Puff and nonsense
As part of the 1992 White Paper on the Health of the Nation, the Government set targets for the reduction in teenage smoking prevalence from 8 per cent to 6 per cent by 1994. This was always an improbable and unrealistic expectation and indeed has turned out to be the first failure from this well-intentioned document. The most interesting question is not why the target was not achieved but why on earth anyone ever thought it might be.
A massive change in trend was required to meet the target, yet no strategic or resource measures were ever put in to place which might have led to any significant change. No new educational initiatives were launched and the only discernible activity was a Government refusal to support a ban on cigarette advertising because they say it is not influential, and the almost simultaneous commissioning of an anti-smoking media campaign targeting young people! The Health Education Authority teenage tracking survey (MORI 1994) indicated not only a total absence of any decline but also a worrying increase in prevalence among girls.
A recent review of two of the UK's largest school-based anti-smoking projects (Family Smoking Education Project, and Smoking and Me) were shown to be disappointingly ineffective. So much so that the HEA, their funding body, was led to reconsider its future role in supporting anti-smoking projects. The most disturbing aspect of this failure is that the projects were very well designed - if they had been second-rate we could have blamed the materials and slept well in our beds. But we are left with the inescapable deduction that researchers, curriculum designers and teachers have been travelling down the wrong road.
It is, therefore, somewhat surprising to see the Department for Education now launching a schools-based drug prevention initiative before it is clear if any lessons have been learned from the failure of the smoking prevention initiatives. Before we flit off on another potentially disappointing escapade, what have we found out about smoking prevention?
First of all, fads and popularism are not restricted to the worlds of media and music, they also pervade the world of academic research. Adolescent smoking research has focused, to the exclusion of almost everything else, on social skills learning models, and curriculum models have tended to follow suit. A social skills model presumes that the motivation to start smoking derives from social influences, such as peer pressure, weak interpersonal skills, etc, and that training pupils in social skills - to "say no" - will alter behaviour. Research has demonstrated that social skills-based lessons may have short-term impact, but that it rapidly decays to insignificant levels after two to three years.
I am involved in research at Reading University which suggests that this over-emphasis on social factors in adolescent smoking may have been a mistake. In a school-based study in Berkshire, major differences were shown to exist between teenage smokers and non-smokers with respect to their "personal constructs" about individuality. We all have personal constructs - our own set of values - through which we interpret our experiences and which we use to describe the world we live in. Different life experiences lead us to develop al-ternative perspectives. Constructs about "individuality" appear to be three times more important to smokers than non-smokers; this was by far the most significant difference between these two groups, and might be an underestimated factor in attracting certain young people to smoking.
Another surprising finding from the Berkshire study was that constructs about "image", widely regarded as a factor in adolescent smoking, were shown to be just as important to non-smokers as they were to smokers.
These findings could explain why the recent over-emphasis of anti-smoking projects on social and image factors - like Smoking and Me - has yielded such disappointing results. Image appears to be equally important to all young people and not just to smokers.
If the "individuality factor" is im-portant, the social and peer emphasis of anti-smoking campaigns and exhortations at young people to stop smoking could act as a powerful validating influence, rather than a deterrent. If a young person starts to smoke as a way of asserting their independence and individuality then messages about becoming part of the sensible crowd are likely to be counterproductive.
A research study in Minnesota has been conducting a long-term trial of a community-wide smoking prevention programme. This is the only published long-term study which has sustained a high level of non-smoking over an eight-year period. The Minnesota emphasis on community-wide education re-duces the inconsistency which exists between classroom and life beyond the school gate. It also removes the opportunity to rebel against didactic messages.
The findings of the Reading University research and the results from Minnesota have been formulated into a unique UK community-focused smoking intervention project for young people in Berkshire. The project centres on a secondary school where pupils have provided data and information about their smoking habits as well as saliva samples to biochemically confirm self-reported behaviour. The main thrust of the educational activities, however, does not occur within the school but outside, where any PSHE learning has to be put into practice. The results of this community-based project will be compared with a matched control school that is continuing its normal classroom curriculum.
This community model uses a wide range of health promotion intervention styles over and above PSHE. These include eliminating local advertising, restricting access to under-16s, informal youth club work, street outreach work, sessions to help parents give up smoking, school policy and local employer policy development, general practioner involvement with patientparent smokers, local media publicity and promotions, courses for parents on adolescent issues, etc.
All this highlights the classical "teaching versus learning" debate: do educators teach people or do they enable them to learn? The difficulty is how to approach a potentially value-laden (legal, moral, ethical) PSHE subject, such as smoking, from an educational perspective; one which stems from the pupils' ability to identify their feelings, beliefs and actions, rather than prescriptive adult directives or potentially suspect social manipulation which borders on indoctrination.
The approach in Berkshire may point the way towards more effective intervention techniques, ones which do not compartmentalise health and social issues but are built on holistic concepts. Classroom-based work on its own appears to be relatively ineffective in achieving long-term behaviour change and teachers should be wary of accepting responsibility for something that they can only deliver in parnership with others.
o Further information about the Berkshire project from Peter Lynch or Debbie Corbridge, Health Promotion Department, West Berkshire Priority Care Trust, Prospect Park Hospital, Honey End Lane, Reading RG3 4EJ