A Randomized Evaluation of Smoking Cessation Interventions for Pregnant Women at a WIC Clinic JEFFREY P. MAYER, PHD, BARBARA HAWKINS, MA, Abstract: Pregnant smokers attending a local health department WIC clinic were randomly assigned to one of two self-help smoking cessation programs or usual care. The multiple component program resulted in larger quit rates than usual care during the last month of pregnancy (11 percent vs 3 percent) and postpartum (7 percent vs 0 percent). Achieving quit rates in WIC similar to those in studies conducted at prenatal care settings, suggests that smoking cessation programs for low-income pregnant WIC clients are feasible. (Am J
Public Health 1990; 80:76-78.)
Introduction Estimates suggest that 32 percent of all women of child-bearing age smoke with only 21 percent quitting during pregnancy.' Evaluations of self-help cessation programs have demonstrated some success with pregnant women receiving prenatal care at an HMO (health maintenance organization),2 private practices,3 hospital clinics,4* and local health departments.' WIC (the Special Supplemental Food Program for Women, Infants, and Children) is an unexplored setting for smoking cessation research. Analyses of matched WIC-birth certificate data for Missouri in 1982 indicated that 45 percent of pregnant women WIC participants were smokers,** 50 percent higher than the 30 percent rate observed among all Missouri women that year. Data on 127,512 pregnant women enrolled in several state WIC programs from 1979 through 1985 suggested that smokers were 2.5 times more likely to deliver a low birthweight infant, and that very few participants stopped smoking following their enrollment in WIC.*** The present investigation is a randomized trial of a self-help smoking cessation program implemented at a local health department WIC clinic.
Method The study was conducted from August 1985 to August 1986 at the Kent County Health Department in Grand Rapids, Michigan. A brief structured interview was used to characterize an incoming pregnant women as a current smoker (at least one cigarette per day), a nonsmoker, or a former Address reprint requests to Jeffrey P. Mayer, PhD, Program Evaluation and Methodology Division, US General Accounting Office, 441 G Street, NW, Rm 5741, Washington, DC 20541. Ms. Hawkins and Dr. Todd are with the Division of Health Education, Kent County Health Department, Grand Rapids, MI. This paper, submitted to the Joumal February 22, 1989, was revised and accepted for publication June 26, 1989. *Secker-Walker RH, Flynn BS, Solomon LJ, Collins-Bumris L, LePage S, Mead PB: Attitudes, beliefs and other smokers: Factors affecting smoking cessation in pregnancy. Paper presented at 114th annual meeting of the American Public Health Association, Las Vegas, Nevada, 1986. **Land GH, Stockbauer JW: WIC prenatals: A major target population for smoking cessation programs. Jefferson City, Missouri: Missouri Center for Health Statistics, 1986. Unpublished manuscript. ***Nieburg P, Fuller M, Wong F: Cigarette smoking and adverse pregnancy outcome in the Special Supplemental Food Program for Women, Infants, and Children. Atlanta, GA: Division of Nutrition, Center for Health Promotion, Centers for Disease Control, 1986. Unpublished manuscript.
