A randomized intervention of smoking for adolescents in urban Wuhan, China
Introduction
The prevention of tobacco-related morbidity and mortality presents a vast opportunity to improve the health of China's population. Over one-fourth of the world's 1.25 billion smokers live in China (Lam et al., 1997, Taylor and Bettcher, 2000, Yang et al., 1999). Most major causes of morbidity and mortality in China are related to passive or active exposure to tobacco (Chelala, 1998, Lam et al., 1997, Lam et al., 2001). If current trends in smoking behavior continue, annual tobacco-related mortality rates in China are projected to double by 2025 (Lam et al., 2001, Peto and Lopez, 2002). A plausible strategy for reducing future tobacco-related morbidity and mortality in China would be prevention programs targeted at adolescents since most smoking initiation worldwide occurs during adolescence or young adulthood (Kumra and Markoff, 2000). Decades of research in the United States and other Western nations have shown that smoking prevention programs with a social normative approach are more effective than those that emphasize only the long-term health consequences of smoking or self-regulating emotions (Botvin and Botvin, 1992, Bruvold, 1993, Bruvold and Rundall, 1988, Flay, 1985, Hansen, 1992, Silvestri and Flay, 1989, Sussman et al., 1995, Tobler, 1986). The social normative approach aims to create and reinforce a more anti-smoking social norm among adolescents, helping them to recognize how their peers and the media might persuade them to smoke and teaching effective skills to resist those influences (Sussman et al., 1987). However, evaluation of the social normative approach to smoking has been limited primarily to Western nations.
Support exists for the use of a social normative approach in China. A smoking prevention trial that focused on knowledge and refusal skill training increased students' knowledge and adults' motivation to quit smoking (Zhang and Qiu, 1993). Unfortunately, that study did not assess effects on actual smoking behavior. Studies of Chinese adolescents (Unger et al., 2002, Wei et al., 1995, Zhang et al., 2000) have indicated that social influences are a powerful motivator of tobacco use in China, similar to findings in the United States and other Western nations.
This study evaluated the effectiveness of a smoking prevention program developed in the US with a social normative approach in China. Although the central purpose of the program is to prevent the initiation of smoking (i.e., primary prevention effects), another important goal is to prevent the continuation or escalation of smoking behavior among adolescents who already have tried smoking (i.e., secondary prevention effects). Some interventions have demonstrated important secondary prevention effects such as reducing cigarette consumption among smokers or slowing the escalation to habitual smoking among experimenters (Chou et al., 1998, Flay et al., 1994, Sussman et al., 1995). Both primary and secondary prevention effects were assessed in this study.
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Study design
The Wuhan Smoking Prevention Trial (WSPT) is a longitudinal, randomized, school-based smoking prevention trial. The trial was initiated jointly by the Center for Disease Control and Prevention in Wuhan, China and the Department of Preventive Medicine at the University of Southern California in 1998. The goal was to develop and test the effectiveness of a school-based social normative smoking prevention curriculum among adolescents in Wuhan, China. With a population of 7.5 million people, Wuhan
Attrition
Table 1 summarizes the return rates at the follow-up observation. The attrition rates were 7.8% among the sample at the baseline. The program group had a higher attrition rate than the control group. While the difference in attrition between the program and control groups was significant among males, it is not significant among females. Attrition rates by baseline smoking status are reported at the bottom of Table 1. Attrition rates varied directly with smoking behavior. Differential attrition
Discussion
This study utilized a longitudinal, randomized experimental design to evaluate a US-developed social normative school-based smoking prevention curriculum in Wuhan, China. The Wuhan Smoking Prevention Trial (WSPT) represents one of the pioneer attempts to implement a prevention strategy developed by the United States in a different economic, educational, social, and cultural context. Implementing and evaluating prevention programs in different cultural contexts are essential for determining
Acknowledgments
This research was supported in part by the University of Southern California Transdisciplinary Tobacco Use Research Center (TTURC), funded by the National Institutes of Health (grant # P50 CA84735). Dr. Chou is also supported by DA16094 and CA98763 from NIH. Support for the Wuhan Smoking Prevention Trial also was provided by the Wuhan Center for Disease Control and Prevention (CDCP), the Wuhan Public Health Bureau, and the University of Southern California. Special thanks are due to Wuhan CDCP
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