Outcome Evaluation of a High School Smoking Reduction InterventionBased on Extracurricular Activities1

K. Stephen Brown, Ph.D.,*,†,2 Roy Cameron, Ph.D.,*,‡,§ Cheryl Madill, M.Sc.,*M. Elizabeth Payne, B.A., DipEd,* Stephanie Filsinger, B.Sc.,*

Stephen R. Manske, Ed.D.,§ and J. Allan Best, Ph.D.‡,�

*Health Behaviour Research Group, University of Waterloo; †Department of Statistics and Actuarial Science, University of Waterloo;‡Department of Health Studies and Gerontology, University of Waterloo; §Canadian Cancer Society, National Cancer Institute of Canada,

Centre for Behavioural Research and Program Evaluation; and �Centre for Clinical Epidemiology and Evaluation, Vancouver Hospital

Preventive Medicine 35, 506–510 (2002)doi:10.1006/2002.pmed.2002.1097

Ca

and Health Sciences Centre and Department of Health

Background. An outcome evaluation of a high schooltobacco control intervention using extracurricular ac-tivities developed by teachers and students is re-ported.

Methods. Eligible subjects (n � 3,028) had partici-pated in a randomized trial of an elementary schoolsmoking prevention curriculum. Their high schoolswere matched in pairs; one school in each pair wasrandomly assigned to the intervention condition, thesecond to a “usual-care” control condition. Data werecollected at the end of Grades 9 and 10.

Results. For Grade 8 never smokers, regular smok-ing rates were significantly lower for males from in-tervention schools (9.8 vs 16.2%, P � 0.02) at the end ofGrade 10. There were no significant differences amongGrade 10 smoking rates for females, or for students ofeither gender with previous smoking experience inGrade 8.

Conclusions. The extracurricular activities ap-proach to tobacco control is practical to implementand has promise. © 2002 American Health Foundation and Elsevier

Science (USA)

1 We gratefully acknowledge NHLBI for funding the core project(Grant 5 R01 HL36171-05). The Canadian Cancer Society/NationalCancer Institute of Canada and the Heart and Stroke Foundation ofOntario provided funds that assisted in preparation of the manu-script. Staff at the Health Behaviour Research Group, University ofWaterloo, were instrumental in carrying out the intervention, datacollection, and administrative tasks. We also appreciate the cooper-ation of the participating teachers and students. This project wasinitiated and analyzed by the investigators.

2 To whom correspondence and reprint requests should be ad-

5060091-7435/02 $35.00© 2002 American Health Foundation and Elsevier Science (USA)All rights reserved.

re and Epidemiology, University of British Columbia

Key Words: smoking prevention; tobacco use preven-tion; tobacco control; adolescent smoking.

INTRODUCTION

After many years of declining youth smoking rates,levels reached a plateau in the mid 1990s and may beincreasing [1–3]. Interventions delivered in high schoolsettings may be useful, either as stand-alone interven-tions or as components in youth tobacco control ap-proaches. Little high school intervention research hasbeen conducted. The few studies that have been pub-lished have focused primarily on in-class interventions,using a social influences approach. These have metwith mixed success [4–8].

The current study is conceptually similar to thehighly successful Florida state-wide intervention [9] inthat it emphasized youth leadership in planning andimplementing interventions. However, the interven-tion discussed here was focused only at the level of thehigh school and required a modest implementationbudget. The approach focused on extracurricular inter-ventions, and treated the student body of each schoolas a community. This approach can circumvent prob-lems associated with in-class interventions (e.g., imple-mentation costs, scheduling challenges). Few examplesof research on extracurricular interventions are foundin the literature. One example was an evaluation of ahigh school “Quit and Win” contest that had minimalimpact on smoking behaviors [10]. Another was a min-imal mail and telephone intervention delivered to highschool age youth at home, which reduced smokingrates among youth who had also received an elemen-

dressed at Health Behaviour Research Group, University of Water-loo, Waterloo, Ontario, Canada N2L 3G1. Fax: 519-746-8171. E-mail:ksbrown@icarus.uwaterloo.ca.

tary social influences program [11]. Finally, Sussmanet al. [12] included a “school as community” extracur-ricular component intended to enhance the school en-

vironment in their evaluation of a teen smoking cessa-tion clinic. The extracurricular component, whenimplemented concurrently with the cessation clinic,did not enhance the outcomes achieved by implement-ing the clinic alone.

METHODS

Design

The first phase of this study [13] was a randomizedtrial, involving 100 elementary schools from sevenschool boards, which demonstrated that (a) teachersand nurses were equally effective providers of a socialinfluences program, (b) self-preparation materialswere as effective as workshop training, and (c) inter-vention was effective only in high-risk schools. Inphase 2 (current study), six of the original boardsagreed to participate in a high school interventionstudy: of 35 eligible high schools (i.e., projected to re-ceive at least 30 students from the elementary cohort),30 (86%) agreed to participate.

