mean agc at the time of the pretest was 12 ycars, 10 months. The schools in this study served urban minority students from low-income families; 39 of the 47 ...
t1EALTH PSYCtiOLOGY, 1992, 11(5), 2W299 Copyright Q 1092, Liiwrencr. Erlbaum Associates, Inc.
Smoking Prevention Among Urban Minority Youth: Assessing Effects on Outcome and Mediating Variables Gilbcrt J . B o t v i n a n d Linda D u s c n b u r y Deprrmenls of Public flralrh om1 P ~ y c h i n t r ~ Cornell University Medial Callrgr Eli
Baker, S u s a n Jarncs-Orliz, and Elizabclh hi. Bolvin Deparrmenl of Public flealth Cornrll University Mzdical Colle~r.
Jon Kcrncr .&IrrnoriillSloan-Kerirrin~Cancer Cenrrr We tested rhc cft'cctivcncss of a social rcsistancclcompc~cnu:cnhanccmcnl approach to smoking prcvcntion among predominantly I lispmicscvcnth ~radcrs( N = 3.153) lrom 47 New York City schools. hfccr blockily on schwl typc @ublic and parochi:~l)and ethnic con~posilion@rent Ilispanic), schools were randomly arsignd cithcr to rcccivc the 1 5 - m i o n prevention program or to wrvc as no-conL~ctcnnlrols. Using Lhc school as lhc unit of analysis, signiliunt program cffccu were lound lor cigarcue smoking, normative cxpxwtions concerning p.cr md adult smoking. smoking prevalcncc knowledge, social aaxpubiliry knowledge. and lcnowlcdgc 01 smoking conqucnws. Using suuccural madcling techniques, a signifiwnt relation w u lound bccwecn Lhc normative expectation and knowledge variablcs affected by the intervention and posttest smoking, s u ~ a t i n bat g chaogc; on 1hc.w variablcs mcdiatcd the impct 01 thz intcrvcnlion on cigarette smoking. Ihis scudy extends Lhc rcsulu of prcviou prevention rcscarch and dcmonsuala the gcncraliwbiliry of m his approach to prwlonlinanu y t Iispanic urban minority students. Key words: IIispanic, adolcszxnl, smoking prcvcntion, raishnct, skills training, wcial inllucncc
Substantial evidence now exists indicating that cigarcttc smoking is a major factor promoting Ihc dcvclopmcnl of chronic discascs such as cancer, cardiovascular disease, and chronic obsrructivc lung disease (U.S. Public IIcalth Service [USPIIS]. 1969). As this cvidcncc has grown, cfforts by tcachcrr and health professionals lo prevent or delay smoking initiation among adolcsccnts havc intcnsiiicd. Kccognizing the limirations o f conventional informational and fear-arousal approachcs to smoking prcvcntion, rcscarchcrs havc attempted to develop more effective smoking prcvcntion rncthods. More than adccadcofrcscarch indicates that the most promising smoking prcvcntion approaches are those that target the major psychosocial factors that appear lo promote the onset of cigarcttc smoking among adolcsccnls-such a s social influcnccs to smoke from peers and the media. Studics testing Lhcsc approachcs have consistently dcmonstralcd significan~reductions in cigarcttc smoking (Arkin, Kocmhild, Johnson, Lucpkcr, Ji Murray, 1981; llurd ct al., 1980; I,ucpkcr, Johnson, Murray, & Pcchacck, 1983; blchlistcr, Pcny, & Maccoby, 1979; Murray. Johnson. Lucpkcr. Pcchacck, & Jacobs, 1980; f'cny, Killcn, Slinkard, & McAlislcr, 1960; l'clch, Killcn, McAlistcr, Perry, & Maccoby, 1982). Follow-up studics have found the prcscncc of program effects for up to 3 years after the initial p o s ~ t c s ~ however, ; thcsc cflccts tend to decay over time (hlurray, Davis-Iicarn. Goldrnan, Piric, & Lucpkcr, 1986; h.lurray, I'iric, Lucpkcr. & l'alloncn, 1989; Murray, llichards, Lucpkcr. Ji Johnson, 1987). suggesting the nccd for ongoing intervention throughout niuch of adolcsccncc.
Kcqucsw for reprink should be sent to Gilkrt I. Dolvin, lnstitutc lor I'rcvention R~scarch,Corndl Ilnivcrsiry Medial College, 41 I I21st 69th Strccr, Ncw York. N Y l N 2 1 .
Notwithstinding ihc generally imprcssivc results o f the newcr psychosocial approiichcs to smoking prcvcntion, past studics havc bccn crilicizcd for having one or more n~clhodologicalw c a k n a e s (c.g., Biglan & r b y , 1965, G. J. 13otvin, 1966; Ilanscn, 1991).lhcsc havc included concerns rclaling to Ihc procedures used to collect self-report data, nonrandom assibnmcnt to conditions, failure to assign wholc schools to condilions to dccrc;~scthe potential for contamination, lack of dcmonstralcd prctcst cquivalcncc of cxpcrimental and control groups, and inabil~lyto track individual studcnts and link data collcctcd at different t i n ~ cp i n & . Moreover, although thcrc is general agrccmcnt that, insludics using thc school ;ISthe unit of x%signmcnt, Lhc school should also bc the unit o f analysis (to climinatc confounding Ircatmcn~andschoolcffccls and rcduccTyp: I error). fcw studies havc included enough schools lo makc this feasible. Beyond methodological issucs, a major limitation of the prcvcntion literature is that virtually all Lhc existing rcscarch h.u bccn conducted with predominantly White, middle-class populations. Little is currently known concerning the cxtcnl lo which that approachcs arc cffcctivc with urban, minority adolcsccnts. I h i s is p:lrricularly important given Ihc growing concern regarding the canccr risk of minority populations. Scvcral factors could polcnti:~lly altcnuatc rhc cffcctivcness of cvcn the most promising psychosocial approachcs to smoking prcvcntion when implcmcntcd with urban, minority youth. I:irst, bec:lusc thcrc is a paucity of basic rcsc;~rch d a t ; ~conccrning the smoking initiation process with minority populations, the factors promoting and maintaining cig;~rcttcsmoking may be sul'iicicntly dillcrcnt for thcsc pc~pul;ttionsthat a difrercnt prcvcnlion strategy would be rcquircd. Sccond, rhc many problems ;\ssoci;ilcd w ~ t h inner-city schools may ni:~kc it dirricult lo implenient this typc of
SMOKING PREVEhTION AMONG URBcW MINORITY YOUTH
prcvcntion program with the dcgrce of fidelity and completeness necessary to be e f f e c t i v e t h e r e b y undermining feasibility. *lhird, unless the material presented is culturally scnsitivc and rclcvant, it may not be acceptable to the target population. In our own work, we have tcsted thc efficacy of a smoking prcvcntion approach that [caches social resistance skill: within thc context of a broader intewcntion promoting gcncral pcrsonal and social competcncc (G. J. Botvin, Baker, Dusenbury, 1-ortu, & E. M. Botvin 1990; G. J . Botvin, Baker, Filazzola, & E. M. Bolvin, 1990; G . J . Botvin, Uakcr, Rcnick, Filazzola, & E. M. Botvin, 1984; G. J . Botvin & h g , 1982; G. J. Botvin, Eng, & Williams, 1980; G. J. Uotvin, Kcnick, & Baker. 1983). Although research testing this prevention approach has bcen conductcd with predorninanlly Whitc. middlc-class, suburban populations, data from two recently complctcd pilot studies provide preliminary evidence for thc feasibility, acocplability, and efficacy of this typc of prcvcntion strategy with predominantly I-iispanic (G. J. Botvin, D u x n b u r y , Baker, JamesOrtiz, & Kerncr, 1989) and Black (G. J. Botvin. B:ILSO~ ct al., 1989) inner-city studen&. ? h e purpose of the current study was to strengthen the cnlpirical cvidcnccsupporting the elficacy of a cognitive-behavioral approach 10 smoking prcvcntion by testing i t in a r i g o r o u l y d c s i p c d study that i n c l u d d using the school as both thr: unit o l assignment and the unit of analysis as well a s several other methodological refinemcnls in response to previous criticism^ of the prcvcnlion literature. Ihis study was also intended to extend previous research with While, middle-class youth to predominantly Hispanic urban minority youth and to explore the mediating mechanisms of this prevention approach.
