Tobacco-Free Youth

Home , Tobacco and other drugs, Tobacco industry, Youth smoking

Scientific and Technical Publication No. 579

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ach to m ever mong ople— cco at grams people pres- of the senal. A “life skills” primer ators, iew of ell as ent of grams

Pan American Health Organization Scientific and Technical Publication No. 579

Tobacco-free Youth

A “life skills” primer

Pan American Health Organization Pan American Sanitary Bureau, Regional Office of the World Health Organization 525 Twenty-third Street, N.W. Washington, D.C. 20037 U.S.A.

2000 Also published in Spanish (2000) with the title: Por una juventud sin tabaco: formación de habilidades para una vida saludable ISBN 92 75 31579 5

ISBN 92 75 11579 6

I. Title II. (Series) 1. SMOKING—in adolescence 2. SMOKING—prevention 3. TOBACCO USE DISORDER—epidemiology 4. HEALTH PROMOTION 5. LATIN AMERICA

NLM WM290

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Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

Tobacco-free Youth: A “Life Skills” Primer was made possible through a generous contribution from the Government of Spain.

ii Table of Contents

PREFACE ...... v INTRODUCTION ...... vii PART I Substance Use and Addiction ...... 3 The Dependency that Kills ...... 4 Tobacco Use in Latin America ...... 5 Tobacco Control Efforts ...... 9 Tobacco Industry Practices in the Americas ...... 10 Young People: A Generation in Jeopardy ...... 13 Addicted By Choice? ...... 13 Psychosocial Determinants of Smoking ...... 14 Unprotected Targets ...... 16 Latin American Youth at Risk ...... 17 Taking Action ...... 19 Tobacco Surveillance ...... 19 Comprehensive Policy Efforts ...... 20 Prevention Programming ...... 20 School-based Programs ...... 22 PART II Life Skills ...... 29 Life Skills Training ...... 29 The WHO Life Skills Initiative ...... 30 Life Skills Programs in Latin America and the Caribbean ...... 31 Adopting the Life Skills Approach ...... 33 Mobilizing Support ...... 33 Life Skills Program Planning ...... 33 Completing a Needs Assessment ...... 34 Setting Goals and Objectives ...... 35 Creating Program Strategies ...... 36 Designing Training Modules ...... 37 Developing Materials ...... 38 Evaluation of Life Skills Programs ...... 39

iii “Trazando el Camino:” The Costa Rican Experience . . . . 41 Background ...... 41 Planning and Implementation Process ...... 42 Teacher Training ...... 43 Evaluating “Trazando el Camino” ...... 43 Process Evaluation ...... 43 Outcome Evaluation ...... 44 BIBLIOGRAPHY AND SUGGESTED READINGS ...... 47 APPENDIX A ...... 51 APPENDIX B ...... 52

iv Preface

If present trends hold, 10 million people will die worldwide from tobacco related causes in the year 2030; fully half of them will live in developing nations. Today, in the Region of the Americas, tobacco causes more deaths than AIDS, alcohol and drug abuse, traffic accidents, and violence combined. And yet, deaths from tobacco use are totally preventable. Unfortunately, tobacco consumption is growing in the Region, bringing with it a deadly toll in lung cancer, cardiovascular diseases, and chronic respiratory diseases. More and more young people—especially girls—are experimenting with tobacco, and they are doing so at ever earlier ages. In short, more and more young people are becoming nicotine addicts. More- over, despite any perceived economic gains to be had from tobacco, facts tell us that tobacco consumption has a net negative effect on the economies of producing countries. Any earnings from tobacco sales or exports are more than offset by higher health expenditures resulting from treating people for cancer, emphysema, and a host of other tobacco-related health problems. In fact, conservative estimates from the World Bank put the net drain from tobacco on the world economy at about US$ 200 billion a year. The true costs are likely to be much, much higher, because of underesti- mation of health costs, diminished quality of life, losses of caretakers in families, and other factors. Alarmed by this situation, the Governing Bodies of the Pan American Health Organization (PAHO) urged that children and adolescents be protected by regulating tobacco advertising, enforcing laws and regulations designed to eliminate the sale of tobacco products to minors, and estab- lishing effective prevention programs. PAHO has been actively engaged in the battle against tobacco since then. We already know, from experts and from experience, that the best approach to tobacco control is to discourage people from ever starting to smoke—but the competition is fierce. Tobacco firms invest huge sums of money in marketing and advertising to persuade people to smoke. Life Skills prevention programs give young people the wherewithal to resist the social and media pressures that encourage tobacco use; as such, they are one of the most effective weapons in our anti-tobacco arsenal. We offer these guidelines as yet another way to level the playing field in the battle against tobacco.

Dr. George A.O. Alleyne Director Pan American Health Organization

v Introduction

In an effort to stem the rising tide of tobacco consumption in the Americ- as, the Pan American Health Organization (PAHO) has sponsored various activities, including research on tobacco control legislation and policies Regionwide; coordination and development of tobacco control action in the countries; and the implementation of a data collection instrument to survey tobacco use, attitudes, and beliefs. The Organization’s support for the Life Skills methodology—an evidence-based prevention tool—holds particular promise as a way to reduce the use of tobacco, alcohol, and other drugs among the Region’s young. In addition to promoting Life Skills school-based pilot programs in the Region, PAHO also will issue a series of publications on the methodology aimed a wide range of decision makers and health and social service providers. This book is the first in that series. Part One details the scope of the tobacco problem, focusing on youth in developing countries in the Region of the Americas. It reviews Regional issues regarding the prevention of tobacco-related diseases and describes effective elements of various approaches to substance use prevention. Part Two provides both theoretical and practical discussions of the Life Skills approach to preventing the use of tobacco and other substances. This sec- tion includes guidelines for the planning and development of a Life Skills substance use prevention program tailored to the needs of developing countries in the Region. Health professionals, program planners, educators, and government policy makers will find here a review of substance use trends in the Americas and the public health response, as well as figures on the increasing toll taken by tobacco use and exposure—currently the number one killer in the world among all lifestyle-related diseases.

vii Substance Use and Addiction

Addiction and related diseases are tak- used alcohol increased from 32.5% in ing an ever greater toll on the health 1996 to 42.8% in 1997 (SAMHSA, and well-being of people everywhere. 1999). In fact, further analysis shows Worldwide trends reflect an overall that the only increase in drug use dur- increase in the use of illicit, addictive ing this period occurred among adoles- drugs and alcohol. Even more disturb- cent smokers and users of alcohol. See ing is the increase in drug use among Figure 1. the youngest sectors of the population. Tobacco is dangerous to health not According to the United States Sub- only because its use frequently leads to stance Abuse and Mental Health Ser- the initiation of other heavier drugs; vice Administration (SAMHSA, 1999), more importantly, tobacco in and of drug use has gradually but steadily itself endangers human health, and its increased, mainly due to increased use use leads to nicotine addiction, tobac- among 12–13-year-olds. The World co related illnesses, and—among half Health Organization (WHO) reports a of all adult smokers—premature death. similar trend among youth throughout As noted by WHO in The World the globe, noting lower ages of initiation of drug use and a greater availabil- Figure 1. Comparison of ity of illegal drugs (WHO,1996). substance use by smoking In both industrialized and develop- status, age-adjusted, ing countries, the use of inhalants and United States, 1997. hallucinogens has increased signifi- 20 cantly among 12–17-year-olds, particularly among street children, indige- 15 nous youth, and other marginalized adolescents. Other substances on the 10

rise include heroin, opioids, cocaine, Percent and alcohol (WHO, 1996). Nicotine, a powerfully addictive 5 substance, has long been known to serve as a “gateway” drug, leading to 0 the use and abuse of other addictive Heavy substances such as alcohol and nar- alcohol use Marijuana/ Other illicit drug use cotics. In the United States, for hashish use instance, household survey data from Current smokers 1997 reveal that the rates of illegal Current nonsmokers drug use by youth who smoked and Source: SAMHSA.

3 Health Report, 1999—Making a Differ- der, cervix and pancreas; and, among ence (WHO, 1999), “The joint proba- infants exposed to maternal smoking, bility of trying smoking, becoming low birthweight and sudden infant addicted and dying prematurely is death syndrome. higher than for any other addiction Exposure to environmental tobacco (such as alcohol, for which the likeli- smoke also has been linked to death hood of addiction is much lower).” and disease. A recent WHO report Furthermore, experts characterize the (WHO, 1999) on environmental dependency caused by nicotine-deliv- tobacco smoke and children’s health ery products (e.g., cigarettes, cigars, reveals an association between this pipes, smokeless tobacco) as greater exposure and pneumonia, bronchitis, coughing, wheezing, worsening of asthma, and middle-ear infections in children. In addition, environmental In 1997, adolescents between 12 and 17 years old tobacco smoke is associated with a who smoked cigarettes were nearly 12 times as like- higher risk of lung cancer —causing an ly as nonsmoking youth to use illegal, addictive estimated 3,000 deaths each year in the United States alone—and it also drugs and 23 times as likely to drink heavily. increases the risk of heart disease (United States Substance Abuse and Mental Health Services Administration) (CDC, 1999). Every year, tobacco is responsible than the dependency caused by either for 3.5 million deaths: it is the leading heroin or cocaine (WHO, 1999). cause of foreseeable deaths around the Studies carried out by the United world. Despite the dangers of tobacco States Centers for Disease Control and use, people continue to smoke, and the Prevention (CDC) reveal that around annual death toll continues to rise. In 70% of smokers want to quit, but less fact, WHO estimates that there are 1.1 than 3% are able to do so and remain billion smokers in the world, and 88 smoke-free over the long-term (CDC, million of them live in developing 1999 August). countries (WHO,1999) (see Figure 2). If this trend is not reversed, tobacco use will be responsible for 10 million THE DEPENDENCY deaths annually by the year 2030, of THAT KILLS which 70% will occur in developing countries (WHO, 1998 April). Nearly thirty-five years have passed Preventing these deaths is of para- since the United States Surgeon Gener- mount importance and a priority al published the first report identifying of public health professionals around the harmful effects of cigarettes on the world. human health. In this groundbreaking The longer a person continues to report, the Surgeon General docu- use tobacco, the greater the health risks. mented that smoking cigarettes led to The mortality rate of smokers is three chronic bronchitis, lung cancer, and times greater than that of non-smokers cancer of the larynx in men (U.S. in all age groups, starting in early adult- Department of Health, Education, and hood. Individuals who become addict- Welfare, 1964). ed to nicotine in adolescence—nearly Subsequent studies have document- 60% of all youth who experiment with ed the relationship between tobacco smoking—have a 50% chance of dying use and more than thirty additional from tobacco as they become adult diseases, such as cardiovascular disease; smokers, with a loss of around 22 years cerebrovascular disease; chronic of normal life expectancy (U.S. Depart- obstructive pulmonary disease; cancers ment of Health and Human Services, of the mouth, esophagus, throat, blad- 1994) (WHO, 1999 May).

TOBACCO-FREE YOUTH Figure 2. WHO estimates of smoking prevalence in developing and developed countries, by gender, May 1999. 50

0 Men Women Developing countries Developed countries

Source: WHO, 1999.

