This study presents data from an assessment of substance use prevention programs in 23 elementary and middle schools in north 48ern and central Illinois. The quality of prevention programming was assessed based on program intensity, focus on tobacco, staff resources designated for prevention programs, and implementation of the Centers for Disease Control and Prevention recommendations for tobacco prevention. Data from these four dimensions were used to calculate a Quality Index Score. Multilevel logistic regression analysis was used to assess the relationship between individual level variables, school level variables and the outcomes of reported current tobacco use, intent to use tobacco in the coming year, and perceived efficacy of substance use prevention programs. No significant effects were found, indicating that exclusive use of even high quality school-based prevention programs may not be sufficient in changing youth behavior. However, school-based prevention programs may be an important component of a broader ecological approach that uses multiple, community-wide strategies to promote normative change. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected] haworthpressinc.com> Website: <https://www.HaworthPress.com" xmlns:xlink="https://www.w3.org/1999/xlink">https://www.HaworthPress.com> © 2002 by The Haworth Press, Inc. All rights reserved.]

Recent population estimates indicate that each day in the United States 4,800 youth try smoking for the first time and almost 3,000 more become established smokers (Gilpin, Choi, Berry, & Pierce, 1999). Tobacco experimentation and regular use increases throughout the middle school and high school years. Upon entering middle school, very few students report having used cigarettes (American Legacy Foundation, 2000). However, by the ninth grade almost one-fourth of students and by twelfth grade more than one-third of students report having used cigarettes (American Legacy Foundation, 2000). A youth's decision of whether or not to use tobacco has serious health consequences. Smoking is the leading preventable cause of death in the United States, killing over 400,000 people each year (Centers for Disease Control and Prevention, 1993). In addition to direct health consequences, the use of tobacco can also put youth at risk for subsequent use of alcohol and other drugs (Kandel, 1989).

Schools can be an important setting for educating youth about healthy behavior and for establishing norms pertaining to those behaviors (Brink, Simons-Morton, Harvey, Parcel, & Tieman, 1988; Rhodes & 49Jason, 1988). A variety of school-based programs for preventing tobacco use have been implemented over the past decades (Lantz et al., 2000). During the 1960s and 1970s, efforts to prevent the initiation of tobacco, alcohol, and other drug use were frequently designed to scare youth, to provide information about drugs and related paraphernalia, to appeal to adolescent morality, or to improve youths' self-esteem (Donaldson et al., 1996). Smoking prevention programs used curricula that were mostly aimed at increasing student awareness of the harmful, long-term effects of cigarette smoking (Perry, Killen, Telch, Slinkard, & Danaher, 1980).

In the 1980s, substance use prevention programs shifted toward curricula based on social influences (Donaldson et al., 1996).The social influences model of prevention education emphasizes the social environment as a critical factor in tobacco use (Lantz et al., 2000) and attempts to address environmental, personality and behavioral risk factors (Perry & Kelder, 1992). Tobacco prevention curricula based on the social influences model generally include seven major components: identification of short-term and long-term social consequences of use, reasons for tobacco use, information on peer norms, analysis of messages from media and role models, refusal skills, and public commitment activities (Perry & Kelder, 1992).

Despite four decades of studies on the effects of prevention programs on smoking rates among youth, there are no readily available tools for assessing the quality of substance use prevention programs in general or tobacco use prevention programs in particular. The evaluation tools that are available focus more on implementation strategies than on curriculum content and are often void of any specific recommendations regarding program content or delivery. Five aspects of school-based tobacco use prevention programs that may be important include use of an empirically based curriculum (Brounstein & Zweig, 1999), program intensity (Tobler, 1986; Tobler & Stratton, 1997), focus on tobacco (Johnson, MacKinnon & Pentz, 1996; Tobler & Stratton, 1997), staff resources (Bosworth, 1998), and adoption of guidelines for best practices published by the Centers for Disease Control and Prevention (CDC, 1994). Each of these aspects is discussed below.

The use of an empirically based curriculum can meet the demands of fiscal accountability that require substance use prevention programs to be validated (Tobler & Stratton, 1997). The Center for Substance Abuse Prevention (CSAP) defines science-based prevention programs as those that have been shown through research to be effective in the prevention or delay of substance use (Brounstein & Zweig, 1999). According to the 50CSAP typology, empirically based curricula have minimally been subjected to an expert or peer consensus process or have appeared in a peer-reviewed journal. At the highest level are programs that have been replicated across populations and settings and appeared in several refereed professional journals. However, a survey of 104 school districts in 12 states and the District of Columbia found that the most widely used curricula are ones that have little or no empirically based research to show that they are effective in reducing substance use (Hallfors, Sporer, Pankratz & Godette, 2000).