METHOD Subjects Of 3,518 available seventh graders, 3,153 studcnls (90%) from 47 schools in lour boroughs of Ncw York City (Manhattan, Bronx, Brooklyn, and Queens) providcd prctest and post~cstdala for this study. Eleven of the participating schools wcrc public schools, and 3 6 wcrc parochial schools. A total of 1,364 (43%) sludcnk were in the parochial school samplc, and 1,836 (57%) wcrc in thc public school sample. T h e studenls were 5 1 % femalc and 49% malc; the mean agc at the time of the pretest was 1 2 ycars, 1 0 months. T h e schools in this study served urban minority students from low-income families; 3 9 o f the 47 schools (83%) had studcnls from families with averagc income levels at o r below 1 5 0 % of the fcdcral povcrty level. Tablc 1 presenls the characteristics of thc samplc brokcn down by condition. Of ihc total sample, 5 6 % wcrc tiispanic, 19% wcrc Black, 14% werc Whitc, and 12% belonged to othcr r a m including Oricntal or Asian. More than half (58%) of thc studcnls lived in two-parent homes, and fcwcr than halfspokc mostly English with their parcnls (42%), whcrcas the vast majority (80%) s p k c mostly English with thclr friends. Research Design Individual schools were randomly assigned to the cxpcrimcnlal and control conditions. Due to c x p c t c d diffcrenccs in cigarette smoking or variables associated with smoking risk, random assignment to conditions was conductcd after l i t blocking on school typc @ublic
TABLE 1 S a m p l e Characteristics Condition i'ariable
E.rpt>r~nienial Control
Race/ethnicity Black White Hispanic Other Parental education (college) Father blother Two-parent iamily Language usr (mostly English) With parents With friends iVotr.
Corrlbined
11.2
19.9 16.7 51.3 12.1
13.7 14.2 55.6 11.6
17.5 15.3 57.5
16.4 16.4 53.5
17.0 15,s 57.9
40.3 61.2
43.4
41.6 60.5
17.7 1 Z. J
55.7
60.2
Numbers 3re pcrcentagcs.
or parochial) and the percentage of tlispanicstudcnki in each school (25% to 49%, 50% to 74%, and 75% to 100%). Thcrc were 25 schools ( I 9 parochial, G public) with a total of 1,795 studcnLs in the cxpcrimcntal condition and 22schools (17 parochiill, 5 publlc) with a t o h l of 1,358 studcnLs in the control condition.' Procedure All thc participating studen& completed a prclest qucslionnaire that mcxsured sclf-rcportcd smoking s t a t u as wcll as scvcral cognitivc. attitudinal, and psychological charactcrisitics hypothcsizcd to bc related to the smoking initiation. 'Ihc quationnairc was comple[ed during a regular. 40-min classroom pcriod; i t was administered in class by a team of three to Lvc d a h collectors from our staff who were mcmbcrs of the samc minority groups as thc studcnls participating in this study. Carbon monoxidc (CO) breath samples wcrc also collcctcd using a varialion of the b o g u p i ~ l i n cprocedure in order to enhance thc validity of self-report data OJauman, Koch, & Bryan, 1988; Evans, Hanscn, & Mittlemark, 1977; tlansen, Mallottc, & Fielding, 1985; Murray, O'conncll, Schmid, & Pcrry, 1987). S ~ u d c n l in s the cxpcrimcntal condition rcczived a 15-session smoking prcvcntion program that was implemented by rcgular classroom tcachcrs. Approximately 4 months after the prctcst, all studcnls wcrc posttcstcd using thc samc q u e s l i o ~ a i r cand , C O samples wcrc once again collcclcd. S m o k i n g Prevention Curriculum 7 h e intewcntion strategy used in this study includcd social resistance skills training and matcrial dcsigncd to facilitalc thc dcvclopmcnt of important pcrsonal and social skills. ? h e goal of thc prcvcntion program is to provide adolcsccnls wilh the requisite knowlcdgc and skills for rcsistingsocial influcnccc to smokc as well as to rcducc potential motivations lo smokc by increasing gcncrnl p r s o n a l compctcncc (G. J. Hotvin, 1982). I h c prcvcntion curriculum was designcd to addrcss the major cognitive, attitudinal, psy-
I ' b o schools withdrew from the study afwr the assignment lo conditions was completed but before Ibe study began, laving an uneven number of schools in the two conditions.