In the United States, more than 20% of wreak havoc on nations around the deaths today are related to tobacco use world at increasing rates as the num- initiated decades ago, when prevalence bers of new smokers continue to climb. of consumption in adults was more In terms of economic costs, U.S. med- than 45%. Since then, adult tobacco ical expenses to treat diseases related to use has decreased to around 25%, and tobacco use have been estimated at $50 has remained somewhat stable for the to $73 billion annually (CDC, 1999 last decade. However, the prevalence of August). WHO has described the tobacco use among adolescents, tobacco epidemic as both a “major although declining in the 1980s, drain on the world’s financial increased in the 1990s. In 1997, smok- resources,” and a “major threat to sus- ing rates among young adults ages 18 tainable and equitable development” to 25 stood at 40.6%, up from 34.6% (WHO, 1998 June). just three years earlier (SAMHSA Of the 1.1 billion smokers in the 1999). world, 88 million live in the devel- Since 1990, the CDC has surveyed TOBACCO USE IN oping world. If smoking rates adolescent smoking at schools across continue to rise, 7 million people in the United States using the Youth Risk LATIN AMERICA developing countries will die of Behavior Surveillance System. Data tobacco-related causes in the from 1997 show that 70% of the stu- Historically, indigenous populations in dents surveyed had experimented with the Americas have used tobacco in heal- year 2030. smoking at least once, 36% of students ing practices, ceremonies, and rituals. had smoked a cigarette in the previous In the first part of the 20th century, thirty days, and 44.5% reported having tobacco began to be increasingly used used some form of tobacco (cigarettes, as the popularity of the cigarette inten- smokeless tobacco, or cigars) in the pre- sified after World War I (DHHS and vious month (CDC, 1999 August). PAHO, 1992). In the past couple of The costs of tobacco use—in both decades, several factors have begun to human and economic terms—will influence an increase in the use of

SUBSTANCE USE AND ADDICTION tobacco in Latin America. Demograph- Brazil, Cuba, Honduras, and Mexico) ic changes have expanded tobacco’s and cigarette-manufacturing countries market potential, including a reduction (e.g., Brazil, Colombia, and Venezuela), tobacco and its products translate into major export earnings (WHO, 1997). Population groups that are vulnerable In Latin America and the Caribbean, tobacco is to tobacco’s appeal—such as adoles- responsible for 135,000 preventable deaths each cents—are likely to be exposed to tobacco if they participate in the tobac- year—a human cost too great to compensate for co production and manufacturing any financial gain from tobacco production. workforce. Such everyday exposure may reinforce a perception that tobacco use in birth rates and mortality with subse- is widespread and socially acceptable. quent population growth; greater In developing countries in the urbanization; greater access to educa- Region of the Americas tobacco is tion, followed by higher employment responsible for some 135,000 preventa- and increased purchasing power; and a ble deaths each year (WHO, 1997). In larger proportion of women in the Mexico alone, an estimated one in four workforce. deaths is related to tobacco-use (Insti- The fact that tobacco is cultivated in tuto Nacional de Enfermedades Respi- the Region also may have accelerated ratorias, 1997) (see Tables 1 and 2). the smoking trend. In many tobacco- Unlike the United States and Cana- producing countries (e.g., Argentina, da, most Latin American and Caribbean

Table 1. Tobacco-related deaths in the Region of the Americas, 1996.

United States 500,000 Latin America 100,000 English-speaking Caribbean 35,000 Canada 35,000 Total 670,000

Source: WHO, 1997.

Table 2. Percentage of population (> 12 years old) using tobacco, by country. At least In the In the once previous year previous month

Bolivia (1992) 46.8 34.1 24.9 Canada (1994) 54.5 27.0 … Chile (1996) 70.2 47.5 40.4 Colombia (1996) 38.8 25.9 22.2 Costa Rica (1995) 35.2 18.3 17.5 Paraguay (1991) … … 24.3 United States (1994) 73.3 31.7 28.6 Mexico (1993) 45.4 … 25.1 Peru (1997) 62.1 42.0 31.7 Venezuela (1996) 31.8 25.7 24.4

Source: PAHO, 1998.

TOBACCO-FREE YOUTH countries do not have country-specific, Dominican Republic, and as many as standardized surveillance systems in one-quarter of all women are smokers place to systematically monitor either in Brazil, Chile, Cuba, and Uruguay the prevalence of smoking or the toll it (WHO, 1997) (See Figure 3). takes on human health and well-being. A PAHO/WHO survey conducted The most recent prevalence data avail- in 1992 showed that in urban areas of able for the Americas was rendered the most developed Latin American through the WHO “Tobacco or countries, young people—especially Health” initiative in the mid-1990s young women—were beginning to (WHO, 1997). smoke at a higher speed than that of Analysis of this important, although their predecessors. Smoking among limited, data reveals that in the early girls has been reported to almost equal 1990s per capita consumption of ciga- smoking among boys in Argentina, rettes in persons over 15 years of age Chile, and Cuba, for instance (see averaged 1,300 cigarettes per year. Figure 4). Low-consumption countries, such as However, the difference in smoking Peru and Guatemala, reported only prevalence between genders is more 350 cigarettes consumed per capita per accentuated in other countries. For year, and high consumption countries, instance, in Honduras in 1995, less such as Venezuela and Cuba, reported than 10% of school age girls were per capita consumption at around reported to smoke, compared to more 2,000 cigarettes per year. than 35% of boys the same age (Insti- According to WHO estimates, 40% tuto Hondureño para la Prevención of men and 21% of women smoke in del Alcoholismo, Drogadicción y developing countries in the Region of Farmacodependencia, 1996) (see Fig- the Americas (WHO, 1998), but this ure 5). And in Bolivia, the difference Tobacco cultivation in the Americ- figure masks the considerable variation in smoking between genders was just as may also have helped to fuel between countries and among popula- as great in urban areas (43% male the increase in tobacco use in tion groups. For instance, data reveal smokers v. 18% female smokers) as Latin America and the Caribbean. that two out of three men smoke in the in rural areas (44% v. 17%) (Centro Adolescents working in tobacco production are exposed to tobacco on a daily basis, which may Figure 3. Percentage of current smokers and lifetime reinforce their view that tobacco prevalence of smoking among 3,635 students, use is widespread and socially by school grade and gender, Argentina, 1997. acceptable.

0 Current smokers Lifetime prevalence 11th grade females 8th grade females 11th grade males 8th grade males

Source: Morello, 1997.

SUBSTANCE USE AND ADDICTION Latinoamericano de Investigacion Uruguay in the 1980s revealed the Cientifica, 1998). average age of smoking initiation to be Although the reported age of smok- between 15 and 16 years old (Ruocco, ing initiation varies across the Region, et al., 1989). it does appear to be dropping. As Partly as a result of earlier smoking measured by a nationwide survey in onset, the number of young smokers Cuba, for example, more than 35% addicted to nicotine continues to of adult smokers surveyed in 1995 climb through adolescence into adult- started smoking before the age of 14 hood (see Figure 6). In Cuba, almost (Ministerio de Salud Pública, 1995). A half of adolescent smokers between the survey of students conducted in ages of 17 and 19 years old described

Figure 4. Percentage of 12–18-year-olds who smoked in the previous month, by gender, Chile, 1994–1996. 35

0 1994 1996 Male Female

Source: CONACE, 1996.

Figure 5. Percentage of Figure 6. Smoking prevalence school-age children among youth 15-to-16 and reported to have ever smoked, 17-to-19 years old, by gender, by gender, Honduras, 1995. Cuba, 1995. 25

40 20

30 15 Percent 20 10 Percent 5 10

0 0 Male Female Males Females 15–16-year-olds 17–19-year-olds

Source: IHADFA, 1996. Source: MINSAP, 1995. 8

TOBACCO-FREE YOUTH that they had tried to quit at least once nomic output (WHO, 1999 April). (Ministerio de Salud Pública, 1995). They further state that “the alleged economic benefits of tobacco are illusory TOBACCO CONTROL and misleading” when all the costs associated with the product are not EFFORTS considered. Unfortunately, the eco- Tobacco control achievements vary nomic losses associated with these between countries in the Region of the drugs are rarely measured or factored Americas: the United States and Cana- into the equation. da have made great progress regulating The perceived economic benefits of tobacco, but other countries have made tobacco also may be part of the reason less progress in reducing tobacco use. why so few developing country govern- This was reflected in the late 1980s, ments in the Americas have initiated when tobacco use in Latin America comprehensive tobacco control or pre- declined only modestly (11%) while vention campaigns. Nongovernmental the United States and Canada experi- organizations have taken on much of enced a reduction of 28% and 35%, the responsibility for leading such respectively (PAHO, 1989). tobacco control activities as World No Economic and political factors seem Tobacco Day or smoking cessation and to be responsible for the disparity substance abuse prevention programs. between tobacco control efforts in Despite the lack of progress in industrialized countries in North tobacco control relative to their indus- America and developing nations in the trialized neighbors, several developing Region. The latter countries may be countries in the Region have made hindered in their ability to achieve bet- impressive strides. For instance, some ter tobacco control due to the fact advertising restrictions are now in place that many of these countries depend in Chile, Colombia, Costa Rica, Mexi- heavily on income generated from the co and Panama, and smoking has been production or manufacturing of tobac- banned on most commercial flights in co products. the Region (WHO, 1999). The relative lack of national regula- The Coordinating Committee of tory action in some countries in the Tobacco Control in Latin America Region is likely associated with the (CLACCTA), founded in 1985, has Tobacco-control efforts vary from dubious power of the tobacco industry been actively involved in motivating country to country, and can range to stimulate the economy and generate countries in the Region to adopt tobac- from prevention campaigns, to jobs and taxes. Both tobacco and alco- co control policies. In addition, the advertising restrictions, to legisla- hol are “legalized drugs” that con- Interagency Committee for the Con- tion. This sign on a building in tribute much needed income for trol of Smoking in Latin America was Costa Rica attempts to enforce a resource-poor countries through taxa- created in 1995. It includes representa- smoking ban legislation. tion policies. In an effort to preserve tion from the Centers for Disease Con- this income, policy makers frequently trol and Prevention, the Society Against fail to implement restrictions on the Cancer and the National Cancer Insti- promotion and consumption of ciga- tute, both from the United States, rettes. Anti-tobacco legislation is often CLACCTA, the International Union of minimal at best and is rarely enforced. Struggle Against Cancer, Health Cana- Economic losses resulting from da, and the Pan American Health tobacco, although staggering, have not Organization. The Interagency Com- been clearly communicated. WHO mittee’s main function is to provide reports that most analyses of the eco- financial and technical support for par- nomic effects of tobacco reveal that a ticipating national programs that decline in production would not result reduce the supply of and the demand in overall lower employment or eco- for tobacco.

9 SUBSTANCE USE AND ADDICTION 9 SMOKING PREVENTION AND CONTROL PROGRAMS IN THE REGION According to the report on the Regional Encounter on Smoking, which took place in Rio de Janeiro in August 1998, the status of smoking prevention and control programs in the Americas can be described as follows: • Almost all the countries in the Region have a basic governmental or non-governmental infrastructure for the prevention and the control of smoking. • Smoking cessation services are frequently led by ecclesiastic and community organizations. Financing by governments is rare. • These systems use a multidisciplinary approach to monitor smoking. • Educational programs in schools have not been used much in these control activities, although evaluation studies indicate that these programs can be effective. • In almost all the countries, public information activities are carried out, but their effectiveness and impact on tobacco use behavior are unknown.

Research for International Tobacco Control, 1998.