76
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RANDALL TODD, DHSc, MPH
smoker. Current smokers were asked to participate in the study and to complete an informed consent statement and a pretest. Following informed consent, participants were randomly assigned to one of three groups. The usual care (UC) group received printed information about the risks of smoking during pregnancy and completed the clinic in the traditional manner. The multiple component (MC) group received a 20minute one-to-one counseling session which included both risk information and behavior change components. The risk information component employed the Because I Love My Baby materials developed by the American Lung Association. These materials included a "flip chart" used by the health educator in presenting the information and a printed brochure given to clients to take home. The behavior change component of the MC intervention employed a self-help manual adapted from Windsor, et al,5 and from the American Lung Association's Freedom From Smoking program. Behavioral contracting and self-monitoring were the primary strategies. An individual behavioral contract was developed during the session which specified a quit date and selection of some significant other as a cosigner. Self-monitoring included charts for recording daily smoking behavior, and the development of an individualized plan of action for breaking recorded behavioral chains. The risk information (RI) intervention was a face-to-face session of about 10 minutes duration. The health educator used the same "flip chart" as the MC group and provided the factual brochures, but did not present behavior change counseling, or furnish the self-help manual. During the postpartum WIC visit, the posttest was completed, which included questions about smoking during the final month of pregnancy as well as postpartum. The postpartum self-reports, on average, occurred 4.7 weeks following birth of the infant, a relatively short period. Saliva samples (N = 66) were collected from the last one-third of the participants. The correlation between the saliva thiocyanate and self-report measures (r = .25) was similar to correlations found in more extensive analyses with larger samples that showed excellent sensitivity and specificity.6'7 Saliva samples were equally distributed across groups (28 percent of MC participants, 30 percent of RI participants, and 32 percent of UC participants). Resource constraints did not allow collection of more complete data. Demographic and health service data were abstracted from WIC program records for study participants and for the women who refused to participate. Agreement rates between different coders, and between the WIC record and prenatal care medical record, for a 30 percent random sample, were 99.2 percent and 87.9 percent, respectively. Results Two hundred and seventy-one of 641 pregnant women entering the clinic were identified as current smokers (42 percent); 219 volunteered to participate in the study (81 percent). Of these 219, posttest data were collected from 186 (15 percent attrition rate) (about one-fourth actually refused to complete the posttest; three-fourths either moved from the community, left the AJPH January 1990, Vol. 80, No. 1
PUBLIC HEALTH BRIEFS
WIC program, or miscarried). Those lost to follow-up were treated as continuing smokers in the foilowing analyses. Differences between study participants and refusals on variables available from the WIC record were relatively minor for important variables as were study group differences (Table 1). Table 2 presents the quit proportions and differences by treatment group for both follow-up periods. The MC group quit rate was higher than the UC group at both post time periods. While all UC participants had returned to smoking postpartum, some proportion of the participants in the MC and RI groups remained smoke free.
group (11 percent) was just under that found at prenatal care settings serving low-income women. Both Windsor, et al,5 and Secker-Walker et al,* in studies conducted at low-income public maternity clinics, reported quit rates of 14 percent. Although limitations of the present formative evaluation study include small sample size, and lack of complete biochemical verification, the findings have preliminary implications for extending health education services to pregnant smokers visiting WIC clinics. The high level of program acceptance among our WIC participants (81 percent) is impressive. Although prenatal care settings see pregnant women more regularly, offering the possibility of multiple health education contacts (and potentially improved quit rates), the WIC program, with broader eligibility than typically found at public prenatal care clinics, would seem to offer greater opportunity to reach a larger share of low-income women. Additionally, WIC clinics offer the advantage of a centralized site where health educators and public health nurses can be made available to provide one-to-one counselings.
Discussion
The 42 percent smoking rate among pregnant women entering the WIC clinic was similar to the estimates of Land and Stockbauer,** and was indicative of the important need for smoking intervention at WIC clinics. The quit rate for the MC
TABLE 1-Comparison of Multiple Component, Risk Information, Usual Care, and Refusal Groups on Selected Demographic and Health Care Variables
Variables
Moan Age Parity % Primiparous % Multiparous Race % Black % White % Other Trimester Prenatal Care Began % First % Second %Third Trimester of First WIC Clinic Visit % First % Second % Third Source of Payment % Insurance or HMO % Medicaid % Self-pay or other Received Advice from Physician to Quit % Yes % No Mean Number of Years Smoking Mean Age Smoking Began Number of Quitting Attempts Prior to Pregnancy % None % One or more Number of Quitting Attempts Following Pregnancy % None % One or more Mean Number of Cigarettes per Day Prior to Pregnancy
Multiple Component (n = 72)
Risk Information (n = 70)
Usual Care (n = 77)
Total (n = 219)
Refusals (n = 52)
22.3
23.4
22.4
22.7
23.8
33.8 66.2
27.9 72.1
23.4 76.6
28.2 71.8
21.2 78.8
18.3 78.9 2.8
25.0 75.0 0.0
19.5 71.4 9.1
20.8 75.0 4.2
18.9 75.5 5.7
88.7 11.3 0.0
80.3 18.2 1.5
82.7 16.0 1.3
84.0 15.1 0.9
NA NA NA
22.5 54.9 22.5
27.5 44.9 27.5
19.5 48.1 32.5
23.0 49.3 27.6
23.1 50.0 26.9
14.5 79.0 6.5
9.1 80.0 10.9
21.0 71.0 8.1
15.1 76.5 8.4
8.5 80.9
68.6 31.4
67.1
32.9
68.9 31.1
68.2 31.8
NA NA
7.2
7.5
7.3
7.4
NA
15.1
15.8
15.1
15.3
NA
26.4 73.6
34.3 65.7
28.9 71.1
29.8 70.2
NA NA
69.4 30.6
64.3 35.7
66.2 33.8
66.7 33.3
NA NA
19.9
19.7
20.3
19.9
NA
10.6
NOTE: All differences between MC, RI and UC groups are not statistically significant at the .05 level using chi-square tests for categorical variables and ANOVA for differences between means. Differences between the total intervention group and the refusal group are also not significant. Sample size may vary slightly due to missing data. NA = not available from WIC record.
