.
Concerning implications for public health practice, as stated eloquently and accurately by Sussman et al., without enlightened and effective action now our nation's youth will continue to take up smoking and die in disheartening numbers. The conclusion from the HSPP trial and the other three trials that evaluated the long-term impact of the social-influences approach for school-based smoking prevention seems clear: The social influences approach has worked no better than the usual health curricula already in the schools in long-term deterrence of youth smoking. In our study, one quarter of 12th grade youth smoked daily, regardless of the presence of a comprehensive social-influences intervention.
So, what to do now to help our nation's youth? Unfortunately, the HSPP trial does not give the answer to this question. The answer must come from positive experiences from other intervention approaches. For example, the experience and results from statewide initiatives in California and other states indicate that a comprehensive statewide anti-tobacco program may be effective. Also, it is clear that parents' smoking is an important risk factor for their children becoming smokers. Accordingly, action to inform and change the behavior of parents who smoke is worthy of consideration.
Noteworthy from the HSPP trial was the tremendous cooperation received from youth, parents, and teachers, which helped to provide the excellent data participation and implementation rates that contributed to the trial's high scientific integrity. For the nation, such cooperation is a promising sign that the citizenry may cooperate in new initiatives to help our nation's youth avoid tobacco. Our responsibility is to ensure that such initiatives are based on the best evidence available. In particular, from the null results of the HSPP trial and three other trials that investigated longterm impact of the social-influences approach, there is strong evidence that a school-based, social-influences approach alone is unlikely to be the answer.
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