In 1995, the Interagency Commit- TOBACCO INDUSTRY tee established the following five goals PRACTICES IN THE for participating countries: AMERICAS • to increase by 10% the number of former smokers within five years, As tobacco control tightens in industri- • to reduce by 10% the incidence of alized countries, multinational tobacco tobacco use among young people companies are strategically increasing between 12 and 16 years old with- their penetration into resource-poor in five years, countries in the Region, where they can direct their efforts at potentially lucra- • to raise by 2 years the age at which tive markets vulnerable to the tobacco tobacco consumption is permitted appeal, such as adolescents and women. within five years, and By and large, these groups are not sufficiently protected by regulations • to reduce by 5% mortality rates limiting tobacco promotion or access to from noncommunicable, tobacco- tobacco. Industry marketing and adver- related diseases within ten years. tising that target these groups remains In order to meet these targets, largely unchallenged. The tobacco despite the tobacco industry’s organized industry in developing countries— opposition, committed policy support whose financial resources often outstrip and the assistance of private and gov- those of national governments—have ernmental organizations is critical. organized powerful tobacco lobbyists

TOBACCO-FREE YOUTH who have managed to thwart tobacco products, however, this enormous effort control legislation in countries such as and expense hardly seem warranted. Argentina and Uruguay as part of an The use of publicity as a strategic aggressive tobacco promotion strategy tool to increase tobacco use is ubiqui- aimed at increasing consumption in the tous in the Region’s developing coun- Region (Weissman, 1998 [as cited in tries, where extensive publicity and Hammond, 1998]). promotion of tobacco have become Promoting tobacco products not commonplace. Promotional products only involves lobbying against tobacco such as clocks, lights, displays, and control, but it also entails a huge attractive posters have made their way investment in publicity and marketing to the most isolated towns and kiosks. campaigns—which, in effect, dimin- In addition, most televised sports (e.g., ishes the impact of any existing nation- auto racing and soccer matches) and al policies that attempt to regulate cultural events have been sponsored by tobacco. Publicity is a very important the tobacco industry for decades, mak- component of the tobacco industry’s ing sports leagues now heavily depend- strategy, and it is used worldwide to ent on tobacco money. maintain tobacco demand. In 1996 the In addition to promoting their U.S. Federal Trade Commission esti- potentially lethal products, tobacco mated annual tobacco industry pro- companies also use publicity campaigns motional expenses at $5 billion in the to try to shape their public image as an U.S. alone. industry concerned about the health of The industry has traditionally adolescents. These campaigns frequent- argued that their tremendous invest- ly involve the creation of alliances ment in publicity and marketing cam- between tobacco manufacturers or paigns is not intended to increase con- retailers and Ministries of Health and sumption but to merely preserve market of Education, tobacco control organi- share, maintain the loyalty of smokers zations, or Offices of the First Lady. As to a given brand, and promote cigarettes a result of such alliances, government, with low tar and nicotine content. Since university, or nonprofit organizations very few smokers change brands of that have joined forces with the tobac-

THE CASE OF MEXICO In the recently published Addicted to Profit: Big Tobacco’s Expand- ing Global Reach (1998), Ross Hammond describes the rise of ‘big tobacco’ (a.k.a. Philip Morris and British American Tobacco) in Mex- ico upon the opening of its markets to foreign investment. In July 1997, the two industry giants paid a total of US$ 2.1 billion for two Mexican cigarette companies. The report explains that Mexico is especially attractive to multinational cigarette producers because of its cheap labor, quality tobacco leaf, young population, and few restrictions on tobacco. Industry critics believe that one of the primary goals of the buyouts is to establish the country as a platform from which to cheaply produce cigarettes for export to other developing countries. However, the potential to develop Mexican markets (including the world’s fifteenth largest cigarette market) has apparently not gone unnoticed. The foreign subsidiaries have boosted marketing expenditures and honed their advertising strategy to portray their product as meeting Mexican consumers’ desires for international status, romance, and rebellion.

SUBSTANCE USE AND ADDICTION co industry are subsequently limited in beginning to help these countries pro- their power to reduce tobacco con- mote national and local tobacco control sumption through anti-industry strate- measures. In addition, some developing gies. Unfortunately, such alliances are countries—Guatemala, Nicaragua, and all too common in the Region’s devel- Venezuela, for example—have followed oping countries. the example of the United States and Industrialized countries have recent- have begun to hold multinational ly begun to acknowledge the conse- tobacco companies accountable by quences of the tobacco industry’s target- demanding compensation for health ing of developing countries on the care costs stemming from tobacco- global burden of disease, and they are related death and disease.

TOBACCO INDUSTRY PRACTICES Marketing Cigarettes can be heavily promoted with very positive imagery that promotes a notion that smoking is acceptable, even healthy, or that risk-taking is glamorous. Tobacco companies have also been allowed to engage in often quite deceptive behavior that reassures smokers and keeps them in the tobacco market. Tobacco companies, often unfettered by governments, manipulate the dependence of smokers by offering justification for continued smoking and marketing alternatives to cessation. Public Relations Either directly, or through funded ‘front’ groups, tobacco companies often attack the scientific evidence on the effects of smoking. The industry also adopts the stance that smoking is not as harmful as other activities, or that “everything” is harmful. These public relations strategies are often so far removed from scientific reality that they would not work for most consumer products. But tobacco, because of the dependency it creates, is not like other products. Smokers are often strongly motivated to find ways to justify continued smoking, and while others might recognize these strategies as attempts to deceive consumers, smokers may view them as a beacon of hope in their efforts to justify continued smoking there- by avoiding the hardship of a cessation attempt. Packaging and Labeling Cigarettes are sold in attractive packaging and offered in small Although required by law, health quantities—such as a single day’s supply). If health messages are messages on cigarette packages required on packaging and advertising, tobacco companies often often are inconspicuous or diffi- successfully ensure that messages are as small and inconspicuous cult to read. Note the contrast as possible, and are rarely updated, essentially undermining the between the crisp and clear brand effect of the warnings. name on the front of the pack and the almost illegible health mes- Products sage on the side. A lack of health-based product standards means that cigarettes can be manufactured in order to be very effective nicotine delivery systems. Nicotine delivery can easily be manipulated and cigarettes can be made more palatable by leaf blending and using additives.

PAHO, 1999.

TOBACCO-FREE YOUTH Young People: A Generation in Jeopardy

Young people today face many attrac- to influence them—family, media pro- tive choices and challenges in both the fessionals, educators, counselors and industrialized and developing worlds. teenagers themselves. They are exposed to, and frequently influenced by, powerfully persuasive messages through the ever-growing media—messages that often compete ADDICTED BY CHOICE? with traditional family values and may exert more influence over lifestyle choic- WHO reports that three out of five es. This barrage of information and young people who experiment with constant shift in fads is very compelling tobacco will become addicted, daily and can be overwhelming to young peo- smokers into adulthood, half of whom ple who are trying to make choices. will die prematurely (WHO, 1998 In most societies, the family and the April), and the majority of whom will school remain the key emotional sup- suffer needlessly as a result of their ports needed for youths’ healthy devel- nicotine addiction. Unfortunately, opment. But the psychosocial pressure young people who choose to smoke caused by rapid cultural change and and use other tobacco products may competing messages may lead young not understand the nature of addiction people to distance themselves from traditional protective influences. Experts theorize that these traditional mecha- nisms for passing on values and life Three of every five young people who experiment skills may no longer adequately balance with tobacco will become addicted smokers into the power of other—often negative— influences to which young people are adulthood—half of them will die prematurely. exposed (WHO, 1997b). It is important to create opportuni- or appreciate the long-term conse- ties where young people can acquire the quences of their behavior. What begins skills and knowledge necessary to sort as experimentation more often than through this onslaught of information not evolves into a daily dependence on and the growing challenges encoun- tobacco products to satisfy the craving tered as they approach adulthood. In for nicotine. order to keep young people tobacco- Furthermore, research has shown and drug-free, youth development also that young people who choose not to must involve all who are in a position smoke before the age of 20 are not

13 likely to start smoking as adults • Cigarette smoking often leads to (WHO, 1998b). This means that the the use of other heavier drugs and prevention of the onset of smoking at is associated with distinct health an early age in effect reduces smoking problems among teens—mainly at all ages. respiratory diseases. Various stud- Despite 30 years of decline in over- ies demonstrate that adolescent all smoking prevalence, many young smokers have diminished lung people are beginning to smoke and capacity and contract a greater become addicted every day. Clearly, number of respiratory diseases then, preventing smoking among than their non-smoking peers young people is critical to stemming (Woolcock, 1984). the epidemic of tobacco use. In 1994, the United States Surgeon General’s • Combined efforts, especially those report on smoking and health focused, that give adolescents the skills nec- for the first time, on young people. essary for rejecting tobacco, can The six major conclusions from that effectively reduce smoking onset report can be summarized as follows: (DHHS, 1994). • Between 75% and 90% of adult • Risk factors have been identified smokers started smoking before that are associated with increased turning 18, which means that ado- likelihood of tobacco use by young lescence is a crucial stage for the people. prevention of tobacco use and tobacco-related deaths (DHHS, 1994). While the age of smoking PSYCHOSOCIAL initiation is increasing slightly in DETERMINANTS OF the U.S., the rate of increase is extremely gradual, roughly one SMOKING month per year (SAMHSA, 1999) Over the decades, social scientists have (see Table 3). tried to understand why some adoles- • The promotion of tobacco con- cents experiment with smoking and sumption in the mass media is others don’t. Current research on the linked to greater consumption etiology of smoking has largely focused among youth (DHHS, 1994). on the identification of psychosocial There has been a continuous shift predictors of the onset of smoking. from advertising to promotion, Researchers have identified several largely because of banning cigarette domains of predictors, including social ads from the broadcast media. bonding variables, social learning variables, and intrapersonal variables such • A growing number of adolescent as refusal skills, knowledge, attitudes, smokers are already addicted to and intentions. In a meta-analysis of nicotine and describe withdrawal nearly 30 studies that included symptoms when they attempt to prospective data on the beginning of quit smoking. Once they become tobacco use, a combination of social daily smokers, successful cessation and personal factors were found to be is very difficult (WHO, 1998; related to smoking onset (Conrad, DHHS, 1994). Flay, and Hill, 1992):

Table 3. Average age of first use by adolescents aged 12 to 17, U.S.A.

1988 1990 1991 1992 1993 1994 1995 2000 (baseline)

Cigarettes 11.6 11.5 11.5 11.7 11.7 12.2 12.3 12.6

TOBACCO-FREE YOUTH • having parents or best friends who Social learning theories assume that smoke, experimental substance use originates in the substance-specific attitudes and • having poor self-esteem, behaviors of people who serve as ado- • performing poorly in school or lescent‘s role models, especially family having dropped out of school, and close friends. This theory suggests that a key to prevention lies in making • having positive attitudes regarding substance-using role models less salient tobacco use, and substance-abstaining role models • engaging in other risk-taking more salient. An additional key to pre- attitudes, vention lies in teaching refusal skills and enhancing refusal self-efficacy • not having necessary refusal skills, (Bandura, 1969). and Conventional commitment and social attachment theories (Elliott, Hawkins • feeling anxious or depressed. and Weis, 1985) are based on classic The problem is that, although sociological theories of control that researchers are now aware of most of argue that deviant impulses presumably the determinants that contribute to shared by all persons often are con- experimental substance use, they do trolled by strong bonds to convention- not know yet how they all interact. al society, family, and school. When Over the years, various theories have adolescents have weak bonds to con- focused on different determinants, ventional society, they feel they have lit- with subsequent implications for pre- tle to lose through attachment to vention strategies. deviant peers. These theories imply that According to cognitive-affective theo- the prevention of substance use ries, the roots of experimental substance requires the nurturing of interpersonal use are found in adolescents’ attitudes and academic skills among children and beliefs about substances. The theo- long before they form substance-specif- Young people who do not start to ry of planned behavior posits that self- ic beliefs as adolescents and become smoke by the time they turn 20 are efficacy directly affects intentions and involved with substance-using peers. unlikely to smoke as adults. Clear- behavior (Ajzen, I and Fishbein, M., Several theories try to explain sub- ly, preventing the onset of smoking 1980). Refusal self-efficacy represents stance use by the existence of intraper- at an early age reduces smoking adolescents’ beliefs in their abilities to sonal characteristics such as stress, low at all ages. resist social pressure to begin using sub- self-esteem, or emotional distress, but stances. According to this approach, longitudinal studies suggest that these prevention relies on persuasive mes- intrapersonal characteristics are poor sages that: predictors of substance use. • increase adolescents’ expectations The problem behavior theory (Jessor regarding the adverse conse- and Jessor, 1977) assumes that suscep- quences of experimental substance tibility to problem behavior results use and decrease their expectations from the interaction of the person and about its potential benefits, the environment and tries to integrate the other theories. It implies that ado- • emphasize the cost rather than the lescents are at risk for substance use if benefits, they are unattached to their parents • challenge adolescents’ perceptions and are more influenced by their peers concerning the normative nature than by their parents. It also holds that adolescents who are prone to one of substance use, and problem behavior also are prone to oth- • provide information and skills that ers. Since tobacco use usually begins in directly promote feelings of refusal adolescence and is associated with other self-efficacy. risky behaviors, understanding the psy-