chological, and social factors that are either empirically or conceptually related to adolescent cigarette smoking. The prevention program contained five major componenls: 1. A cognitive component designed to provide information concerning the short-term consequences of smoking, prevalence rates, the currcnt social acceptability o l smoking, and the addictive nature of regular smoking. 2. A decision-making componcnl designed to facilitate critical thinking and indcpcndcnt dcc~sion-making. 3. A component that helps studcnb develop skills for coping cffcctively with anxiety. 4. Acomponcnt designed to tcach social skills and assertiveness skills, includingspecific techniques for resislingintcrpcrsonal influences to smoke. 5. A self-dirccred bchavior change component designed lo lacilitate self-improvement and a sense of personal conhol. 1)clailed lesson plans were provided to each teacher implementing the prcvention curriculum in a 120-page teacher's manual. 7 h c techniques uscd to tcach the matcrial in the prevention program included instruction, group d i s c m i o n , modeling, and behavioral rehearsal. I3ccausc previous rcscarch evaluating rhc efficacy of this prevcntion program has been conducted with predominantly White suburban s t u d e n b , i t was subjected lo an cxtcnsive rcvicw bcforc implcmcn~ationin order to increase ib appropriatcncss for an urban minority population. T h e details of the rcvicw p r o m s arc dcscribcd in G. J . Botvin, Duscnbury ct al. (1989). Although no revisions wcre rccommcndcd concerning the underlying prevention strategy, modifications were made with rcspcct to reading Icvcl, cxamplcs used to illustrate program content, and suggested situations for behavioral rehearsal excrciscs. 7 h e prevention program was implcmcntcd by rcgular classroom tcachcrs who had attended a 1-day lcachcr training w o r k h o p . The purpose of the workshop was to familiarize lcachcrs with the contenl o l t h c prevention program and the rationale for this type of prevcntion strategy (Tortu & G. J . Botvin, 1989). T h e workshop includcd a brief overview of the problem ofcigarettc smokingand i l s etiology as well as a review of the rcsulls of evaluation studics testing tradilional informational approach- rosmoking prcvcntionand past research with this prevention approach. T h e main emphasis of the workshop was on discussion, demonstralion, and rehcanal of the prcvcntion curriculum activilics.
Assessment of Program Implementation In order to assess the complctcncss of program implemcntalion, trained observers m o n i t o r c d d u r i n g unannounced v i s i t s r a n domly sclcctcd classes taught by the tcachcrs in the cxpcrimcntal condition. Using observational forms dcvclopcd for cach session, the observer checked off the curriculum matcrial covcred during the scssion obscrvcd. I'rogram implementation was observed over thc entire intervention period. Elcvcn observers asscsscd 45 tcachcn implcmentnting the intervention during 118 class sessions for an average of 2.62 timcs/tcachcr. lntcrratcr reliability (Kerlingcr, 1973) was dcterm~nedbased on the pcrccnt agreement (82%) o i pairs of observers during 1 7 obscrvationscssions. A quantilativc assessment of the completeness of program implrmentation was calculated on thc basis o f the proportion of curriculum objectives achieved during
cach class session observed (number of objectives covcred divided by the total number of actual curriculum objectives for the particular session observed). Quantitative implementation scores werc calculated for cach observation srssion and were then averaged over all sessions observed.
Measures 7 h c variables included in this study werc asscsscd u ~ i n gtwo questionnairc forms that wcre randomly distributed to students in each class s o that each questionnaire form was completed by half the samplc. Both questionnaires contained the same items; however, the order was rcvcrscd for the measures included on Ihc last half of the questionnaire in an effort 10 collect as much information as possible within the available time and to minimize data loss due to fatigue, boredom, or inadequate time.' lncludcdon thcqucslionnaircs wcrc ilcms c o n c e r n i n g r a ~ / c t h n i c ity, gender, and age; itcms a s c s s i n g the smoking bchavior of rcspondcnb and their significant others (parents, older siblings, and friends); and items assessing smoking knowledge, skills knowledge, altitudes and normative beliefs, skills use, skills confidence, skills cificacy, self-efficacy, and psychological well-being. T h e variables assessed in this study wcre derived from the theoretical model guiding this invcstigalion, which posils that cigarette smoking is the result of the interaclion of environmental factors promotingsmoking and individual charnctcrisiia that dclcrrninc vulnerability to thcsc influences (G. 1. Botvin, 1982). N1 the itcms/scalcs used wcrc dcrivcd from well-known and widely uscd instruments. 7 h e y have been uscd in prcvious prcvcntion studics and arc described clscwhcrc (c.g.. G. J. Botvin, Baker, Duscnbury ct al., 1990; G. J . Botvin, Duscnbury ct al., 1989). However, bccausc the itcms uscd to measure several of thcsc variablcs had originally been dcvclopcd for use with While, middle-class students, they wcrc pilot-tcstcd and revised whcn ncccssary to cnsurc their suitabilily for the target population of this study. 7 h c mcasures sclcctcd for use in this sludy arc dcscribcd later; whcn appropriate, reliability cslimatcs (Cronbach's alpha) for the study samplc arc prcscntcd in parcnthcscs.
Cigarefle smoking. Self-reportcd s m o k i n g status was asscsscd using two types of items. Consislcnt with prcvious smoking prcvcntion rcscarch with this age group, the primary focus of this sludy was currcnt “experimental" smoking, which was measured using a dicholornous ( y e s n o ) item assessing smoking during the pas1 month. More rcgular smoking was arscsscd using similar dicholomous measures of smoking during the past wcck and past day.
'Completion ratcs for thc firs1 half of the questionnaire-which c o n h i n d itcms conccrning besmoking bchavior of responden~sandsignificant othcrr, demographic items, and normnlive expechtion item-were 98% or bclter. As c x ~ c r c d ,completion rates for Lhc knowledge, attitude, and pcrsonalily swlcs on thc second half of the questionnaire, although lower, were more than 6010. This u)mparcs favorably wirh d a ~ from l a similar qucsti0nn;iirc and with a similar population showing on1y 50% rnmplction rates for thc l a s t few ilcms whcn only one form of the questionnairc is used. Thus, using Iwo qucslionn;lirc forms with b c order ofscales on the sccond half oI b e second lorn, revcrwd appcarcd to bc an effective method of maximizing cnmplction ratcs. Pattcmssllggrsting cithera rcsponscsrt or Inacarateinformation werc found on 1.6% of thcquationnaires. Theaffecled scctions of these questionnaires werc delcted from the data set and trearrd ar missing dab.
SMOKING PREVEhTlON AMONG URBAN MINORITY YOUITI
In addition, a general measure of current smoking was used, which consisted o f an 11-point scalc, and intention to smokc in the future (behavioral intention) was asscsscd using a 5-point scalc (G. J. Botvin, Baker, Filazzola, & E. M. Hotvin, 1990).