AJPH January 1990, Vol. 80, No. 1
77
PUBLIC HEALTH BRIEFS TABLE 2-Qult Proportions and Differences at the Ninth Month of Pregnancy and Postpartum
Multiple Component (N = 72)
Risk Information (N = 70) Usual Care (N = 77) Total (N = 219)
At Ninth Month
Postpartum
.111 (.039, .183)
.069 (.010, .128)
.071 (.011, .131)
.071 (.011, .131)
.026 (-.009, .062) .068 (.035, .101)
.000 (0.00, 0.00)
Difference .085 .045 .040
95% Cl (.004, .166) (-.025, .115) (-.054, .134)
.069 .071 .002
(.011, .128) (.012, .130) (-.082, .086)
.046
(.018, .074)
Note: 95% Cl in parentheses At Ninth Month MC vs UC Rl vs UC MC vs RI Postpartum MC vs UC RI vs UC MC vs RI
ACKNOWLEDGMENTS The views and opinions expressed herein do not reflect the position of the General Accounting Office. This work was completed as the doctoral disser-
tation of the first author at the Department of Psychology, Michigan State University. We thank William Davidson, PhD, Charles Johnson, PhD, Robin Redner, PhD, and Jeffrey Taylor, PhD, who served on the first author's dissertation committee. Another version of this work was presented at the annual meeting of the American Evaluation Association in Boston, October 1987.
REFERENCES 1. National Center for Health Statistics, OT Thornberry, RW Wilson, P Golden: Health promotion and disease prevention: Provisional data from the National Health Interview Survey. Advance Data From Vital and Health Statistics, No. 119, DHHS Pub. No. (PHS) 86-1250. Hyattsville, MD: NCHS, Public Health Service, 1986. 2. Ershoff DH, Mullen PD, Quinn VP: A randomized trial of a serialized self-help smoking cessation program for pregnant women in an HMO. Am J Public Health 1989; 79:182-187. 3. Sexton M, Hebel JR: A clinical trial of change in maternal smoking and its effect on birth weight. JAMA 1984; 251:911-915. 4. Baric L, MacArthur C, Sherwood M: A study of health educational aspects of smoking in pregnancy. Int J Health Educ 1976; 19:(2)1-17. 5. Windsor RA, Cutter G, Morris J, Reese Y, Manzella B, Bartlett EE, Samuelson C, Spanos D: The effectiveness of smoking cessation methods for smokers in public health maternity clinics: A randomized trial. Am J Public Health 1985; 75:1389-1392. 6. Sexton M, Nowicki P, Hebel JR: Verification of smoking status by thiocyanate in unrefrigerated, mailed saliva samples. Prev Med 1986; 15:25-34. 7. Bliss RE, O'Connell KA: Problems with thiocyanate as an index of smoking status: A critical review with suggestions for improving the usefulness of biochemical measures in smoking cessation research. Health Psychol 1984; 3:563-581.