YOUNG PEOPLE: A GENERATION IN JEOPARDY chology of adolescent “risk-takers” is an greater the number of risk factors important step in understanding how to encountered, the greater the number of prevent tobacco and other substance protective factors are needed to coun- use. These risk-takers often desire inde- teract that risk (PAHO, Nov. 1998). pendence and autonomy, want to Neither risk factors nor protective assume the adult role, give importance conditions, however, function in a con- to the peer group in decision-making, sistent, predictable pattern. They are need to act in accordance with peer dynamic and affect individuals differ- group rules, and feel “invulnerable.” ently. Most of these factors or character- The domain model by Huba and istics constantly interact with environ- Bentler, a more comprehensive model, mental influences, affecting and is an attempt to catalogue most of the modifying each other. For instance, causes of substance use. It includes individual characteristics interact with more than 50 potential causes catego- social and environmental conditions rized into four domains: such as publicity, family behaviors, and • biological influences—genetic perceived social norms, and subsequent- influences, physiologic reaction to ly either increase or diminish the indi- substances, general health; vidual’s likelihood of using substances. • intrapersonal influences—beliefs, personal values, sensation seeking, UNPROTECTED impulsiveness, sociability, extraver- TARGETS sion, anxiety, and low self-esteem; • interpersonal influences—charac- Tobacco industry documents that teristics of the people in close con- recently have been made public reveal tact with the teen; how the industry has targeted its tobac- The tobacco industry has targeted co promotion campaigns to adoles- most of its promotional campaigns • sociocultural influences—media, cents. In an attempt to keep product to young people. By portraying market availability, social sanctions. demand high, adolescent consumers smoking as attractive and feeding The emphasis on adolescents’ rebel- are frequently targeted to replace the on young people’s desire to feel liousness and sensation seeking and the large number of adult consumers who grown up and free, tobacco mar- recognition that substance use is relat- die each year from tobacco-related dis- keters attract youth and keep ed to easy access to substances are eases. For example, Philip Morris, in a them hooked. important features of this theory that 1981 internal document cited in the incorporates the concept that legal 1998 Campaign for Tobacco-Free Kids, measures must be added to the preven- stated, “Today’s teenager is tomorrow’s tion efforts. potential regular customer, and the Just as certain conditions or qualities overwhelming majority of smokers first have been associated with increased risk begin to smoke while still in their of substance use, specific characteristics teens... The smoking patterns of are associated with decreased consump- teenagers are particularly important to tion. These protective factors range from Philip Morris (cited in Campaign for behavioral characteristics such as harm Tobacco-Free Kids, 1998). R.J avoidance and coping abilities, to posi- Reynolds attempted to encroach on tive life experiences and events. Philip Morris’s young clientele with its Risk and protective factors that are own Camel campaign. A 1975 memo modifiable are more appropriate vari- recommends that the national expan- ables to target with prevention pro- sion of the “successfully tested “Meet grams. Factors more sensitive to change the Turk’ ad campaign and new Marl- include attitudes (e.g., negative view of boro-type blend is another step to meet tobacco use), beliefs, and behavioral our marketing objective: to increase our competencies (Pandina, 1996). Re- young adult franchise. To ensure search has shown that, in general, the increase and longer-term growth for

TOBACCO-FREE YOUTH Camel Filter the new brand must LATIN AMERICAN increase its share of penetration among YOUTH AT RISK the 14–24 age group which have a new set of more liberal values and which Many conditions experienced by young represents tomorrow’s cigarette busi- people in developing countries in the ness” (Multinational Monitor July/ Americas intensify their risk and may August 1998). hinder the reversal of adolescent smok- Studies show that adolescents are ing trends in the Region: particular susceptible—by some Tobacco regulation in the Region accounts three times as sensitive as tends to be weak and, where it exists adults (Pollay, et al., 1996)—to ciga- at all, it is often not enforced. Multi- rette advertising schemes. In the U.S., national tobacco companies and their this is manifested by youth loyalty to subsidiaries in the Region are relatively the three most heavily advertised free to publicize and promote tobacco brands: Marlboro, Camel, and New- use among young people, and their port. The United States Centers for efforts are both sophisticated and per- Disease Control and Prevention reports vasive. They sponsor events popular that close to 90% of the nation’s teen with youth such as high school sporting smokers choose these three brands, as and cultural events. At times, the opposed to only about one-third of industry will comply with one regula- adult smokers (CDC, August 1994). tion just until the next loophole is The tobacco industry has conducted found. For example, it is not uncom- sophisticated marketing studies identi- mon to see tobacco ads jump from the fying the psychological and develop- billboard to the T-shirt. mental factors that make youthful Anti-tobacco messages are often ‘replacement smokers’ the most vulner- poorly disseminated. The widespread able to tobacco initiation: namely, their ignorance of the real dangers of tobac- desire to feel “grown up”, free, and co among the general public serves to independent, but also to “fit in” social- safeguard the social acceptability of ly. As a result of industry advertising, smoking. Even health professionals in adolescent smokers often see the ciga- many areas lack sufficient knowledge rette as the essential element needed to and training in the health risks of achieve popularity and “sex appeal.” tobacco consumption. This results in Cleverly manipulating these factors, missed opportunities to promote pre- tobacco marketers have managed to vention among young people and ces- portray smoking in a way that attracts sation among patients who are already youth and keeps them hooked. In fact, tobacco dependent. the majority of tobacco advertisements Anti-tobacco messages are often show healthy, active young people of poorly developed. Some so-called both sexes having a good time while tobacco prevention messages dissemi- smoking in some social situation. nated in the Region cleverly disregard Tobacco marketing messages promote common adolescent attitudes that myths such as: value rebellion, risk-taking and adult • smoking is a ‘rite of passage’ to the behavior in their purported preven- adult world; tion messages. Such alleged attempts • people who are popular and who to reduce youth smoking often are achievers smoke; only encourage young people to assert their independence and start or con- • cigarettes help to loosen you up tinue smoking by crafting messages when you are in a group; that emphasize authority and age • cigarettes are healthy and symbol- (Coe, 1999). ize freedom; Young people constitute a large • the whole world smokes. share of the general population. In

YOUNG PEOPLE: A GENERATION IN JEOPARDY the Region’s developing countries, easy to purchase. For instance, the young people represent anywhere from purchase of a pack of cigarettes in one-third to one-half of the economi- Argentina would require only eight cally active population (Burt, 1996; minutes of labor at the minimum OAS, 1990). Most young people live in wage, compared to twenty-two urban areas—by the year 2000, 80% of minutes in Canada and twenty-three young people will live in urban areas— minutes in the United Kingdom where they may experience an erosion (WHO, 1997). of family and social support, poor Regional data collection describ- housing and sanitation, and high ing youth tobacco consumption and levels of violence (PAHO, 1998 the general demographics of youth November; World Bank/PAHO, 1999 is conducted sporadically and is February). These stresses can increase insufficient for monitoring the true anxiety levels, a major risk factor magnitude of the problem. Country- for substance use among youth. level research analyzing the status of Young people in Latin America tobacco use by youth in discrete areas sometimes work in tobacco-related also is needed in order to target young jobs. While not widespread, children people most at risk with appropriate and adolescents in many countries in the prevention programs. Lack of ade- Region work cultivating tobacco in rural quate information that describes the areas and have been observed working magnitude of the tobacco problem— for tobacco companies by handing out including “the causes, consequences free product samples; in some urban and costs of tobacco use”—may con- areas, they even sell cigarettes. tribute to the reluctance of area policy In some countries in the Region, makers to support tobacco control cigarettes are relatively cheap and action (WHO, 1999).

Most tobacco advertisements show active, healthy young people having a great time. If restrictions on tobacco advertisements curtail roadside ads, smoking messages often will leap from the billboard to t-shirts or other marketing objects.

TOBACCO-FREE YOUTH Taking Action

For policy makers and practitioners alike, the public health model can serve SAMPLE NATIONAL as a framework for building compre- PLAN OF ACTION hensive health services and planning FOR COMPREHENSIVE actions. The public health approach to TOBACCO CONTROL reducing disease (such as tobacco-related death and disability) involves acting Health Promotion on all three domains of the problem. • No-tobacco days One key to reducing tobacco use in the Americas—and the increased mor- • Media advocacy tality associated with it—is to develop • School-based programs strategic actions to reduce consumption • Community-based initiatives (host), diminish the power of tobacco • Sponsorship of cultural and (agent), and lower the accessibility and sporting events acceptability of tobacco use (environment) at the country and regional lev- Health Protection els. Tobacco control strategies may take • Legislative efforts • Fiscal measures The host The agent Capacity Building • Training health and education professionals The environment • Partnerships between public and private health organizations the form of surveillance, policy initia- • Collaboration across sectors tives, public information activities, pre- (e.g., health, education, youth vention interventions, or, ideally, a development, children’s rights) combination of all of these activities. Monitoring and Evaluating • Programs and policies TOBACCO • Surveillance of tobacco use SURVEILLANCE Recognizing the importance and the 1997). This publication identifies need for improved tobacco surveillance, important indicators for monitoring in 1990 the World Health Assembly tobacco use. It targets the following cat- commissioned WHO to monitor the egories as fundamental areas to survey magnitude of smoking and tobacco use in each country or Region: in the nations around the world. WHO • the sociodemographic situation; then collected available country level statistics, later published in Tobacco or • the tobacco-production and tobac- Health: A Global Status Report (WHO, co industry situation;

19 • tobacco consumption; (U.K. Secretary of State for Health, • the prevalence in different popula- 1998; Hibbs, 1999). Norway, Belgium, tion groups: e.g., adults, young Portugal, and Thailand also have adopt- people, pregnant women; ed prevention measures that include a ban on tobacco propaganda, control of • the rates of morbidity and mortal- consumption in enclosed spaces, ity related to smoking; and increase in cigarette taxes, and develop- • existing legislation related to the ment of national prevention and cessa- tobacco use and its application. tion campaigns (WHO, 1998). The problem of smoking is one of Such efforts have resulted from suc- the greatest challenges for preventive cessful advocacy and public informa- medicine in the Region. The lack of tion campaigns that have effectively country-specific data needed to inform informed policy makers of the grave project design has been an obstacle to health consequences and enormous adequately respond to the challenge; economic costs resulting from tobacco standardized, disaggregated baseline use and exposure. data on tobacco consumption is not Fighting tobacco through legislative routinely available for many of the initiatives is an important component Region’s countries. Country specific of national action plans. However, the data can be transformed into effective actual impact of legislation varies and policy, advocacy, and health promotion must be better evaluated in order to tools. According to the International guide policy action, implementation, Union Against Cancer (1990), this type and enforcement. For instance, legisla- of data is required to: tion affecting the design or manufac- • influence policy and decision ture of cigarettes would theoretically makers; have the most immediate and powerful • recruit tobacco control allies impact on tobacco use, but such initia- among health professionals, educa- tives have not been evaluated or pro- tors, and the public at large; moted. More frequently, policy makers favor legislation that influences tobacco • select or design appropriate inter- advertising and purchase instead. These ventions; and types of legislative efforts can achieve an • monitor progress in decreasing eventual impact, but over a longer peri- tobacco use. od. The feasibility of implementing and enforcing various types of legislation COMPREHENSIVE must also be considered in the evaluation of policy options (see Figure 7). POLICY EFFORTS The Toxic Substances Board of New Although tobacco control policies are Zealand conducted a study on the rela- gaining ground around the world, some tionship between the regulation of countries have made more headway tobacco promotion policies and con- than others. As early as 1977, Finland sumption trends in thirty-three coun- prohibited smoking in public places. In tries between 1970 and 1986. They 1988, Canada prohibited the advertise- found that, overall, the greater the ment of tobacco products. More recent- restrictions on tobacco promotion, the ly, the United States and England have greater the average annual reduction in begun to restrict the promotion, sale, tobacco use (Roemer, 1995). and consumption of tobacco. The British government, for instance, PREVENTION recently drafted legislation that will ban most tobacco advertising, and it plans to PROGRAMMING abolish all tobacco promotion—includ- Simply put, prevention works. It works ing sponsorship of sporting events such not only to reduce disease and death, as Formula One—by the year 2006 but in the case of tobacco, it also serves

TOBACCO-FREE YOUTH Figure 7. Impact over time of legislative efforts targeting various aspects of tobacco manufacture and consumption.