Knowledge. Ten true-false itcms assessing thrcc variable domains were used to nlcasurc smoking knowlcdgc. ? k c three typcs of knowlcdgc asscsscd were imrnediatc/short-lcrm effects of cigarcttc smoking (6 items), thc prevalence of cigarcttc smoking (2 itcms), and the social acceptability of cigarcttc smoking (2 itcms). Elcvcn truofalsc itcms were uscd to measure social skills knowlcdgc. Three-month tcst-retest rcliabilitics for smoking knowledge and social skills knowlcdgc havc been reported previoucly (G. I. Uotvin & Eng, 1982) as .76 and .75, rcspcctivcly.
Smoking attitudes. Attitudes about smoking, smokcrs, and Lhe perceived benefits of smoking wcrc mcasurcd using 10 itcms ( a = .69) derived from an item analysis of the Teenager's Sel/Tesr: Cigarerre Snroking (USPHS, 1974). Iicsponscs for cach item wcrc scorcd using a 5-point Likcrt scalc ranging from slrongly disagree (1) to srrongly agree (5). Individual items wcrc summed for a total score. with high scorcs indicating anti-smoking attitudes.
Normative expectations. T w o items werc used to measure rcspondcnts' normative cxpcctations concerning cigarettc smoking (G. J. Botvin. Baker, Duscnbury ct al., 1990). One item was uscd to measure respondents' belief in the prcvalcnce of smoking among adullr ("In your opinion, how many adults smoke cigarettes?"), and the other item was used to measure thcir bclief in Lhc prevalence of smoking among peers ("In your opinion, how many people your age smokc cigarettes?"). Kcsponscs were ratcd on a 6-point scale ranging from none (1) to almost all (6).
Decision making. Scvcn itcms ( a = .82) wcrc uscd to assess dccision making. This measure was derived from Lhc ninc-item subscalc of Lhc Coping Inventory (Wills. 1986) concerning problem solving and dircct action. The scvcn i t e m uscd to asscss decision making in this study wcrc sclectcd by including items with factor loadings of .SO or higher. The decision-making mcacurc asscsscd the use of sound decision-making skills (c.g., "When I havc a problcm. I get information that is needed to deal with thc problem"). Kcsponscs were ratcd on a 5-point scalc ranging from never (1) to almost always (5).
Assertiveness. Asscrtivencss was asscsscd using an 18-item scalc ( a = .72) derived from the Assertion Inventory (Gambrill & Richcy, 1975). Validity for this inslrumcnt has bccn previously cstablishcd by showing cxpcctcd relations bctwccn clinical and nonclinical samplcs as well as significant correlations with the ratings of blind obscrvcrs conccming the lcvcl of asscrtivcness demonstrated in role-play situations. Rcsponscs were ratcd on a 5-point Likcrt scalc ranging from never (1) lo almo.sl always (5). Gtarnplcs of assertive behaviors include returning dcfectivc merchandisc, complaining when somconsslcps ahzad in linc,andsaying "no" in various situations.
293
Skills efficacy. Kcspondcnts' confidcncc in Lhcir ability to use spccific personal and social skills was rncasurcd using 14 itcms ( a = .80). These items wcrc dcsigncd to asscss spccific skills taught in Lhc intcrvcntion and wcrc judged by a team of four psychologists to validly asscss thc efficacy of cach skill domain. Items ratcd eachskill on a 5-point Likcrt scalc ranging from nor ar all confienf (1) to very confident (5).
Self-efficacy. Sclf-efficacy was asscsscd using five iiems from Lhe Personal Efficacy subscalc of Lhc Sphcrcs of Control Scale (Paulus. 1983). This scalc mcasurcd the cxtcnt to which rcspondcnts believed they could achieve personal goals through thcir own efforts. It has bccn found to havc test-rctcst rcliabilitics greater than .90after 4 weeks. 7 h c reliability of the shortened five-item scalc uscd in this study was reasonably good ( a = .75). Kcsponscs werc scorcd on a 5-point Likcrt scalc ranging from sfrongly disagree ( I ) to srrongly agree (5).
Self-esteem. Sclf-csrccm ( a = .80) was mcasurcd by the 10item scale dcvelopcd by Koscnbcrg (1 965). Statements wcrc typical evocations of self-cstecm (e.g., "I take a positive attitude toward mysclf.""I feel Lhat I havc a numberof good qualities"). Kesponscs were scored ona 5-point 1-ikcrt scalc ranging from srrongly disagree (1) to strongly agree (5).
Psychological well-being. Psychological well-being was asscssed using an empirically reduced vcrsion of the Mcnlal Hcalth lnvcntory Scale dcvelopcd by Vcit and Ware (1983). Items were sclectcd from the tkuicty, Depression, General Positive Affect, and Emotional Tics subscalcs and wcrc judged to be valid by a team of four psychologis~s.?hesc i t e m wcrc Lhcn pilot-tcstcd and factor-analyzcd. I t e m with factor loadings of .SO or greater were sclccted for inclusion in Lhc final 12-item scalc (a = .60). Items conccmcd self-statements about the frequency of feeling rested, happy, and relaxed in the last month. Kcsponscs wcrc ralcd on a 5-point Likcrt scalc ranging from none ofrhe time (1) to most o/!he time (5).
Data Analysis Only individuals providing data at both prctcst and posttcsl ( N = 3,153) wcrc included in the analyscs rcportcd here. Aftcr linking pretest and posttcst data for cach individual, data wcrc thcn aggrcgated for each school in ordcr to conduct data analysis with the school serving as the unit of analysis. Overall school means wcrc uscd as entries into thc analysis-of-variance matrix. tifter cstablishing prctcst cquivalencc on the primary dcpcndcnl variablcs, all posttcsl data wcrc thcn analyzed using the SAS 6.03 (SAS Institulc Inc., 1988)gcncral linear model procedure. Prctcst scorcs were uscd as covariatcs in all analyses (except the analysis of smoking onset) in ordcr to improve an:llytic precision (Cohcn & Cohcn, 1983). In ordcr to overcome sl;~lislicalproblems associated with proportions. a log transfomiation was uscd (Cohcn & Cohcn, 1983) before analyzing the schoolwide smoking prcvalcncc rates. A scrics of analyscs was then conducted to dctcrminc the impact of the intcrvcntion on cigarcttc smoking and several hypothesized mediating variablcs. Following thcsc analyses, the relation bctwecn hypothc-
TABLE 2 P e r c e n t a g e of t h e Intervention Implemented by School T y p e a n d Ethnic Composition
TABLE 3 P e r c e n t a g e of S t u d e n t s Smoking During t h e P a s t Month Condition
Percent Hi~poriic-' School Type
Mediurn
High
Combined
63.8 15.6
57.4 19.9
61.4 23.0
60.7 lS.E
School type Public
43.3 16.0
42.2 2.7
49.7 7.1
45. I 5.7
Parochial
58.6 17.3
54.0 18.5
58.5 20.3
56.9 IS.!
Parochial .L.l
SD
School Type arid E[hrrrc Cor~rpositiorr
Low
IM SD
Public iLf SD
.bf SD
Combined
M SD
'Ethnic conlposition of schools was defined in trrrns of the pcrctlntase of Hispanic students in each school: low = 25% to 499'0, rncdium = 50% to 7470, hiyh = 75O;o to 100%.