Eight-Year Follow-Up Results of an Adolescent Smoking Prevention Program: The North Karelia Youth Project ERKKI VARTIAINEN, MD, PHD, UNTO FALLONEN, PHD, ALFRED L. MCALISTER, PHD, PEKKA PUSKA, MD, MPOLSCI Abstract: In the North Karelia Youth Program five to 10 classroom sessions over two years taught skills to resist pressures to start smoking to 13 to 15 year old students. Compared to students from comparison schools, the treatment groups reported less smoking immediately after the intervention and in a four-year follow-up survey. At the eight-year follow-up, there was consistent evidence of possible preventive effects only among those who had been nonsmokers when the program began. (Am J Public Health 1990; 80:78-79.)
Introduction From 1978 to 1980, a study to demonstrate methods for reducing cardiovascular risk factors in 13-year-old students Address reprint requests to Erkki Vartianen, Department of Epidemiology, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki Finland. Dr. Puska is also with that department at the Institute; Dr. Pallonen is with the Division of Epidemiology, University of Minnesota School of Public Health; Dr. McAlister is with the Center for Health Promotion Research and Development, University of Texas Health Science Center at Houston. This paper, submitted to the Journal July 11, 1988, was revised and accepted for publication June 8, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
78
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was carried out in the province of North Karelia, Finland. One of the main aims was to prevent the onset of smoking.' Although many studies of the effectiveness of persuasive and behavioral approaches to smoking prevention have been carried out,2 long-term follow-up is rare.3'4 Details of the methods and the outcome of the intervention immediately after the rogram', after half a year5, and two years after the program are reported elsewhere. This brief report describes the follow-up results eight years after the program ended.
Methods In brief, three pairs of matched schools were chosen for the program. In two "direct" program schools, 10 sessions were carried out during a two-year period from 1978 to 1980 by the project health educator and trained peer leaders. In two "county-wide" program schools, five behavioral sessions were to be carried out by health education teachers at the schools who were trained as part of an effort to disseminate new curricula throughout North Karelia. Two schools were chosen for controls from another province in eastern Finland. In each matched pair, one school was chosen from the capital of the county and the other from a rural village. The program began in 1978 among the seventh graders and finished with the ninth grade in autumn 1980. During the persuasive-behavioral sessions, students were taught about AJPH January 1990, Vol. 80, No. 1
Public Health 1990; 80:76-78.)
Introduction Estimates suggest that 32 percent of all women of child-bearing age smoke with only 21 percent quitting during pregnancy.' Evaluations of self-help cessation programs have demonstrated some success with pregnant women receiving prenatal care at an HMO (health maintenance organization),2 private practices,3 hospital clinics,4* and local health departments.' WIC (the Special Supplemental Food Program for Women, Infants, and Children) is an unexplored setting for smoking cessation research. Analyses of matched WIC-birth certificate data for Missouri in 1982 indicated that 45 percent of pregnant women WIC participants were smokers,** 50 percent higher than the 30 percent rate observed among all Missouri women that year. Data on 127,512 pregnant women enrolled in several state WIC programs from 1979 through 1985 suggested that smokers were 2.5 times more likely to deliver a low birthweight infant, and that very few participants stopped smoking following their enrollment in WIC.*** The present investigation is a randomized trial of a self-help smoking cessation program implemented at a local health department WIC clinic.
Method The study was conducted from August 1985 to August 1986 at the Kent County Health Department in Grand Rapids, Michigan. A brief structured interview was used to characterize an incoming pregnant women as a current smoker (at least one cigarette per day), a nonsmoker, or a former Address reprint requests to Jeffrey P. Mayer, PhD, Program Evaluation and Methodology Division, US General Accounting Office, 441 G Street, NW, Rm 5741, Washington, DC 20541. Ms. Hawkins and Dr. Todd are with the Division of Health Education, Kent County Health Department, Grand Rapids, MI. This paper, submitted to the Joumal February 22, 1989, was revised and accepted for publication June 26, 1989. *Secker-Walker RH, Flynn BS, Solomon LJ, Collins-Bumris L, LePage S, Mead PB: Attitudes, beliefs and other smokers: Factors affecting smoking cessation in pregnancy. Paper presented at 114th annual meeting of the American Public Health Association, Las Vegas, Nevada, 1986. **Land GH, Stockbauer JW: WIC prenatals: A major target population for smoking cessation programs. Jefferson City, Missouri: Missouri Center for Health Statistics, 1986. Unpublished manuscript. ***Nieburg P, Fuller M, Wong F: Cigarette smoking and adverse pregnancy outcome in the Special Supplemental Food Program for Women, Infants, and Children. Atlanta, GA: Division of Nutrition, Center for Health Promotion, Centers for Disease Control, 1986. Unpublished manuscript.