Design Manufacturing

Sale Efficacy Purchase Advertisement

Consumption

Time

to reduce the astronomical economic children and adolescents who are alive costs associated with lost productivity today (WHO, 1999b April). Targeting and health care costs. WHO estimates young people with tobacco use preven- that effective tobacco prevention efforts tion programs can prevent the life-long cost around US$ 20–US$ 40 per year dependence on nicotine that is associat- of life gained in a developing country ed with a myriad of diseases and even- setting (1999 April). But this cost is tual premature death. minuscule in comparison to the esti- In order to incorporate elements mated US$ 18,000 per year required to that will help target prevention pro- treat a lung cancer victim. grams, it is necessary to examine the Experts around the globe agree that huge body of evidence describing such effectively reducing death and disabili- programs. Behavioral scientists Dusen- ty caused by tobacco use requires strate- bury and Falco (1995) did this in their gies that integrate prevention efforts review of youth-focused, drug preven- such as policy advocacy, health promotion and public awareness campaigns, with cessation programs for both adults The most effective strategies for reducing death and adolescents. Regarding tobacco dependence, sec- and disability from tobacco couple prevention ondary prevention often addresses the efforts with smoking cessation programs. early detection and primary care of tobacco dependents, including education programs implemented between tional and behavioral approaches to 1989 to 1994. They also surveyed a quitting smoking. Tertiary prevention, group of fifteen experts in the field. on the other hand, aims to treat and Their investigation identified the fol- rehabilitate individuals suffering more lowing as essential features of effective advanced tobacco-related disease, such prevention programs: as emphysema, cardiovascular disease, • methods are based on behavioral lung and larynx cancer. theory (social learning theory); Targeted, primary prevention efforts • information is concrete and are essential to preventing the suffering present-oriented; as well as the predicted premature tobacco-related death of 250 million • programs are school-based;

TAKING ACTION PUBLIC INFORMATION EFFORTS Policies that ensure that smokers and potential smokers are told the truth about tobacco must be developed and implemented. This entails three key steps: 1. Protecting children. Children are incapable of making fully informed decisions about tobacco use and should be protected from becoming dependent on tobacco. Messages that state that “smoking is for adults” may be one of the most effective incen- tives for children to start smoking; it is probably no coincidence that tobacco companies endorse such campaigns. In order to put a dent on tobacco sales to children, there must be consistent messages that restrict when, where, how, and to whom tobacco products may be sold. 2. Providing detailed information to the public. Fully informed decisions require more detailed knowledge of the diseases caused by tobacco use, the increased risk of such outcomes, and the prognosis. The public also should know the benefits and methods of cessation, as well as where and how to access cessation assistance. 3. Protecting the public from misinformation. Tobacco industry efforts resulting in consumer deception must be prevented; past deceptive practices must be acknowledged and corrected.

PAHO, 1999.

• normative education and interac- (IUAC, 1990). A successful conceptual tive teaching are employed; framework incorporates as many social • teachers are adequately trained; channels of influence as possible. • programs offer at least 10 sessions, plus follow up or booster sessions SCHOOL-BASED in subsequent years; • programs are culturally appropri- PROGRAMS ate (i.e., attuned to the target pop- Since almost 90% of smokers begin ulation’s culture); and using tobacco before the age of 18, and • programs are evaluated for effec- youth begin trying cigarettes on average tiveness. at around 13 years of age, tobacco use prevention efforts logically have the It also is important to examine effec- greatest impact when focused on chil- tive programs implemented in specific dren and young people. Indeed, the locales or cultural settings. A fundamen- majority of such prevention programs tal strategy for better targeting preven- are directed toward school-age chil- tion programs is to carefully design pri- dren, making schools an ideal setting mary prevention programs so that they for the application of these programs. meet the unique needs of young people Of the six billion inhabitants of the living in specific settings. Prevention world, one billion are registered in programs that effectively influence pos- schools. In developing countries, 80% itive change in young people’s behavior of young people are enrolled in schools, (regarding the decision to smoke, for and of these, 60% complete at least four instance) must address not only individ- years of schooling (WHO, 1998b). The ual factors but also the societal context school is a place of special importance of the behavior targeted for change for the implementation of prevention

TOBACCO-FREE YOUTH Conceptual Framework

Family Knowledge Peers Self Attitudes Behavior School Beliefs Media

Intervention opportunites

campaigns, since many, many youth at the first years of primary school. Other a critical stage in their development can programs have targeted fifth, sixth or be reached. It is important to keep in seventh graders—that is, students who mind, however, that the young people have already reached a level of intellec- most at risk for substance use may no tual maturity sufficient to assimilate longer be attending school and may critical knowledge. In addition, chil- have dropped out of the formal educa- dren at these higher-grade levels are tional and social service system alto- nearer the ages identified as “at risk” for gether. Prevention programs targeting experimenting with substances. out-of-school youth through non-for- The Region of the Americas boasts mal venues also should be explored. one of the highest school enrollment In addition to reaching most chil- rates in the world, providing an exten- dren and adolescents, schools present sive infrastructure for health promotion effective channels for reaching other and prevention programs (World segments of the population (i.e., school Bank/PAHO, 1999 February). In personnel, families, and community developing countries in the Region, members). As a result, the formal edu- there are five times as many teachers as cational system can be an important health workers, and these teachers, for vehicle for the dissemination of public the most part, have regular and long- health information. term contact with students. Also, Although a consensus exists that teachers have identified tobacco, alco- schools are an ideal place to carry out hol, and other drug use as major barri- substance use prevention efforts, ers to learning. This may facilitate the experts do not always agree on the best acceptance on the part of school dis- grade level for initiating such a cam- tricts to utilize class time for substance paign. Some programs have focused on use prevention curricula.

CARRYING OUT PREVENTION CAMPAIGNS IN SCHOOLS CAN:

• Reduce program costs by using existing infrastructure; • Expedite short and long term evaluation; • Facilitate counseling and experimentation; • Utilize experienced and capable teachers; • Improve credibility with parents and links to community; and • Lead to healthier, more productive adulthood

Botvin & Tortu, 1988; WHO, 1998b; World Bank/PAHO, 1999 Feb.

TAKING ACTION The U.S. National Cancer Institute has designated the following elements as essential to school-based prevention programs: • Sessions should be held at least five times each year between the 6th and 8th grades. • Emphasis should be placed on social factors associated with smoking initiation, short-term consequences of smoking, and refusal skills. • Program should be integrated with the school curriculum. • Program should be introduced during the transition between primary and secondary schools (around the seventh grade). • Students should participate interactively in the program. • Parental involvement should be promoted. • Teachers should be appropriately trained. • Program should be adapted to the culture of the target population.

CDC, February 1994.

In a recent analysis of school-based school-based substance use prevention health interventions (World Bank/ programs have been grouped into four PAHO, 1999 July), preliminary find- general categories (Botvin, 1979). ings indicate an increased collaboration In the 1960s, prevention strategies between the health and education sec- were based on the empirical-rational tors in developing countries across the theory that increasing the knowledge of Region, particularly in Colombia, the negative consequences of selected Ecuador, and El Salvador. These find- behaviors (e.g., substance use) will ings imply that area governments view result in the rational decision to avoid school-based prevention programs as the behavior. These strategies assumed increasingly important. A stronger link that adolescent smokers must be unin- between sectors has resulted in an formed of the adverse effects of smok- expansion of school-based prevention ing. Prevention programs sought to programming targeting substance use, improve the students’ level of knowl- school violence, accidents, and sexually edge through books, videotapes, pam- transmitted diseases. This analysis also phlets, and posters. However, evalua- suggests that there is both a real and a tion of these programs demonstrated perceived need for more skills-based (as that they were not effective at lowering opposed to disease-specific) school smoking rates (Thompson and Good- health projects, with particular assis- stadt, 1978). Although focused, updat- tance needed for teacher training and ed information on the effects of sub- program development. stance use is fundamental to substance School-based prevention programs use prevention, programs that only Teachers have identified the use can be universal, aiming to reach the offer information are not sufficient. of tobacco, along with alcohol and general population of students, regard- Furthermore, there is reason to believe other drug abuse, as a major bar- less of their background risk; selective, that such an approach may just pique rier to learning. This should facili- targeting adolescents that have predic- the curiosity of young risk-takers, tate the acceptance of smoking tors for high risk behaviors; or indicated, resulting in increased experimentation prevention curricula by school targeting youth that show early signs of with substances (Kaminer). districts. high-risk behavior involvement (Insti- Another popular approach used dur- tute of Medicine, 1994). Historically, ing the 1960s and early 1970s involved

24 24TOBACCO-FREE YOUTH affective education, which focused on debunks the myth that most people increasing self-understanding and smoke by giving adequate data and acceptance through activities such as promoting student’s participation in values clarifications and responsible prevention programs. Many of these decision making; improving interper- prevention programs based on the sonal relations by fostering effective social influence model include the use communication, peer counseling and of peer leaders who have a higher cred- assertiveness; and increasing students’ ibility among young people. abilities to fulfill their basic needs Finally, the competence enhance- through existing social institutions. ment approach teaches general personal Evaluations of these strategies have not and social skills in combination with shown an impact on behavior. selected components of the social influ- Starting in the 1970s, prevention ence model. The most extensively used programs began to utilize the bulk of research competence enhancement evidence from the social literature that approach to drug abuse is the “Life skills recognized that social factors played a training program” (Botvin). The theo- major role in the initiation of substance retical foundation for this approach is use. The use of “psychological inocula- based on the social learning theory (Ban- tion” was intended to make students dura, 1977) and the problem behavior aware of the various social pressures theory (Jessor and Jessor, 1977), which they would encounter that encouraged proposes that the social environment The Region of the Americas them to smoke, so they would be psy- and intrapersonal factors affect the sus- boasts one of the highest school chologically prepared (inoculated) to ceptibility to use substances. enrollment rates in the world, resist these influences (Evans, 1976). At The social influence approach is which translates into an exten- the same time, the emphasis on teach- designed to impart information and sive infrastructure for carrying ing “drug resistance skills” or “drug teach norms and refusal skills with a out health promotion and preven- refusal skills” increased. Students were problem-specific focus. Competence tion programs. taught how to recognize, avoid or enhancement approaches such as “life respond to high risk situations in the skills training” emphasize the applica- most effective way and also how to rec- tion of general skills to situations ognize the pressure to use substances directly related to substance use, such as coming from the media. This approach the application of general assertive skills views the teaching of basic and general to situations involving peer pressure. life skills as a holistic way to promote Research concerning the etiology of youth development. The social devel- drug abuse and adolescent development opment adherents promote involve- indicates that a critical time for experiment in cooperative learning during mentation with tobacco, alcohol, and elementary school to avoid resorting to illicit drugs occurs at the beginning of aggressive or other problem behaviors adolescence. For this reason, most drug with impressive results. This group has abuse prevention programs are imple- identified a set of risk factors for prob- mented among seventh graders. How- lems (such as substance use, delinquen- ever, there is a general agreement that at cy, teenage pregnancy, and school fail- least some risk factors may have their ure), as well as a set of protective factors roots in early childhood, arguing for (such as bonding to prosocial family, beginning interventions at a younger school, and peers and clear standards or age. Programs aimed at aggressive/ norms for behavior) that reduce one’s disruptive classroom behavior and poor risk for later problems by buffering the academic achievement among first and effects of exposure to risk factors second graders have shown to be effec- (Hawkins, Catalano, 1999). Another tive in reducing the incidence of smok- component of the social influence ing initiation among male students approach to substance use prevention (Kellam and Anthony, 1998).