Control
Pret~.sf
Posttest
Preiest
Poslfest
5.97 2.17
4.54 3.35
5.90 1.77
7.52 I.S1
4.51 4.15
5.40 4.72
4.77 4.97
7.05 3.99
5 29 3.01
5.4s 5.72
5.03 6.19
6.71 3.30
3.50 3.48
3.47 3.59
5.53 3.30
7.28 3.59
5.96 4.71
6.84 3.36
5.67 2.37
7.67 4.17
4.86 3.78
5.19, 4.38
5.03 4.44
7.15, 3.57
Ethnic composition Low Hispanic ,if
SD hlcdium Hispanic I\!
sized mediators and smoking outcome was examined using i'roc Calis (SAS Institute Inc., 1990) to run EQS. a structural modeling computer program dcvelopcd by Bcntler (1969).
E.rprrinimto1
SD High Hispanic 1Lf
SD
RESULTS Combined Implementation Fidelity Ixvel of intervention implcmcntation was calculated both overall and with respect to school typc and cthnic composition @crccnf Ilispanic). For all the students in the cxperimcntal condition, the mean lcvcl of implementation fidelity was 59.79% (SD = 28.15). Examination of thc distribution of implcmcntation scores indicatcd that half the participants in the cxpcrimcnfal condition received at least 60% of rhc intcrvention. Tablc 2 presents Lhe means and srandard deviations for implcmcntation fidelity scorcs brokcn down by school t y p and cthnic composition. A 2 x 3 GLM analysis of implemcnlation scorcs by school typc and cthnic composilion rcvcalcd a trcnd toward lower implemcntalion by thc public schools relaiivc to the parochial schools, F(1, 19) = 3.29, p < .09. No main cffects wcrc found for cthnic composition, and no interaction cffccls 3 were found for School Typc x Ethnic Composition. S m o k i n g Behavior Comparison of prctcst smoking variables using a scrics of t tcski indicated that the cxpcrimcntal and control groups wcrc equivalent before intcrvention. Analyses of the primary dcpcndcnt variablcs wcrc conducted using a scrics of GLM analyscs including school type (public or parochial), pcrccnt Hispanic (low, medium, or high), and condition (experimcnlal or control) as class variables. prctcst
'ln addirion to examining Lhc level of intervention implcmenhlion wilh rtlspccl to school lypc and clhnic composition, wc also cxanlincd the relation bcrwccn intcrvcn!ion irnplcrncnlation and smoking oumrne using two wparatc multiple-regression analyscs. In h e first a significanl rclallon was found between Icvcl of intervcnlion implcmcnhlion and posttest smoking. controlling for school type and prcrcstsmoking (p = -.03;SE = ,017; p c .04, one-Wiled). I n tihc second, a significanr relation was found 'cctwccn level of intcrvention tmplernenL~tionand posttest smoking, wntrolling for ethnic composition and pretest smoking (f3 = -.03; SE = ,016;p < .05,one-mild).
,Lt
SD
Note. %leans and standard deviaiions from the School Type x Ethnic Composition interaction are no[ included. &leans with the same subscripts are significantly different at p < .05.
smoking a s a covariatc (cxccpt for the onset analysis), and posttcst smoking a s the dcpcndunt variable. Table 3 prcscnE the proportion of studcnls reporting cigarette smoking during the pasf month at prctcst and posttcst for c x p r i m c n tal and control conditions combined as well as brokcn down by school typc and cthnic composition (pcrccnt liispanic). Comparison of the smoking prcvalcnce rat- of thc two conditions based on the past-month measure showed that thcrc wassignificantly less postrcst smoking for thc studcnu in the cxpcrimcnlal condition than for control studcnki. F(1, 41) = 4.14, p < .05. I h c s e condifions wcrc also comparcd in t c m s of smoking onscf among prctcsl nonsmokcn who rcportcd smoking at posttest. C o m parison of thc smoking onset rates for cxperimcntal and control conditions using thc past-mont!! mcasurc rcvcalcd significantly fewer ncw s m o k c n in thc cxpcrimcntal group than in thc control ~ .03. group, F(1, 42) = 5 . 7 4 , < No niain cffcctswcrc found for school type or cthnic composition. Similarly, a separate scrics of analyscs failed to find any inferaction cffccts bctwccn cxpcrimcntal condition and either school iypc o r perccnt llispanic.' Ihc cxperimcntal and control conditions wcrc also comparcd usingothcr measures ofsmoking. Comparison of the cxpcrin~cntaland control condirions using the general maasurc of current smoking approached significance, (.'(I, 41) = 3.27, p < .OS, showing less smoking among Lhc students receiving Lhc prevention 'Il)uc to the limi~aliohsof statistiuil power in analyses conducrcd with lhc dciign model using school as the unit of analysis, Ihcsc analyscs were also conducled usiny subject as the unit of analysis. R u u l ~ sreplicated lhose found in the school-lcvcl analysis, revealing no inleraction ellec~sfor school typcand trearrnenl conditionor for perccnti.lispanicand treatmcntcondilion.
SMOKING P W V E X I l O N AMONG URBAN btlNORlTY YOUIT1
program. No significant differences werc found for smoking during the pxit week or past day or for behavioral intention.