76
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RANDALL TODD, DHSc, MPH
smoker. Current smokers were asked to participate in the study and to complete an informed consent statement and a pretest. Following informed consent, participants were randomly assigned to one of three groups. The usual care (UC) group received printed information about the risks of smoking during pregnancy and completed the clinic in the traditional manner. The multiple component (MC) group received a 20minute one-to-one counseling session which included both risk information and behavior change components. The risk information component employed the Because I Love My Baby materials developed by the American Lung Association. These materials included a "flip chart" used by the health educator in presenting the information and a printed brochure given to clients to take home. The behavior change component of the MC intervention employed a self-help manual adapted from Windsor, et al,5 and from the American Lung Association's Freedom From Smoking program. Behavioral contracting and self-monitoring were the primary strategies. An individual behavioral contract was developed during the session which specified a quit date and selection of some significant other as a cosigner. Self-monitoring included charts for recording daily smoking behavior, and the development of an individualized plan of action for breaking recorded behavioral chains. The risk information (RI) intervention was a face-to-face session of about 10 minutes duration. The health educator used the same "flip chart" as the MC group and provided the factual brochures, but did not present behavior change counseling, or furnish the self-help manual. During the postpartum WIC visit, the posttest was completed, which included questions about smoking during the final month of pregnancy as well as postpartum. The postpartum self-reports, on average, occurred 4.7 weeks following birth of the infant, a relatively short period. Saliva samples (N = 66) were collected from the last one-third of the participants. The correlation between the saliva thiocyanate and self-report measures (r = .25) was similar to correlations found in more extensive analyses with larger samples that showed excellent sensitivity and specificity.6'7 Saliva samples were equally distributed across groups (28 percent of MC participants, 30 percent of RI participants, and 32 percent of UC participants). Resource constraints did not allow collection of more complete data. Demographic and health service data were abstracted from WIC program records for study participants and for the women who refused to participate. Agreement rates between different coders, and between the WIC record and prenatal care medical record, for a 30 percent random sample, were 99.2 percent and 87.9 percent, respectively. Results Two hundred and seventy-one of 641 pregnant women entering the clinic were identified as current smokers (42 percent); 219 volunteered to participate in the study (81 percent). Of these 219, posttest data were collected from 186 (15 percent attrition rate) (about one-fourth actually refused to complete the posttest; three-fourths either moved from the community, left the AJPH January 1990, Vol. 80, No. 1
PUBLIC HEALTH BRIEFS
WIC program, or miscarried). Those lost to follow-up were treated as continuing smokers in the foilowing analyses. Differences between study participants and refusals on variables available from the WIC record were relatively minor for important variables as were study group differences (Table 1). Table 2 presents the quit proportions and differences by treatment group for both follow-up periods. The MC group quit rate was higher than the UC group at both post time periods. While all UC participants had returned to smoking postpartum, some proportion of the participants in the MC and RI groups remained smoke free.
group (11 percent) was just under that found at prenatal care settings serving low-income women. Both Windsor, et al,5 and Secker-Walker et al,* in studies conducted at low-income public maternity clinics, reported quit rates of 14 percent. Although limitations of the present formative evaluation study include small sample size, and lack of complete biochemical verification, the findings have preliminary implications for extending health education services to pregnant smokers visiting WIC clinics. The high level of program acceptance among our WIC participants (81 percent) is impressive. Although prenatal care settings see pregnant women more regularly, offering the possibility of multiple health education contacts (and potentially improved quit rates), the WIC program, with broader eligibility than typically found at public prenatal care clinics, would seem to offer greater opportunity to reach a larger share of low-income women. Additionally, WIC clinics offer the advantage of a centralized site where health educators and public health nurses can be made available to provide one-to-one counselings.