25 TAKING ACTION 25 Life Skills

As do earlier prevention programs, to practice new skills acquired during “Life Skills” programs in operation instruction. Program activities actively today also are based on the social involve young people through work in learning theory. This theory promotes small groups, peer facilitation, role- opportunities for processing life expe- playing techniques, games, presenta- riences, structuring experiences, and tions, and other interactive events. actively gaining experiences (Bandura, Aside from the actual benefits of the 1977 [as cited in Botvin, 1986]). newly acquired Life Skills, this curricu- The Life Skills approach is built la also result in improved student/ around creating opportunities for teacher relations, better academic per- youth to acquire skills—such as media formance, higher school attendance literacy or critical thinking—that rates, and fewer behavioral problems in enable them to avoid manipulation by the classroom (WHO, 1998 April). outside influences. Most importantly for the purposes of The idea is for young people to be this discussion, the Life Skills able to recognize the coercive forces of approach, as used in the prevention of social pressures, as well as organized substance use, has been shown to campaigns, such as tobacco advertis- reduce smoking initiation by between ing, that promote behaviors known to 25% and 87% at one- to six-year fol- jeopardize their health. The Life Skills low ups (Botvin, Renick, and Baker, approach aims to assist young people 1983; Botvin and Eng, 1982; Botvin, to regain control over their behavior G., Baker, Dusenbury, Botvin, E. and while taking informed decisions that Diaz, 1995). can lead to positive behaviors and values (e.g., deciding not to smoke). Additional Life Skills generally taught LIFE SKILLS TRAINING by such programs include self-awareness, stress management, assertiveness, Beginning in 1979, noted behavioral and negotiation. scientist and professor of psychiatry, Curricula based on this theory stress Dr. Gilbert Botvin, published a highly experiential learning and opportunities effective Life Skills training program

UNICEF (1997) recognizes several levels of Life Skills: • Basic psychological and social skills (strongly shaped by cultural and social values); • Situation-specific skills (e.g. negotiation, assertiveness, conflict resolution); • Applied life skills (e.g., challenging gender roles or refusing drugs).

29 for youth in the seventh through ninth process through a variety of experiential grades. The training employs strategies techniques such as discussion groups that build students’ abilities to refuse and presentations to peers. the offer of drugs through improved Botvin’s Life Skills Training has been assertiveness, decision making, and implemented in different school set- critical thinking skills. Opportunities tings, including urban schools serving a to learn and practice these “problem- predominantly Hispanic population in specific” skills are just one aspect of a New York City. The intervention has broader instructional program that been adapted to target various popula- teaches more general Life Skills. tions ranging from public school students to high-risk youth incarcerated in juvenile detention centers. The program has also experimented with dif- Studies show that teaching and learning these skills ferent program facilitators (teachers, as a generic group of “life skills” is more effective in older students, and “investigators”) the prevention of harmful behavior than teaching showing impressive results at each location and with each type of facilitator, the skills as isolated solutions to specific problems particularly with peer facilitators such as teen pregnancy or substance abuse. (Botvin, et al., 1995).

Botvin’s intention in developing this program was to create a single prevention strategy that could effec- THE WHO LIFE SKILLS tively target multiple types of sub- INITIATIVE stance use behaviors (Botvin, G., Baker, Renick, Filazolla, and Botvin, The World Health Organization pro- E., 1984). His conceptual framework motes Life Skills school-based pro- is based in part on Jessor’s problem grams as a means to develop skills behavior model (1977, [as cited in among young people that lead to Botvin, et al., 1984]), which recognizes healthy lifestyle choices and optimum that an interaction of social and per- physical, social, and psychological well- sonal factors facilitates the use of a being. Depending on the culture, dif- variety of substances, including tobac- ferent specific abilities are emphasized. co. Botvin conceptualized smoking as a WHO considers the following Life socially learned behavior that results Skills to be the most essential from the highly complex interaction (WHO,1993): of social and personal factors (Botvin, The ability to make decisions helps et al.,1984). students assess their options and care- Through interactive modules, his fully consider the different conse- program offers students opportunities quences that can result from their to ‘socially learn’ skills to resist peer and choices. media pressure to use substances like tobacco. Skills learned in the program The ability to solve problems helps include: assertiveness, critical thinking, students find constructive solutions to decision making, and problem solving their problems. This skill can signifi- abilities. These skills boost protective cantly reduce anxiety. factors in students, such as self-confi- The capacity to think creatively is dence, self-esteem, autonomy, and self- essential to decision making and control (Botvin, et al., 1995). problem solving. It enables students Program materials include a teacher’s to explore all possible alternatives manual, a student guide, and a relax- together with their consequences. It ation audiocassette tape. The students helps students look beyond their per- are actively involved in the educational sonal experience.

TOBACCO-FREE YOUTH The capacity to think critically LIFE SKILLS PROGRAMS helps students objectively analyze IN LATIN AMERICA available information along with their own experiences. It is this ability that AND THE CARIBBEAN helps students recognize the factors that influence their behavior, such as Life Skills school-based programs have societal values, peer influence, and been implemented in several countries influence of the mass media. in the Region, including Chile, Colom- bia, Mexico, Peru, Venezuela, Uruguay, The ability to communicate effec- Brazil, Costa Rica, and the Caribbean tively helps students to express their countries (World Bank / PAHO, 1999 feelings, needs, and ideas to others— February). verbally or otherwise. In the Caribbean, the Caribbean The ability to establish and main- Community (CARICOM) operates a tain interpersonal relations helps Health and Family Life Education proj- students to interact positively with ect responsible for introducing Life people whom they encounter daily, Skills curricula in all preschool, pri- especially family members. mary, and secondary schools in partici- Knowledge of self is the capacity of pating Caribbean countries (UNICEF, students to know who they are, what 1997). The Life Skills curricula address they want and do not want, and multiple health issues (WHO, in press). what does and does not please them. The CARICOM project is made up of It also helps students recognize stress- partners representing UN agencies, the ful situations. University of the West Indies, and ministries of education and of health. The capacity to feel empathy is the ability to imagine what life is like for another person in a very different situation. It helps students to under- “Life Skills” programs not only help prevent smok- stand and accept diversity, and it ing among adolescents, they have the added value improves interpersonal relations of improving student-teacher relations, academic between diverse individuals. performance, and school attendance rates. The ability to handle emotions enables students to recognize their emotions and how they influence In 1996 in Costa Rica, the Latin their behavior. It is especially impor- American Network of Health Promot- tant to learn how to handle difficult ing Schools adopted Life Skills Educa- emotions such as violence and anger, tion as one of its priorities for improv- which can negatively influence health. ing health education in the school The ability to handle tension and curriculum reforms. A workshop on stress is a simple recognition by stu- life skills education conducted at the dents of the things in life causing time produced excellent feedback. In them stress. 1998 in Mexico, the Latin American Network of Health Promoting Schools With the Global School Health Initia- reinforced the commitment made tive and the Health-Promoting Schools two years before and another workshop campaign, WHO has supported Life was offered to participants. Materials Skills activities through workshops, the for the workshop included a translation development of materials, and the con- of the WHO documents on Life Skills. sultation with governmental and non- The Ministries of Health and of governmental agencies interested in this Education of Colombia, with support approach to youth health and develop- from PAHO/WHO and other agencies, ment (WHO, 1995 and 1998b). also developed a school-based Life Skills

LIFE SKILLS program in response to high rates of bian cities, with participants totaling mortality and morbidity associated with around 15,000 students (WHO, 1998; homicide and violence. The Colombian World Bank / PAHO, 1999 February). Life Skills program includes instruc- In situations such as these, where tional materials and activities designed the Life Skills methodology is already for grades four through nine (Bravo, being used and the infrastructure is Galvez, and Martinez, 1998). To date, adequate to support an expansion the Life Skills program serves some of the program, tobacco or substance eighty-five health-promoting schools in use prevention could be easily incorpo- very poor urban areas in twenty Colom- rated into the Life Skills program.

Through “Life Skills” interactive training, students learn assertiveness, critical thinking, decision making, and problem solving. These skills, in turn, boost their self-confidence, self-esteem, self- control, and autonomy.

TOBACCO-FREE YOUTH Adopting the Life Skills Approach

If the Life Skills approach is to be Political support also can be gener- incorporated into prevention efforts ated by connecting the school-based that are part of a national education or Life Skills program with a broader health curriculum, there must be suffi- campaign or national priority, such as a cient political will to support the initia- national tobacco control campaign or a tive at the country level. Public health citywide, youth development initiative. professionals, educators, and social Integration into existing initiatives, service providers are in a unique posi- along with the support of intersectoral tion to make the case for adopting this partnerships, can help ensure a broader important intervention. community of participants, increased public attention, and sustainability of the program. When looking for appro- MOBILIZING SUPPORT priate campaigns with which to part- ner, moving beyond the health and In order to win a place for the Life education sectors—that is, the tradi- Skills intervention in school curricula, tional advocates of substance use pre- decision makers must appreciate the vention—and linking up with other methodology’s capability to promote social welfare and children’s rights ini- students’ psychosocial development tiatives can help ensure a broader base and improved overall well-being. Policy of support for the Life Skills initiative. makers must understand that by using The health sector can certainly play the Life Skills approach one can simul- an important role in advocating the taneously address a variety of issues adoption of the life skills methodology. threatening the health and well-being of youth (e.g., conflict, violence, smoking, depression). This approach also can prevent substance use by passing LIFE SKILLS PROGRAM on to students skills for conflict resolu- PLANNING tion, stress management, decision making, and drug refusal skills. In generat- The long-term success of prevention ing the political commitment needed programs can benefit from a participa- to spur the adoption of the Life Skills tory approach that ensures the active methodology, the connection between involvement of as many stakeholders as these skills and improved health, matu- possible. Stakeholders are persons or rity, and emotional intelligence must organizations that could benefit from be made clear. The cost-effectiveness program involvement or successful pro- and economic benefits of the approach gram outcomes. Stakeholders of a Life also must be argued. Skills school-based substance use pre-

33 vention program may include youth, The needs assessment is a useful tool parents, teachers, administrators, and for identifying the gaps that exist in health and social service practitioners. services and resources, as well as the Participating stakeholders in the possible barriers to meeting needs. In planning process should provide input addition, this assessment can provide into the definition of the problem (par- policy makers with country-specific ticularly regarding “perceived needs”) evidence needed to facilitate policy and feedback on planned activities. In changes and commitment of resources. addition, the active participation of Upon describing the magnitude of teachers and other practitioners can the problem (e.g., increased tobacco inform the efforts of planners regarding use by teens) the program hypothesis the design of appropriate training activ- can be created (i.e., “If teens have the ities. Early and active participation by skills to resist social influence to smoke, stakeholders not only increases their then smoking prevalence among this connection to the project, ensuring a group will decrease”). Next, the needs higher level of support and involve- assessment process should determine ment, but it also makes program ele- the target audience and catchment area ments more realistic and relevant to that the program will serve. participants’ life experiences. The target audience and catchment area should be rendered as precisely as possible. In order to target the interven- Completing a Needs tion toward reducing risk among the Assessment most susceptible individuals, planners must examine the patterns of individual The first step in designing a prevention characteristics or social conditions program is to determine as precisely as inferring the greatest risk on youth. possible the extent of the problem. This Possible characteristics of the target assessment of the problem, often audience and catchment area include: referred to as a needs assessment or situa- • age group—for instance, preteens tion analysis, is meant to describe in demographic terms precisely what the or older adolescents; problem is, who is affected, and why. • gender; Even though data in the Region are • socioeconomic status—education scarce, it is important that program level, social class, economic factors; planners review all available secondary data, including research and program- • ethnicity—language and cultural matic literature, that can help describe context; the nature of the tobacco problem. In addition, it may be necessary to collect primary data. This body of information Data sources for assessing can provide a baseline from which to and evaluating activities; measure trends in tobacco use and • surveys or questionnaires, related beliefs or attitudes. • interviews, This diagnosis ideally should • observation, include a description of all the resources needed to solve the problem, • focus groups or community for example, financial resources, forums, human resources (e.g., client partici- • medical and program litera- pants and staff), and material resources ture, (e.g., facilities, materials, equipment, • vital statistics, and supplies). The analysis should con- • clinical and school records, sider country-specific methods for dis- and seminating new ideas, behaviors, and • physical examinations. trends (IUAC, 1990).