H y p o t h e s i z e d Mediating V a r i a b l e s
The impact of the intcrvcntion on several variablcs hyporhcsizcd to mcdiatc the impact of the intcrvcntion onsmokingwasalso assessed. Smoking-specific variablcs wcrc conccptualizcd as bcing proximal to smoking behavior, whereas morc generic variablcs wcrc conccptualizcd as bcing more distal. It was hypothesized that thc studcnls in the cxpcrimcntal condition would havc (a) higher postrest scorrs than controls for smoking and social skills knowledge, anti-smoking attitudes, decision making,skills efficacy,sclf-cfficacy,andpsychological well-being and (b) lowcr posttcst s w r c s than controls on Lhc two normative expectation mcasurcs. S i p l f i w n l p r o w c f f x ~ wen: s round forscvcral o f the prosimal mediating variables; no cffecls wcrc round for the more distal variablcs. Table 4 prcscnls the prctcst and posttcst m c m for the smoking-specific mediating variablcs. Data werc analyzed in the same manner as for the smoking v a r i a b l a , using school as the unil of analysis and prctcst scorcs as covariatcs. I h c schools rccciving the prevention program had signilicantly higher posttcs! knowledge scores than the control schools for smoking prevalence knowledge, F(1, 43) = 36.81, p i ,0001; immediate consequences knowledge, F(1.43) = 6.13, p i.007; and social acccptabilily knowledge, F(1, 43) = 16.6s. p i,0002. Significant program cffecb wcrc also found for chc two normative cxpcctatiom measures in the predicted dircction.lhcschools rccciving the prevention program had significantly lowcr normative cxpcctation scorcs than the controls for pcrccivcd smoking among p e n , F(1.43) = 1 9 . 6 0 , p i,0001, and significantly lowcrnomativc expectation scorcs for pcrccivcd smoking among adulls, F(1, 43) = 46.69, p i.0001.
Relation B e t w e e n H y p o t h e s r z e d Mediating Variables a n d S m o k i n g I h c relalion bctwccn significant proximal variablcs hyprhcsizcd to mcdiatc the impact of the intcrvcntion on smoking behavior was assesscd using a structural modeling approach (Rcntlcr, 1969). Figure 1 prcscnls a modcl thar specifics relations bctwccn cigarette smoking and hypothesized rncdiating variablcs s s c s s c d a1 prctcst and posttcst.'lhis rnodcl includes 4 latcnt variablcs and 15 measured variablcs. Several p s s i b l c models wcrc tcstcd to dctcrminc the best fitting modcl and whether the observed intervention cffccls wcrc mcdiatcd by the posttcst proximal variablcs. I h c two major paths tcstcd wcrc a direct path from the intcrvcntion to p o s t t a t smoking (indicated by the broken line) and a mcdiatcd path from the intcrvcntion to posttest smoking through the p o s t t a t proximal variablcs. T w o measures werc used to dctcrminc the goodncxs of fit of the models tcstcd: the Bcntlcr and Bonnctt (1960) non-normed indcx (NN1) and the Ucntlcr (1969) comparative fit indcx (Cf..I). A modcl could be said to t i t if the NNl and C l 3 havc values greater than .W. After several iterations involving constraining and releasing paranlctcrs a s s u g g a t e d by thcmoditication indices, a modcl (A) including both direct and mcdiatcd paths from the intervention to p o s t t a t smoking was found to havc a reasonably good fit, x2(76, N = 37) = 100.22, p < .05, NNI = .92, CFI = .93. One of the strengths of the structural modeling approach is the ability to tcstonc or more paths by comparing models both with and without the specified paths. In order to tcst the hypothesis thar the five proximal variablcs significantly affected by the intcrvcntion rncdiatcd the impact of thc intcrvcntion on smoking bchavior a1 the posttcst, a rcsuictcd modcl (B) without the path bctwccn thc intcrvcntion and the latcnt variable representing the psychosocial variablcs at the postta! was comparcd to the modcl (A) including this path. I h c morc rcstrictcd modcl without the path leading from the
TABLE 4 Pretest and P o s t t e s t Means for Smoking-Specific Mediating Variables Condition
Vorioble
Poss~ ble Score
Control
Experimental Prerest
Posttest
itlinimunl
iLiaxim urn
Pretest
Posrrest
0.91 0.2 1
0.86"' 0.20
0.88 0.19
0.57 0.19
0.00
2.00
3.93 0.28
4.32' 0.48
3.89 0.2 1
3.94 0.33
0.00
6.00
0.91 0.11
1.17" 0.17
0.83 0.19
0.91 0.21
0.00
2.00
3.43 0.32
3.42"' 0.25
3.54 0.44
3.74 0.32
1.00
5 .00
4.73 0.31
4.29"' 0.37
4.80 0.73
4.31 0.20
1 .OO
5.00
Smok~ngprevalence knowledge ILI SD
Immediate conscqucnces knowledge ,tl
SD Social acceptability knowledge !Ll
SD ,Anti-smoking attitudes hi SD Normatiit e'rpectations (peers) itl
SD Normative expectations (adults) ,\I
SD I
'p
.
Responses wcrc scored so t h a ~high scorrs indicate more of the variable assessed.
< .Ol.
" p
< .m1. " ' p
.50. Bccausc the inclusion of a dircct path from Lhe intcrvcntion to posttcst smoking did not significantly improve the model and was lcss parsimonious, it was not includcd in lhc final modcl. ? h e final modcl (C) is presented in Figurc 1 and includes only the paths rcpracntcd by solid lines. This model has the advantage of having a reasonably good fit and being parsimonious. The results of rhcsc analyses ~ r o v i d empirical c support for Lhc hypothesis that [he impact of the intcrvcntion on cigarette smoking was mcdiatcd by the changes i t produced on the proximal mediating variables.
DISCUSSION I h c rcsulrs o f the currcnt study indicate that [his typc. of prcvcntion slratcgy can havc a significant impact on cigarette smoking in an inner-city sample o f prcdominan[ly (86%) minority youth. 7 h c studcnts rccciving the prcvcntion program had smoking prcvalencc and smoking onset ratcs that wcrc airnost 30% lower than thosc o l
the control studcnts. I h c strength of thcsc findings is bolstcrcd by the use of a true cxpcrimcntal dcsign with random assignment, prc[cst cquivalcncc across conditions, careful collcction of sclf-repofl data using thz bogus pipclinc proccdurc, unique ID ccdcs to pcrmit an accurate asscssmcnt of changw in smoking s t a r u for individual students, and standardized data collcction proccdurcs. In addition, schools wcrc assign& to separate conditions to climinarc Lhc potential for contamination across conditions,and the school was used as the unit of analysis in ordcr to eliminate any porcntial confounding of treatment and school cffccts. The behavioral effects of the prcvenlion program in this study were limited to cxpcrirncntal s m o h n g during thc past monrh. N though lhis type of smoking has b w n Lhe main dependent variable in previous smoking prevention studies (c.g., G. J. Botvin ct al., 1964; G. J. Rotvin ct al., 1983) and is rcgardcd as appropriate for m e s s i n g the efficacy ofsmoking prcvcntion intcrvcntions with lhis age group, i t might bc argued that this docs not provide cvidcncr. that is meaningful with respect to chronic discasc risk reduction. hiorcover, because smoking was asscsscd in terms of currcnt smoking in rhc present study, i t is possible that some of the individuals includcd in the onset analysis may havc tried cigarcttcs at somc point in the past; instead of being Lhc initial onsct for t h s c individuaLs, the smoking reported may mcrcly rcprcscnt the most rcccnt round of starting (and possibly stopping). If prevention programs wcrc able only lo prevent cxpc.rimcnral smoking o r to rcducc smoking anlong individuals who would be likely to stop after somc brief pcriod of cxpcrimcntation, they would accomplish little. Clcarly, the ultlmatc objcctivc of smoking prcvcntion programs should be the prcvcntion 01rcgular cigarctic smoking. Although the data from the prcscnl study cannot nddrzss thcsc issucs, cvidcncc from other studics that
.