Discussion
The 42 percent smoking rate among pregnant women entering the WIC clinic was similar to the estimates of Land and Stockbauer,** and was indicative of the important need for smoking intervention at WIC clinics. The quit rate for the MC
TABLE 1-Comparison of Multiple Component, Risk Information, Usual Care, and Refusal Groups on Selected Demographic and Health Care Variables
Variables
Moan Age Parity % Primiparous % Multiparous Race % Black % White % Other Trimester Prenatal Care Began % First % Second %Third Trimester of First WIC Clinic Visit % First % Second % Third Source of Payment % Insurance or HMO % Medicaid % Self-pay or other Received Advice from Physician to Quit % Yes % No Mean Number of Years Smoking Mean Age Smoking Began Number of Quitting Attempts Prior to Pregnancy % None % One or more Number of Quitting Attempts Following Pregnancy % None % One or more Mean Number of Cigarettes per Day Prior to Pregnancy
Multiple Component (n = 72)
Risk Information (n = 70)
Usual Care (n = 77)
Total (n = 219)
Refusals (n = 52)
22.3
23.4
22.4
22.7
23.8
33.8 66.2
27.9 72.1
23.4 76.6
28.2 71.8
21.2 78.8
18.3 78.9 2.8
25.0 75.0 0.0
19.5 71.4 9.1
20.8 75.0 4.2
18.9 75.5 5.7
88.7 11.3 0.0
80.3 18.2 1.5
82.7 16.0 1.3
84.0 15.1 0.9
NA NA NA
22.5 54.9 22.5
27.5 44.9 27.5
19.5 48.1 32.5
23.0 49.3 27.6
23.1 50.0 26.9
14.5 79.0 6.5
9.1 80.0 10.9
21.0 71.0 8.1
15.1 76.5 8.4
8.5 80.9
68.6 31.4
67.1
32.9
68.9 31.1
68.2 31.8
NA NA
7.2
7.5
7.3
7.4
NA
15.1
15.8
15.1
15.3
NA
26.4 73.6
34.3 65.7
28.9 71.1
29.8 70.2
NA NA
69.4 30.6
64.3 35.7
66.2 33.8
66.7 33.3
NA NA
19.9
19.7
20.3
19.9
NA
10.6
NOTE: All differences between MC, RI and UC groups are not statistically significant at the .05 level using chi-square tests for categorical variables and ANOVA for differences between means. Differences between the total intervention group and the refusal group are also not significant. Sample size may vary slightly due to missing data. NA = not available from WIC record.
AJPH January 1990, Vol. 80, No. 1
77
PUBLIC HEALTH BRIEFS TABLE 2-Qult Proportions and Differences at the Ninth Month of Pregnancy and Postpartum
Multiple Component (N = 72)
Risk Information (N = 70) Usual Care (N = 77) Total (N = 219)
At Ninth Month
Postpartum
.111 (.039, .183)
.069 (.010, .128)
.071 (.011, .131)
.071 (.011, .131)
.026 (-.009, .062) .068 (.035, .101)
.000 (0.00, 0.00)
Difference .085 .045 .040
95% Cl (.004, .166) (-.025, .115) (-.054, .134)
.069 .071 .002
(.011, .128) (.012, .130) (-.082, .086)
.046
(.018, .074)
Note: 95% Cl in parentheses At Ninth Month MC vs UC Rl vs UC MC vs RI Postpartum MC vs UC RI vs UC MC vs RI
ACKNOWLEDGMENTS The views and opinions expressed herein do not reflect the position of the General Accounting Office. This work was completed as the doctoral disser-
tation of the first author at the Department of Psychology, Michigan State University. We thank William Davidson, PhD, Charles Johnson, PhD, Robin Redner, PhD, and Jeffrey Taylor, PhD, who served on the first author's dissertation committee. Another version of this work was presented at the annual meeting of the American Evaluation Association in Boston, October 1987.