TOBACCO-FREE YOUTH • special population groups—e.g., pregnant teens or homeless youth; • geographic area—urban, rural, dis- advantaged areas; and • locale—public schools, private schools, schools serving high-risk populations This analysis not only should define who in the catchment area is most at risk, but it also should reveal which risk elements experienced by these youth are modifiable. During recent years, knowledge of the etiology of substance abuse—including tobacco use—has demonstrated that there is no single factor that determines consumption; clearly, tobacco use depends on multiple factors. This makes the design of such prevention programs more complex, since they must address several modifiable risk factors at the same time. The interplay of protective factors must also be carefully assessed.

Setting Goals and Objectives

The next step in the planning process is the formulation of program goals and objectives. Program goals describe in general terms what outcomes are expected from program activities. The goals provide program direction. Pro- To be truly successful, a “Life gram objectives, on the other hand, Skills” program must clearly describe in specific, measurable terms elements that characterize well-written establish its target audience, what the program hopes to achieve. objectives. The first is clarity: any jar- including determining character- The objectives guide the project and gon or confusing terminology should istics such as age, gender, socio- provide indicators and time frames that be eliminated; the easier the objective is economic status, and ethnicity. are useful for determining progress to understand, the more likely it is to towards achieving program goals. be used by program staff. Objectives Careful attention to the develop- also should also be measurable, specify- ment of program objectives will help ing what results are expected and how ensure the success of the Life Skills they will be measured (e.g., post-test, intervention. Objectives are critical observation, or questionnaire). In addi- tools that program monitors (at nation- tion, objectives should be time-limited, al and regional levels) as well as project with specific target dates set for achiev- facilitators (teachers and counselors at ing and measuring results. They should the classroom level) will use to measure also clearly assign responsibility both for progress. achieving and measuring the targeted According to some health planners action. Finally, it is important that (Kettner, et al, 1990), there are several objectives be realistic.

ADOPTING THE LIFE SKILLS APPROACH Since the Botvin Life Skills Training project has been widely evaluated with impressive results, this framework can serve as an excellent model for program planners. The design of the program incorporates the following principal goals: • to promote students’ abilities to resist social pressure to smoke; • to diminish students’ susceptibility to indirect pressure from society to use tobacco and other drugs by creating a greater sense of self-esteem, “self-mastery,” and self-confidence ; • to help students control anxiety produced by certain social situations; • to increase knowledge of the immediate consequences of tobacco and alcohol use; and • to promote the development of negative attitudes and beliefs regarding tobacco and alcohol use.

Botvin, 1979.

Defining program scope, se- adapted such programs (WHO, quence, and duration involves decid- 1997b). WHO recommends carefully ing when to initiate the program (i.e., weighing the costs and time associated at what grade level), what general top- with adapting programs versus devel- ics will be addressed, how to sequence oping programs, keeping in mind program sessions (e.g., when to sched- how much each offers toward obtain- ule booster sessions), and how long the ing a culturally and linguistically intervention will run. (See Appendix B appropriate intervention. for evaluating results of various formats used in Botvin’s Life Skills Training.) It is important to take into consider- Creating Program ation how the prevention program fits Strategies into the larger existing school curricula. The better the integration of the pro- Whether designing or adapting program into current curriculum initia- gram strategies, the most fundamental characteristic of Life Skills activities is interaction. Examples of instructional activities that are interactive include “Life Skills” program objectives should set specific role playing, debate, dramatization, target dates for achieving measurable results. paired and small group instruction, and cooperative learning activities (e.g., team projects). tives, the more likely the intervention Life Skills are taught using an inter- will be supported and sustained over active, problem-solving approach that the long-term. arranges activities as a series of steps. At this stage in the process, a deci- First, the students identify the prob- sion should be made regarding whether lem, then they brainstorm all possible to design a Life Skills program or to solutions. They then examine the adapt an existing one. For program- advantages and disadvantages of each mers who choose to adapt an existing solution, and the best solution is agreed program, WHO has published several upon. Students next devise plans for resource materials that include samples carrying out selected solutions. Based of Life Skills programs and case studies on these fundamental problem-solving of countries that have developed or and negotiating skills, more specific

TOBACCO-FREE YOUTH abilities can be developed, such as the The training of Life Skills facilita- ability to manage peer pressure or tors should follow the experiential media influence. methods that have been found to be so critical to the success of these prevention programs. The training program Designing Training should offer sufficient assistance to pro- Modules gram facilitators to acquire the necessary expertise in methods they may per- Effective training is critical to the full ceive as unconventional or opposed to implementation of the intervention. their traditional methods. Experiential The Life Skills program should address or participatory training validates the technical assistance needs and resources trainees’ expertise and insight, and cre- in terms of program orientation, initial ates ample opportunities to share infor- training in Life Skills, ongoing support mation and practice new skills. Oppor- and motivation, and program evalua- tunities to practice program activities tion. Whether the instructor chosen for can serve as both a skill-building and this intervention is a classroom teacher, confidence-building tool. school counselor, or peer facilitator, Training modules should include opportunities should be created for activities that provide trainees with an program facilitators to interact with understanding of the theoretical and student leaders during the training and conceptual framework underlying Life orientation phases (IUAC, 1990). Skills; such an understanding is needed In the training assessment, plans to increase facilitators’ commitment to should carefully note the traditional the program. Eventual mastery of pro- teaching styles and methods used in gram methods and belief in program regional and local settings. In some principles by facilitators will prove countries in the Region where didactic crucial to full implementation of the methods or learning “by rote” or mem- intervention. orization is the preferred approach to In addition to building facilitators’ instruction, the interactive, seemingly expertise in the instructional methods non-formal methods that characterize and theory behind Life Skills, most Life Skills instruction may be complete- facilitators will likely need additional ly new to teachers and counselors. In training on the facts and issues related this case, such innovative methods may to substance use among young people. appear to threaten the status quo, and To serve as a resource for their students, programmers must plan accordingly. they must exhibit a good grasp of the

Elements of the facilitator training program may include: • rationale for implementing Life Skills in schools; • allocation of decision making authority and resources to a training coordinator responsible for planning, managing, and coordinating training activities; • development of a trainers-of–trainers group to conduct initial training; • regularly scheduled follow-up or in-service training to address facilitators’ concerns and provide updates on tobacco use and progress toward reaching program goals; and • evaluation of training activities to assess both skill and confidence levels of participants.

Adapted from WHO, 1998 June.

ADOPTING THE LIFE SKILLS APPROACH facts. Training in this area will also can facilitate material design in a more increase their confidence with students cost-effective manner, such as: and their commitment to reducing • Enlist the support of universities or substance use. research institutions that are look- Particular attention also should be ing for training and publication given to developing the program capac- opportunities for their graduate ity needed to carry out intervention students or research associates. • Adapt materials that have already been tested with groups as similar as possible to the target audience. Although the amount and variety of training materials will differ according to local needs and resources, many Life Skills substance use prevention programs have found the following types of materials necessary: • training guides, including materials for simulation exercises ; • instructor’s manual, including background information, suggested strategies, and discussion guides for each session; • student workbooks;

“Life Skills” activities rely on inter- • visual aids (e.g., videos, posters, action—role playing, debates, dra- evaluation activities. Planners should and cassette tapes); and matizations, and paired and small- explore a wide range of options for • evaluation materials (e.g., surveys, group instruction. Facilitators for addressing this type of capacity build- interview guides, checklists). these activities can be teachers, ing. For instance, it may be that a core Some of Colombia’s experience school counselors, or peers. staff of trained evaluators already exists working with parents has shown that at the national level, whether working there might be a need to develop work- through the ministries of health and of books for parents (Bravo, Gálvez and education or attached to universities or Martínez 1998). There also has also non-governmental organizations. If the been some experience working with decision is made to train local facilita- peer facilitators, and training guides for tors to conduct evaluation activities, young people may also be needed. special care should be taken to stream- Program developers may also choose line and simplify the activities so that to develop or adapt promotional mate- facilitators do not feel overburdened by rials that schools and regional officials these additional demands. can use to advise the media and larger community of their Life Skills sub- Developing Materials stance use prevention efforts. This effort would educate the public, enlist The development of program materials its support for program activities, and can often become a resource-intensive publicize progress toward reducing aspect of program design, due to the tobacco use. amount of time, money, and technical Before moving from the planning to expertise required to produce high the implementation stage, program quality, effective products. Program- developers should outline the responsi- mers should explore alternatives that bilities of stakeholders, staff, and part-

38 38TOBACCO-FREE YOUTH nering institutions so that accountabili- • intention to smoke, and ty is clearly communicated. Reaching • quit rates. consensus on the assignment of respon- Other “soft” indicators describe stu- sibilities is particularly critical to the dents’ level of knowledge regarding the success of large, national programs that negative effects of smoking, the percep- involve players from a range of sectors tion of social acceptance of tobacco and organizations. use—or norms—and the awareness of tobacco advertising and promotion EVALUATION OF LIFE (i.e., media literacy). In addition, the SKILLS PROGRAMS evaluation should include an open- ended segment where other, perhaps Life Skills interventions for substance unexpected, indicators of success can use prevention should be evaluated to be described, such as parental and com- ensure their effectiveness, optimal oper- munity involvement, media reaction, ation, and overall impact of the pro- changes in participants’ self-esteem or gram. Evaluation objectives should be confidence, anti-tobacco or peer educa- quantifiable, clear, and explicit, and tion materials produced by students, they should incorporate baseline data and initiation of spin-off programs in describing both the target population the larger community. and the parameters of the problem It also is important to include demo- identified during the program plan- graphic information in the assessment ning. The purpose of the evaluation is tools used. This type of data is needed to measure program operation and out- to identify whether the intervention is comes in relation to stated objectives. equally effective among all types of par- Evaluation should begin at the start ticipants (DHHS, 1993). of program implementation by piloting The ideal evaluation instrument the newly adopted materials. This incorporates an experimental design makes it possible to determine how the comparing case and control groups. program is functioning and which ele- Data describing both groups is collect- ments are working the best. This type ed via a pre-tested survey to assess and of evaluation, often called process or compare the prevalence of smoking, formative evaluation, should be repeat- age of onset, and knowledge, attitudes ed periodically to determine the extent to which planned activities are being carried out. It provides an opportunity to “fine tune” program operations and Prevention programs that do not incorporate evalu- activities. It also assesses the acceptance ation or that do not act on evaluation findings can of the program by both instructors and operate inefficiently or ineffectively, target the students, and it can gauge their level of participation in planned activities. wrong group, relay confusing messages, or waste Outcome evaluation, another type of scarce resources. program evaluation, measures program outcomes. Outcome evaluation can and practices associated with tobacco also include an assessment of the over- use. However, using controls may not all impact of the intervention. be feasible and could raise ethical ques- Indicators related to substance use tions about unequal access to services. that could be assessed pre- and post- There also are limitations to a survey intervention include: design (e.g., impossible to ensure the • use of tobacco, accuracy of the information self-reported; difficult to control completeness of • age of onset, answers), and the high level of expertise • cotinine (a metabolite of nicotine) needed to design such an instrument or carbon monoxide levels, might be prohibitive. However, existing

39 ADOPTING THE LIFE SKILLS APPROACH 39 pre-tested tools are certainly available assess the accuracy, cost, and time asso- for adaptation and their use should ciated with each option in order to be encouraged. choose the best evaluation method. Primary data also can be collected Planners should consider using existing through interviews, observations, or and available validated instruments or physical examinations, such as measur- partnering with research institutions ing the cotinine levels of student or organizations skilled in evaluation participants. Program planners must methods.