-
SfvlOKING P R E V L W O N r U t O N G URBAN htLVOKITY YOUITI
have tested this prevention approach suggests that i t produces effects that arc reasonably durable and that initial rcductions in expcrimcnbl smoking translate into later reductions in regular (weekly or daily) smoking (c.g.. G. J. Botvin, Baker, Filazzola, & E. M. Botvin, 1990; G. J. Botvin st al., 1983). Noncthcless, additional data from longer term follow-up studics arc needed to morc fully understand the potential for prevcntion programs to produce meaningful reductions in smoking among minority youth. ? k c findings o f this study arc consistent with those obtained in othcr recently published prevcntion studies utilizing interventions teaching social resistance skills either alone (Pcnu, Dwycr et al., 1969; Pen=. M a c G n n o n ct al., 1989)or in combination with generic personal and social skills ( G . J . Dotvin, Bakcr, Duscnbury ct al., 1990; G. J. Uotvin, Baker. Filazzola, & E. M. Botvin, 1990). T o gether, thcy provide strong empirical support for the cfficacy of prevcntion approaches that focus on the psychosocial factors bcIlevcd to promote adolcsccnt cigarette s m o h n g . Furthermore, the rcsulrs of this study, combined with the rcsults of othcr studics involving minority youth (G. J. Botvin, Hatson ct al., 1969; G . J. Uotvin, Dusenbury et al., 1989; Ellickson & Bell, 1990) suggcst that prcvcntion strategies that wcrc initially dcvclopcd and found to be cffsctivcwith Whitesuburban youth may bcmorc g c n c r a l k b l c than previously cxpcctcd. In addition to a s s u s i n g the impact of this prevcntion approach on smoking behavior, several psychosocial variables hypothcsizcd to mediate the impact of the prevention program o n smoking behavior wzrc also assesrcd. l h c s e variables wcrc included bccausc they had bccn previously found to be associated wilh cigarette smoking, wcrc rzlatcd to the goals of the prcvention program, or were of thcoretiwl impoflance. The kind of information conlaincd in traditional smoking education programs has not been found lo dctcr cigarette smokmg, However, the results of this study suggest that some information may be a valuable component of prcvcntion program.?. if i t rclatcs to rhc psychosocial factors promoting adolcsccnt smoking in a manncr that is dcvelopmcntally appropriate and personally salicnl. In addilion to demonstrating intcrvcntion effects on the three knowlcdgc and two n o m a t i v c expectation variables included in this study, the rcsults o f thecausal modeling analysis provideempirical suppon for the hypothesis that the impact of the intcrvcntion o n cigarctic smoking was mediated by Lbcsc variablw. Providuig studcnrs with information about the prevalence of s m o k i n g a m o n g adults and adolrsccnts as well as information about the decliningsocial acccptability of cigarcttc smokingmay alter studcnts' perceptions of social norms about cigarcttc smoking and decrease pcrceivcd social support for smoking. Moreover, providing studcnts with information conccrning the morc immediatc negativc conscqucnccs of cigarcttc smoking may bc morc relevant to their day-to-day conccrns and, therefore, easier to pcrsonalizc than traditional health knowledge conccrning the long-tcm hcalth consequences of smoking. ? h e prcvention strategy tcstcd in this study w a s also dcs~bmedto have an impact on more distal mediators of smoking initiation (c.g., sclf-cificacy, self-cstccrn, decision making, asscrtivcncss, psychological well-bcing). T h e abscncc of effects on thcsc hypothcsizcd mediators in the presence of behavioral cffects suggesrs that having an impact on thc more distal mediating variablcs is not a necessary condition for producing shofl-term prcvcntion effects with this population. Individual distal variablcs such a s self-efficacy and wcllncss may be cspccially resistant to change in disadvantaged youth for whom altcmativcs to drug use and hopc lor the €ulure arc morc limited. Although skills training appears to bc cssentinl to the
297
succcss o f smoking prevention, there must be opportunities lo apply h o s e skills and practice them in a supportive environmsnt-somcthing that may bc Icxi likely in schools and wmmunitics with lirnitcd resources and overwhelming demands. I t might also be argued that the exlent to which an intervention has an impact on hypothesized mcdiating variables would be related to the magnitude of Lhc cffccl on the major outcome variablc(s). Thus,the abscncc of cffccb on h e distal mediating variablcs may offer one explanation of why the effects on smoking were smaller in this study than in past studits (e.g., G. J . Ibtvin, Bakcr, Filanola, & E. M. Botvin, 1990; G. J . Botvin ct al., 1964; G. J. Botvin & Eng, 1982; G. J. Ebrvin ct al., 1980; G . J . Botvin ct a]., 1963). From this pcrspcctivs, i t sccms reasonable to conclude that, ifthc prevention program hadsucccedcd in producingeffccrs o n the distal mediating variablcs, t h sffccrs ~ on smoking might havc bccn larger. Quality of program implcmcntation is one o f several factors that might reasonably becxpcctedtoaffectthcextcntto whichprcvcntive intcrventions arc cffcctivc ( M o s k o w i q 1969). If i n t c ~ c n t i o n sarc not propcrly implcrncntcd, i t is unlikely lhat thcy will produce the dcsircd rwults. Indccd, the rcsults of this study and othcr prcvcntion studics indicate that program efficacy is rclatcd to level o i program irnplcmcnblion (G. J. Botvin, Bakcr, t'ilazzola, & E. hi. Botvin, 1990; G. J . Rotvin, Dusenbury ct al., 1989). Examination of the implemcnfation d a u from the current study wilh inncrxily schools indicates that implcmcntation fidclity was lower than in past sludics w i h suburban schools. f'or cxamplc, in this study only half the studcnts rcccivcd 60% or more of [he inlcrvcntion, whcrtas thrcc fourths of the studcnts in a study involving picdominantly White, suburban schools rcccivcd an cquivalcnt amounl of the in~crvcntion (G. J. Ebtvin. Bakcr. Duscnbury et al., 1990). In order to product the maximum public