REFERENCES 1. National Center for Health Statistics, OT Thornberry, RW Wilson, P Golden: Health promotion and disease prevention: Provisional data from the National Health Interview Survey. Advance Data From Vital and Health Statistics, No. 119, DHHS Pub. No. (PHS) 86-1250. Hyattsville, MD: NCHS, Public Health Service, 1986. 2. Ershoff DH, Mullen PD, Quinn VP: A randomized trial of a serialized self-help smoking cessation program for pregnant women in an HMO. Am J Public Health 1989; 79:182-187. 3. Sexton M, Hebel JR: A clinical trial of change in maternal smoking and its effect on birth weight. JAMA 1984; 251:911-915. 4. Baric L, MacArthur C, Sherwood M: A study of health educational aspects of smoking in pregnancy. Int J Health Educ 1976; 19:(2)1-17. 5. Windsor RA, Cutter G, Morris J, Reese Y, Manzella B, Bartlett EE, Samuelson C, Spanos D: The effectiveness of smoking cessation methods for smokers in public health maternity clinics: A randomized trial. Am J Public Health 1985; 75:1389-1392. 6. Sexton M, Nowicki P, Hebel JR: Verification of smoking status by thiocyanate in unrefrigerated, mailed saliva samples. Prev Med 1986; 15:25-34. 7. Bliss RE, O'Connell KA: Problems with thiocyanate as an index of smoking status: A critical review with suggestions for improving the usefulness of biochemical measures in smoking cessation research. Health Psychol 1984; 3:563-581.
Eight-Year Follow-Up Results of an Adolescent Smoking Prevention Program: The North Karelia Youth Project ERKKI VARTIAINEN, MD, PHD, UNTO FALLONEN, PHD, ALFRED L. MCALISTER, PHD, PEKKA PUSKA, MD, MPOLSCI Abstract: In the North Karelia Youth Program five to 10 classroom sessions over two years taught skills to resist pressures to start smoking to 13 to 15 year old students. Compared to students from comparison schools, the treatment groups reported less smoking immediately after the intervention and in a four-year follow-up survey. At the eight-year follow-up, there was consistent evidence of possible preventive effects only among those who had been nonsmokers when the program began. (Am J Public Health 1990; 80:78-79.)
Introduction From 1978 to 1980, a study to demonstrate methods for reducing cardiovascular risk factors in 13-year-old students Address reprint requests to Erkki Vartianen, Department of Epidemiology, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki Finland. Dr. Puska is also with that department at the Institute; Dr. Pallonen is with the Division of Epidemiology, University of Minnesota School of Public Health; Dr. McAlister is with the Center for Health Promotion Research and Development, University of Texas Health Science Center at Houston. This paper, submitted to the Journal July 11, 1988, was revised and accepted for publication June 8, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
78
AND
was carried out in the province of North Karelia, Finland. One of the main aims was to prevent the onset of smoking.' Although many studies of the effectiveness of persuasive and behavioral approaches to smoking prevention have been carried out,2 long-term follow-up is rare.3'4 Details of the methods and the outcome of the intervention immediately after the rogram', after half a year5, and two years after the program are reported elsewhere. This brief report describes the follow-up results eight years after the program ended.
Methods In brief, three pairs of matched schools were chosen for the program. In two "direct" program schools, 10 sessions were carried out during a two-year period from 1978 to 1980 by the project health educator and trained peer leaders. In two "county-wide" program schools, five behavioral sessions were to be carried out by health education teachers at the schools who were trained as part of an effort to disseminate new curricula throughout North Karelia. Two schools were chosen for controls from another province in eastern Finland. In each matched pair, one school was chosen from the capital of the county and the other from a rural village. The program began in 1978 among the seventh graders and finished with the ninth grade in autumn 1980. During the persuasive-behavioral sessions, students were taught about AJPH January 1990, Vol. 80, No. 1
