Activism prompts teen smokers to cut back on cigarettes, Stanford study finds

March 01, 2004

STANFORD, Calif. - Scare tactics and lectures don't persuade teenage smokers to change their habits, but engaging them as anti-smoking activists does, say Stanford University School of Medicine researchers.

A study involving 10 Bay Area continuation, or alternative, high schools found that among students who were regular smokers, those who engaged in anti-tobacco advocacy efforts significantly reduced their own cigarette use compared to teens in traditional drug abuse prevention classes. What the researchers found even more encouraging was that the decrease continued six months later - a rarity in the efforts to reduce cigarette use among teens.

"The real, sustained change we saw is different from most other studies on teenage smoking. In past studies where smoking behaviors changed, the effect was very transitory," said Marilyn Winkleby, PhD, associate professor of medicine at the Stanford Prevention Research Center and senior author of the paper published in the March issue of the Archives of Pediatrics and Adolescent Medicine.

Smoking remains the leading cause of illness, disability and death in the United States, with adolescents being the most likely to begin using tobacco, Winkleby said. In 2001, 36 percent of high school students reported smoking cigarettes within the past 30 days. That rate is closer to 70 percent at continuation high schools, which serve students who are at risk of failing or dropping out of regular school or have been removed from their school for other reasons.

Ten continuation high schools in the San Francisco/San Jose area were selected for the study, with five randomly assigned to a new anti-tobacco advocacy curriculum and the other five to an existing curriculum on drug and alcohol abuse prevention. Juniors and seniors were recruited during each of four semesters to attend a weekly class for which they received credit.

Students were surveyed to determine their tobacco use at the beginning of each semester. Roughly 35 percent were non-smokers (never or former smokers), 40 percent were light smokers (less than a pack a week) and 25 percent were regular smokers (a pack or more a week). Students breathed into a carbon-monoxide monitor to confirm their reported level of smoking. At the end of the semesters and again six months later, they were re-surveyed about their tobacco use.

For students in the advocacy curriculum the most significant change was among regular smokers, whose smoking decreased by 3.8 percent at the end of the semester and an additional 1 percent six months later. By comparison, the rate among regular smokers in the drug and alcohol prevention curriculum increased by 1.5 percent at the end of the semester. "Without any intervention, you would expect to see even larger increases in smoking during a period of six months to a year," Winkleby said. "The fact that the regular smokers in the advocacy curriculum made a significant decrease in their usage and sustained that behavior for another six months is very encouraging."

The goal of the advocacy program was to heighten students' awareness of the cues in their school and community environments that promote cigarette use, Winkleby said. "It's not the traditional approach of providing individuals with information to get them to change their own behavior. It's an indirect way to bring about behavior change by making students aware of the social context of smoking behavior."

Students learned about tobacco availability and advertising strategies, and assessed tobacco promotion in their communities. "Most of them were surprised and then angry when they realized how extensive it was," Winkleby said. "Teenagers don't like it when other people try to influence them."

The students then developed, implemented and evaluated advocacy projects that included: forming a task force to enforce campus smoking bans; increasing store compliance with laws limiting tobacco ads on building exteriors; eliminating magazines with cigarette ads from medical and dental offices; and convincing city council members to decline campaign contributions from tobacco companies.

The drug and alcohol prevention classes for the five other schools were adapted from a highly regarded curriculum that had proven effective among continuation students, Winkleby said. It focused on health motivation, social skills and decision-making regarding drug and alcohol use.

The success of the advocacy approach in changing smoking behavior makes it a strategy worth evaluating for other health-related issues, such as helping teens make better food and exercise choices, Winkleby said.
Other co-authors of the study include statistical computer analyst David Ahn, PhD, and Joel Killen, PhD, professor (research) of medicine at the Stanford Prevention Research Center. The study was funded by a grant from the National Institute on Drug Abuse. Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital at Stanford. For more information, please visit the Web site of the medical center's Office of Communication & Public Affairs at

PRINT MEDIA CONTACT: Susan Ipaktchian at 650-725-5375 (

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EMBARGOED FOR RELEASE UNTIL: March 1, 2004, at 1 p.m. Pacific time to coincide with publication in the Archives of Pediatrics and Adolescent Medicine

Stanford University Medical Center

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