hcalrh impact, il will be ncccssary to d c t e m i n c how smoking prcvcntion programs demonstrated to be cffec~ivc within the context of conlrollcd cxpcrimcnb can bc disscminatcd in a manncr that facilitatcs high-qualily implementation. T h i s challenge is cvcn greater for inncr-cily schools, whcrc barriers lo high implcmcntation fidelity includc limitcd rcsourccs, large class s u m , class management difficulties, low t a c h c r morale, tcachcr bumout, and multiple competing city and state mandatcs affecting the availability of timc for prevention programs. Although thesc are f o m i d a b l c barriers, implementation fidclity might bc improved by strengthening the m i n i n g and suppofl provided to tcachcn given the responsibility fur implementing prcvention programs. Indccd,educaIional rcxarchcrs havc long ruognized that teacher kaining and staff dcvcloprncnt arc critical to fidelity o i implemcnfation, particularly when curricular innovation is involved (Fullan, 1 9 8 5 ; M c L a u g h l i n & M a r s h , 1978; Pattcrson & C7ajkowski, 1979). In view of thc rcsults of this study and prior research, it is evident that prcvention researchers intcrestcd in working with inner-city youth should focus greater attention on dcvcloping and asscssing strategies for morc cffectivc tcachcr training and team building including fostering the involvcmcnt of administrators, guidance counselon, and othcr school support staff. A l t h o u g h this s t u d y c x t c n d s o u r u n d e r s t a n d i n g o f t h e gcncrali;.abilily of this prcvcntion approach by denionsuating its cfficacy with a predominantly minority population attending innercity schools, an obvious limitation is ib inability to dctcrrninc the relative cffcctivcncss of this type of prcvcntion strategy for ~ h c v a r i o u subgroups rcprcsentcd in this sample. Despite thc f a c ~that h e prcvenlion program may havc differential cffcctivcncss for thesc subgroups, the dcsign of (his study p m i t t c d asscssmcnt ofonly thc
interaction bchvccn condition and the ethnic composition of schools, which was defined in terms of the pcrccntagc of studen& who were Hispanic (25% to 4 9 % , 5 0 % to 74%. and 7 5 % to 100%). Still, thc abscncc of interaction cffcc& betwccn trcalnicnt condition and the ethnic composition of schocls suggcsts that this prevention strategy may produce similar cffccts across different groups. Additional rcscarch should attcmpl to determine the rclativc cfficacy of prcvcntion approachcs similar to the o n e tcstcd in this study with spccific subgroups to further our understanding of the role of cultural factors in enhancing o r attenuating intcrvenfion cffccts. ' l h e factors p r o m o t i n g a n d sustaining cigarcttc s m o k i n g appear to b e largcly thc s a m e for v a r i o i ~ spopulations; however, thc rclativc Importance of spccific factors m a y vary. F o r example, recent evidence s u g g e s t s that s m o k i n g a m o n g Hispanics may be related m o r e o f t e n to social rather than physiological c u e s (Mirrin. Marin, Pcrcz-Stable, Otrro-Sabogal, 6( S a b o g a l , 1990). s o that normative prcssurcs and expectations would takc o n even greater significance than for o t h e r groups. Tailoring intcrvcn[ions lo m o r c intensively a d d r e s s lhcsc social rcalities may increase thcir effcctivcness with minority youth. Moreover, i l may be ncccssary to d r v c l o p morc cornprehcnsivc interventions that arc able to deal with the needs ofdisadvantagcd youth by [caching thcm a broader array of lifc skills and providing thcm with realistic life options (G. J. Botvin &: Dusenbury, 1992; Duscnbury & G. J. Botvin, 1'992). Pilot work to test s u c h an intcrvcntion is currently underway with homclcss youth living in New York City shcltcrs (Duscnbury, G. J. Botvin, & James-Orfiz, 1989). In s u m m a r y , the present study provides further support for the cfficacy of a s m o k i n g prcvcnlion approach that addresses the social influences bclicvcd to promolc cigarctlc s m o k i n g within the contcxt of a broadcr intervention designed lo c n h a n c c general personal and social compctcncc. Imporfanlly, this study providcs empirical cvidcncc for thc gcncralizability of this approach to predominantly Hispanic urban minority students. Limitations of this study include thc focus o n current c x p c r i m c n h l smoking rarhcr than morc regular smoking. which makcs i t difficull, in the abscncc of longer tcrm follow-up, Lo meaningfully asscss its potcntidl for chronic discasc risk reduction with this population a n d its inability ( o provide m o r c spccific informalion c o n c e r n i n g thc rclativc cfficacy of the intcrvcntion with rhc various racial/cthnic s u b g r o u p s rcprcscntcd in [his s a m p l e . Conscqucntly, additional rcscarch is ncedcd to bcttcr undcrstand the cxtcnt to which psychosocial prevention approaches such as the o n c tcstcd in this study can cffecluatc cigarettc smoking reductions that arc durablc in urban minority populations. Research is also n c d c d to idcntify polcntial diffcrcnccs in thc cfficacy of this lypc of prevcntion approach with d i f f c r c n ~minorily populalions in an effort to dctcrmine thc cxtcnr lo which modifications may bc ncccssary to maximizc its impact on the broadest possiblc rangc of a d o l c s c c n ~or, altcmatively, to tailor it lo the nccds of spccific populations. L s t , altcntion nccds to bc directed at issues relating to [he large-scale dissemination of cffcctivc smoking prcvcntion app r o a c h ~in a manner that prcscrvcs thcir cffcctivcness with a broad rangc of sfudenLs and providers.
ACKNOWLEDGMENTS 'lhis rcscarch was supporrcd by National Cancer Institute Grant K I S
C/\ 39280.
Special thanks arc d m o Joanne Gessula, Vinccnt Toth, Kathleen
St. Lcgcr, and Erick L ~ w d c r - F r c n c hfor thcir assistance in coordinating and collecting the d a b for this rcscarch and lo Elcnita Sabino for her assistance in preparing the manuscript.
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