The 30 schools were matched within school board (bysize, number of elementary school cohort students pro-jected to attend, and proportion of cohort students fromthe elementary school control condition), and then ran-domized within pairs to intervention or control condi-tions. Grade 9 cohort students attending the 30 schools(n � 3,028) were eligible. Institutional review board-approved passive consent procedures were used. Thestudy was reviewed and approved by the University ofWaterloo IRB, and all participants and their parentsprovided informed consent.

Intervention

The intervention focused on mobilizing staff and stu-dents, and involving as many students as possible inactivities inconsistent with smoking, to build commit-ment to nonsmoking [14], and to strengthen nonsmok-ing as a school social norm. In each of the 15 interven-tion schools, a teacher facilitated students, staff, andcommunity participants in planning and implementingprevention and cessation activities tailored to each in-tervention school. Research staff provided consulta-tion, conducted semiannual workshops for teacher andstudent leaders, developed resources (based on proto-cols developed within individual schools) for dissemi-nation to all intervention schools, produced newslet-ters, and provided a $1,000 per school (an average ofabout $.70 per student) annual intervention budget.Intervention occurred when the cohort was in Grades 9and 10. Control schools received “usual care.”

Data Collection

Using procedures to ensure confidentiality, studentscompleted surveys in class at the end of Grades 9 and

10. Data collectors were not part of the interventionsupport, and were blind to the treatment status of theschool. Preannounced CO breath samples were col-lected, as a “bogus pipeline” method, to enhance thevalidity of self-reported smoking behaviors [15]. TheseCO data were meant to be a true bogus pipeline mea-sure; actual CO results were not included in analyses.Data were collected from absent students by mail orphone; no CO samples were collected from these stu-dents.

Questionnaire data provided a “social models riskscore” (high, medium, or low), based on smoking levelsamong family, older siblings, and close friends [16,17]for each student. An elementary school level risk score(high, medium, low, based on senior student smokingrates) had been assigned to the elementary schools inphase 1 [13].

Smoking status was assessed by asking about initialsmoking experiences and current smoking patterns.Students were classified into five categories: neversmoked, tried once, quit, experimental smoker (smokedless than once a week), or regular smoker (smokedweekly).

Analyses

SAS software was used for the analyses. It is wellknown that standard statistical procedures which as-sume independence between individuals within clus-ters cannot be applied in cluster-randomized designs[18]. Further, in this study, schools were pair-matchedprior to randomization to control for potential imbal-ances between intervention and control schools. Don-ner [18] provides a discussion of methods for the anal-ysis of paired cluster designs. In the analyses whichfollow, we applied the procedure suggested by Liang[19] which uses a variance term appropriate to therandomization of schools (rather than individuals)within pairs to intervention or control conditions.

RESULTS

Of 3,028 elementary cohort students who attendedone of the 30 high schools, 2,776 (91.7%) agreed toparticipate. There were no significant baseline differ-ences between intervention and control school partici-pants in (a) Grade 8 smoking status, (b) Grade 8 socialmodels risk score, or (c) level of elementary school risk(Table 1). However, the intervention schools included amarginally higher proportion of students who had beenin an elementary intervention condition (P � 0.10).Reliable data on the number of tobacco control activi-ties in the participating secondary schools in the yearprior to the beginning of the study were not available.However, the randomization of the secondary schoolsto intervention or control conditions should offer pro-

507HIGH SCHOOL SMOKING REDUCTION

tection against confounding level of prior activity andintervention condition.

Data were provided by 2,643 students (95.2%) ofthose who consented) at the end of Grade 10, with nodifferential attrition across conditions, and no differ-ence between dropouts and the retained sample ingender ratio, Grade 8 smoking status, elementarystudy condition, or Grade 8 social models risk score.

There were an average of 3.8 intervention activitiesper school in Grade 9 and 3.5 in Grade 10. Activities,which varied across schools, included assemblies, Quitand Win contests, poster contests, displays, healthfairs, and smoking surveys that were not part of thestudy data collection but were administered by stu-dents to collect information about smoking at theirschool to contribute to evidence-based planning.

Grade 10 smoking rates are shown in Table 2.Among males who had been never-smokers at the end ofGrade 8, the Grade 10 regular smoking rate was lower(P � 0.02) in the high school intervention schools(9.8%) than control schools (16.4%), even after adjust-ing for elementary intervention condition; the overallsmoking rate (experimental and regular smoking) was22.3 vs 28.7% in intervention and control schools, re-spectively (P � 0.12). Among females there were nodifferences between intervention and control schools inGrade 10 regular smoking rates or total smoking rates.Among those who had smoking experience before theend of Grade 8, there was no evidence of an interven-tion effect with either males or females on either reg-ular or total smoking. All these analyses used an in-tention to treat approach; an analysis basedexclusively on students who attended the same schoolin Grades 9 and 10 (i.e., those exposed to the treatmentfor 2 years) (n � 2,533) yielded similar results. Ad-justing for elementary school condition did not affectresults.

DISCUSSION

This study examined a novel intervention approach,which engaged students and teachers in planning and

implementing extracurricular activities designed topromote nonsmoking among high school students. TheFlorida results [9] support the concept of involvingyouth to develop and implement interventions. It isimportant to determine whether that approach can beeffective at the school level. Our results provide someevidence that it may be.