Little research has been published concerning the effect of program intensity on the prevalence of substance use. In a meta-analysis of substance use prevention programs, Tobler and Stratton (1997) addressed the question of whether more intense programs, measured by hours of instruction, had greater positive effects. They found no significant effect due to program intensity. However, the lack of effect may be related to the fact that the mean intensity for all programs was only 10 hours. The high intensity programs were slightly more effective when instruction time was 18 hours. It is also possible that other factors such as the quality of the program itself may have affected these results. An earlier meta-analysis (Tobler, 1986) found a relationship between program intensity and effect size when accounting for the type of curriculum and mode of implementation. Poor quality programs, even when delivered with high intensity, may not produce the intended effect. Conversely, high quality programs that lack sufficient intensity may not yield significant effects.

The most widely used substance use prevention programs address a variety of substances, including tobacco, alcohol, and illegal drugs (Johnson et al., 1996). In considering whether it is more effective to target a single substance, multiple substances, or a broad range of lifestyle behaviors, Johnson et al. (1996) conducted a qualitative review of 13 studies. The programs studied differed primarily in whether the program focused exclusively on tobacco use, more broadly on tobacco, alcohol, and other drugs, or on healthy lifestyles that included prevention of tobacco, alcohol, and other drug use. The review found that multiple-purpose programs appeared no less effective for prevention of cigarette smoking than were programs that focused exclusively on tobacco use prevention. However, there is little corroboration for this conclusion and no tests for statistical significance were conducted. Therefore, specific instruction aimed at tobacco prevention may still be a factor in considering the effects of prevention programs on youth tobacco use.

51Adequate staff resources to implement prevention efforts may also be important. A survey of 76 elementary, middle, and high schools found patterns of staff involvement in the development and implementation of substance use prevention curricula that indicate little use of resources outside of the local school (Bosworth, 1998). Of the schools surveyed, health teachers had the primary role in the development and implementation of substance use prevention curricula. The drug-free schools' coordinators were included in curriculum development in only 18% of schools and only 3% of schools used outside experts in the community. While the survey included only schools that developed their own prevention curricula rather than using commercially available curricula, it raises general questions about the use of staff resources at the school, district, and community levels. Schools, districts, or communities that allocate more resources to substance use prevention in the schools may have a stronger commitment and concern for the health of their youth.

Finally, adherence to the CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction should be considered (CDC, 1994), The guidelines represent expert opinions about best practices for tobacco use prevention and consist of seven recommendations. (A) Schools should have a comprehensive policy on tobacco. (B) The content of prevention instruction should include components equivalent to the social influences model of prevention. (C) Tobacco-use prevention education should be provided in each grade from kindergarten through grade 12. (D) Facilitators should receive program-specific training. (E) Parents and families should be involved in support of school-based prevention programs. (F) Schools should support cessation efforts among students and staff who use tobacco. (G) Prevention programs should be assessed at regular intervals to assess whether or not they are consistent with the CDC guidelines.

The present study is a secondary activity of the Youth Tobacco Access Project (Jason, Engstrom, Pokorny, Tegart, & Curie, 2000; Jason, Pokorny, Curie, Townsend, & Engstrom, 2002), The project is a three-year study designed to examine the impact of tobacco control policies on the prevalence of tobacco use among sixth, seventh, and eighth grade students in eleven communities in northern and central Illinois. In taking an ecological approach, it was determined that influences other than tobacco-control policies should be examined for potential effects on the prevalence rates of tobacco use. One potentially important influence identified was substance use prevention programs in the schools and an index for assessing the quality of school-based tobacco use pre52vention programs was developed. The quality of prevention programming was analyzed in relation to outcomes from a survey of sixth, seventh, and eighth grade students in the participating schools. Outcomes analyzed were students' current use of tobacco, intent to use tobacco in the coming year, and perceived efficacy of substance use prevention programs. It was hypothesized that students in schools with higher quality prevention programs would report lower amounts of current tobacco use, lower intent to use tobacco in the coming year, and higher perceived efficacy of substance use prevention programs.