An intervention must be practical to be useful. Theintervention approach developed and evaluated in thisstudy does not require class time (requiring class timecan be a barrier to adoption), and has the potential toreach all youth in a school. The approach is relativelyinexpensive, since most of the work is done by studentsand teachers without remuneration. Major costs werethe funds we provided ($1,000/year Can) to supportactivities, annual workshops for champions (studentsand teachers), and ongoing support to schools fromresearch intervention staff (about 2 days per school permonth).

In this study, the program was being developed andevaluated concurrently (i.e., champion recruitmentand intervention planning began when the cohort en-tered Grade 9). This is an important limitation of thestudy. The study may underestimate the potential im-pact of the intervention approach, if it is assumed that“mature” programming, developed and refined over aperiod of years, would result in more profound changesin shifting school environments and cultures than pro-grams mounted during a developmental stage. Wewere concerned that the design would work againstfinding an intervention effect, but it was not feasiblefor us to start intervention in high schools prior to thecohort entering Grade 9.

A second limitation of the study is that it was notpossible to assess the relative value of different activ-ities, or optimal mixes of activities. The impact of ac-tivities will vary as a function of the reach and impactof each activity, and potential for synergy across activ-ities. More research is required to clarify which activ-ities, individually or in combination, have greatest im-pact (as a function of participant mix and settingfactors). In addition, reliable data about attendance atactivities were not collected. Such data may have beenable to identify links between particular activities andbehavior change.

The incremental impact of the secondary school com-ponent of the program is seen only in males who werenonsmokers at the end of the Grade 8 (i.e., at the endof the elementary school program). In this group, anestimated 6.8% fewer students were not smoking at theend of Grade 10. When both smokers and nonsmokersare combined, there are an estimated 5.3% fewer youngmale smokers at the end of Grade 10 in the interven-tion schools. If such an effect could be sustained to theend of secondary school and beyond, this would have an

TABLE 1

Baseline Characteristics of Treatment Groups

Percentage with characteristicIntervention(n � 1,563)

Control(n � 1,465)

Attrition 5 5Male 49 50Smoking at the end of grade 8 16 18

Male 15 18Female 17 17

In an elementary interventionschool in grade 8* 84 75*

Grade 8 social models risk scoreHigh 17 19Medium 37 37

* Marginally significant, P � 0.10.

508 BROWN ET AL.

appreciable long-term effect on health for a relativelysmall investment.

For females, there were an estimated 3.5% moresmokers at the end of Grade 10 in the interventioncondition, a difference that was not significant statis-tically. However, the fact that the intervention had, atbest, no effect for females, raises issues for programplanners. Is there something about the type of school-level activities that were designed by teachers, stu-dents, and community personnel that are unattractiveand, potentially, detrimental to young females? It isnot clear why the intervention reduced regular smok-ing rates among males who were nonsmokers at theend of Grade 8, without affecting smoking rates amongfemales or among males who smoked prior to highschool. Svoen and Schei’s [8] high school program hadmore impact on females than males; Peterson et al. [4]found no impact on either gender. The differential pat-tern of results across these three studies, all recent,suggests that different types of programs, imple-mented under varying conditions, may affect males,females, or neither. In principle, it seems that school-based programs can reduce smoking in high-school-ageyouth of both genders, but effects vary as a function ofprogram characteristics and other conditions. Best etal. [20] have noted the importance of a range of vari-ables (content, participant, provider, setting, context,quality assurance) that may influence outcomes as pre-vention programs are disseminated. Little is knownabout most of these factors, or interactions amongthem [21]. More systematic attention to these variablesmay provide a basis for understanding apparent dis-crepancies in findings across studies, and yield impor-tant information for guiding dissemination by clarify-ing the type of program and provider that is most likelyto result in reduced smoking rates among specific typesof participants in particular settings and contexts. Thisinformation is crucial for guiding targeted dissemina-tion of school-based programs: results of the elemen-tary portion of our study [13] suggest that carefullytargeted school programs may be valuable as part of acomprehensive approach to smoking reduction.

In short, our findings suggest that this extracurric-

ular approach to high school intervention has promise,and is practical to implement. Future research is re-quired to confirm the value of the approach, to clarifyoptimal mixes of intervention activities, and to identifybarriers to implementation and strategies for sur-mounting these.

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TABLE 2

Grade 10 Regular Smoking Rates by Gender, Condition, and Smoking Status at the End of Grade 8

Never-smokers at the end ofGrade 8

Ever-smokers at the end ofGrade 8

All students, regardless ofsmoking statusa

Intervention(n � 945)

Control(n � 878)

Intervention(n � 398)

Control(n � 350)

Intervention(n � 1382)

Control(n � 1261)

Male 9.8 16.4 46.7 47.5 21.1 26.4Female 16.7 14.2 56.2 53.0 28.3 24.8Total 13.4 15.2 51.5 50.1 24.9 25.7

a Here, sample sizes do not equal never-smokers plus ever-smokers, as not all students could be classified by smoking status at the end ofGrade 8.

509HIGH SCHOOL SMOKING REDUCTION

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