Program evaluations typically involve the following steps: 1. posing questions about the project and determining outcomes to measure; 2. developing conceptual framework or “logic model;” 3. setting standards (or indicators) of effectiveness; 4. determining level of measurement and type of evaluation needed; 5. selecting or designing evaluation instruments; 6. selecting participants and piloting test instrument and batteries; 7. revising instruments; 8. collecting and analyzing data.

Fink, 1993; DHHS, 1993.

40 40 TOBACCO-FREE YOUTH “Trazando el Camino”: The Costa Rican Experience

The experience of “Trazando el erature on various prevention pro- Camino” in Costa Rica provides an grams, and they identified those that excellent example of a school-based, had been evaluated as having the best culturally appropriate Life Skills pro- results. The Life Skills training gram working to prevent the use of approach set up by Botvin and his col- alcohol and tobacco by young people. leagues in New York was chosen as a model, since it demonstrated excellent BACKGROUND results in both the short- and long- term. Also, some schools had previous- ly received some training in the Life Population-wide surveys conducted in Skills approach, as promoted by Costa Rica in the mid-1990s detected WHO. None, however, had addressed that drug consumption was one of the tobacco use prevention specifically problems deemed most serious by the through the Life Skills curricula. population. In 1995, the Institute on Staff from the three partnering insti- Alcoholism and Drug Dependency tutions supervised the development of (IAFA) examined substance use among “Trazando el camino,” a proposal for the in-school adolescent population the implementation of a national sub- and detected that in the previous year stance use prevention program based 51% of the students had consumed on the teaching of Life Skills. The cur- alcohol, 15% had smoked, and fewer riculum was adapted from Botvin’s than 1% had consumed illegal sub- training manual and includes most stances. While present consumption program components. Every attempt was lowest in the seventh grade, the age was made to reflect Costa Rica’s reality. of substance use initiation averaged The “Trazando el camino” preven- around 13 years old (Madrigal, Sandi tion program includes five major com- and Avila, 1998). ponents: Since adolescent programming had already been targeted as a priority by 1. a cognitive component designed to the Government’s National Center on provide information concerning Drug Abuse (CENADRO), the Min- the short-term consequences of istry of Education and IAFA joined smoking, prevalence rates, the cur- CENADRO to develop a solution to rent social acceptability of smok- the substance use problem. They starting, and the addictive nature of ed by reviewing the programmatic lit- regular smoking;

41 2. a decision making component PLANNING AND designed to facilitate critical think- IMPLEMENTATION ing and independent decision making; PROCESS 3. a stress management component Planners chose to target seventh grade that helps students develop skills students in both public and private for coping effectively with anxiety schools with their national initiative. and peer pressure; However, materials are being developed 4. a communication component de- for the expansion of the program to signed to teach social and assertive- reach students in the eighth and ninth ness skills, including specific tech- grades as well. niques for resisting interpersonal The project’s first phase involved 1) influences to smoke; and reaching consensus on criteria for developing the program, 2) preparing 5. a self-directed behavior change materials (video and audio cassettes, component designated to facilitate student workbook, teacher’s guide, and self-improvement, self-esteem and flip charts; see Appendix A for further a sense of personal control. description of materials), and 3) plan- The initiative also promotes the pro- ning the program evaluation. vision of smoking cessation activities in The second phase consisted of pilot- the schools. This component was ing the program and methodology at added to address the needs of adoles- thirteen public and private schools. cents who already are addicted smok- Specialists from IAFA, CENADRO, ers. It has been demonstrated that stop- and the Ministry of Education assisted ping smoking substantially reduces the with monitoring the pilot programs risk of tobacco related diseases and can and finalizing the curriculum. prevent a great many premature deaths. During the third phase, teacher training was planned and implemented at the national level. The training was done in tiers: first, the IAFA, CENADRO, and “Trazando el Camino” aims to equip students with the Ministry of Education performed an refusal skills, so that substance use is prevented, orientation for the technical advisers and the age of substance use initiation is delayed, and regional supervisors. The regional supervisors then led the training and orienta- the number of youth using substances like tion of instructors at the school level. tobacco is decreased. During this stage, national program staff also conducted a randomized base- Moreover, studies have shown that line survey across the country. A sample without assistance, less than 3% of of 2,600 students completed an exten- individuals who want to stop smoking sive survey incorporating questions on actually achieve and maintain smoking family, social environment, and person- cessation (Hughes, Gulliver, Fenwick, al characteristics to measure students’ et al., 1992). knowledge, beliefs, attitudes, and The initiative, which is based on behaviors related to smoking. The sur- existing policy regarding smoking-free vey results were used to provide both schools, also recognizes the need for baseline measurements and informa- schools to be maintained as smoke-free tion for refining program objectives. environments. Respecting non-smok- The fourth phase marked the imple- ing rules on school campuses works to mentation of the program throughout lower the social acceptability of smok- the country, which began in 1999 at ing and is absolutely necessary for the the start of the school year. At present, full implementation of a school-based the “Trazando el camino” intervention tobacco use prevention program. is in place in more than 95% of the

TOBACCO-FREE YOUTH public high schools across the country. Training. Records of all teachers These schools are implementing the who participated in the training ses- program once a week during an hour sions were kept. earmarked for “counseling” which, Soon after completing the training prior to the intervention, had lacked a sessions, regional supervisors, schools structured curricular component. supervisors, and classroom teachers filled out a survey developed by person- TEACHER TRAINING nel from the Ministry of Education. This survey aimed to identify the ade- The training of the teachers included, quacy of training, including length, as a first step, the training of the region- content, and acceptance. During al assessors who work for the Ministry August, CENADRO distributed a sur- of Education and are in charge of vey in a sample of schools to assess pro- supervising the schools by region. gram implementation. The survey also Their training involved a one-week included a question on adequacy of workshop provided by the Ministry of training. IAFA will conduct a survey at Education, CENADRO and IAFA, the end of the school year that will with support from PAHO. The highly include questions about adequacy and interactive workshop allowed regional compliance with training sessions. assessors to practice their new skills. As Implementation. During the a second step, the regional assessors school year, Ministry of Education per- trained school counselors from their sonnel sent periodic surveys to the region (“orientadores”), also using an schools to monitor the program’s interactive methodology. These school implementation. Efforts have been counselors, in turn, trained guidance made to contact the regional supervi- teachers (“profesores guía”) in their own sors and ascertain if any administrative schools. The length of training received obstacles inhibited full implementation by the guidance teachers depended on of the project. the time that the director of each school Classroom teachers also have been The use of multimedia materials— allocated to training purposes. In most contacted to confirm the extent of pro- video and audio cassettes, student cases, it was a two-day workshop. In gram implementation at the classroom workbooks, teachers’ guides, and private schools, the guidance teachers level (e.g., number of hours devoted to flip charts—was critical to the were trained by IAFA’s personnel. each subject and use of all materials). success of “Trazando el Camino.” CENADRO conducted a survey in EVALUATING a sample of schools to assess implementation compliance independently from “TRAZANDO EL CAMINO” the Ministry of Education. This survey Process Evaluation included questions regarding availability of materials, adequate use of materi- Developers for the “Trazando el als, and number of hours devoted to Camino” program designed evaluation the program. An open-ended question instruments to measure different areas was included to identify any obstacles of interest: for an adequate implementation.

Project design

Experimental group March 1999 School year November 1999

Sample of 7th graders in Costa Rica O1 X O2

Control group

Sample of 8th graders in Costa Rica O2

TRAZANDO EL CAMINO: THE COSTA RICAN EXPERIENCE Acceptance. The Ministry of Edu- The self-reported survey completed cation and the CENADRO surveys by the students aims to answers the fol- included questions about acceptance. lowing questions: For example, the surveys asked whether • Did students exhibit newly the program had been relevant to the acquired skills as a result of the local culture. Other questions includ- program? ed: did facilitators enjoy leading the program; did the students enjoy the • Have these skills resulted in program; did students adapt well to the decreased substance use? participatory methodology; and did • Is there a change in the students’ parents of students accept the existence knowledge? of such a program? • Is there a change in students’ attitudes and beliefs? Outcome Evaluation • Is there a reduction in the number of students who intend to use A sample of 2,600 students completed substances? a baseline survey at the beginning of the school year and will complete one • Is there an increase in the number at the end of the school year. The of students who want to quit instrument that was used at the begin- smoking? ning of the school year has been revised, and it will be conducted at the • Were other changes produced? end of the program’s first year. This • Were relationships between teach- instrument aims to identify changes in ers and students or among students student knowledge, beliefs, attitudes, improved? and behaviors and will measure population-wide declines in the use of • Was the dropout rate or academic tobacco and other substance. At pres- performance affected? ent, all evaluation data are being col- A survey done at the beginning of lected and analyzed in aggregate form, next year will be able to assess whether since the baseline measurements used behavioral changes persist after the pro- for comparison were collected in this gram ends. manner. If the program continues, it Preliminary findings from the project’s has been suggested that individual process evaluation reveal, in general, a data be recorded in the future. It also high acceptance of the program by par- is important to note that the evalua- ticipants and facilitators. Findings also tion of the reduction in age of smok- have revealed some limitations or ing onset will be carried out in subse- obstacles identified by program facilita- quent years. tors, including: A sample of local facilitators also was • Some facilitators did not have surveyed before the beginning of the school year, so as to have a baseline of enough time. teachers’ consumption of tobacco and • It required more than one other substances. Not surprisingly, session per subject to develop the many facilitators refused to complete curriculum the survey. Nonetheless, the plan is to ask the same sample similar questions • Some facilitators felt they did not at the end of the program. It is hypoth- have a grasp of the background of esized that there may be some associa- the substance use problem and, tion between the facilitator’s attitude therefore, could not adequately field toward substance use and changes in questions from students or serve as a the attitudes of their students. good resource on the issue.

TOBACCO-FREE YOUTH • Video and audio materials were Preliminary analysis suggests that inconsistently used because neces- implementation could be made more uni- sary equipment often was not form by strengthening the ongoing train- available. ing and support provided to regional and local facilitators. To this end, it may be • Some schools did not receive all helpful to revise the instructor’s manu- the materials they needed to fully al to include more background infor- implement the program mation on the substance use problem • Some facilitators found it difficult so that facilitators feel more confident to use participatory methods in about the subject matter. classrooms of 35 or more students. The usefulness of using videos or audiocassettes to relay program infor- • In some cases, students were chron- mation also should be reconsidered. ically absent during the “counsel- Many resource-poor schools simply do ing” hour used for “Trazando el not have the necessary equipment to Camino” sessions. make use of such audiovisual aids. Ses- • In many cases, parents were not sions that require the use of the audio informed about the program. tape should be revised to ensure fuller implementation. A more practical use Other elements also could be in- of program resources might be to hibiting the full implementation of the increase the size and quantity of posters program. First, there seemed to be some for use in large classrooms. inconsistencies in the performance of Implementation also might be project facilitators charged with local strengthened by training staff from the implementation. This is not unusual; three partnering institutions to period- previous research has shown that similar ically monitor training and implemen- prevention curricula are not always uni- tation at the local level and to assess formly implemented by participating adherence to the program protocol. An teachers (Botvin, et al., 1995). In addi- ongoing consultation by national proj- tion, the process evaluation revealed ect staff might also remedy the prob- that the pre-test needed to be revised— lem by better supporting teachers as it was too long and students often failed they encounter barriers to program to fill it out completely. Finally, some implementation, such as low student schools complained of low participation participation. due to a lack of motivation among stu- The analysis of evaluation results also dents who feel that substance abuse is suggests that program credibility needs to not a problem. be strengthened among students, facili- One reason for the inconsistency in tators, and parents. In order to coun- implementation could be related to the teract low levels of motivation or par- selection of facilitators. It has been ticipation, it is important to reinforce hypothesized that facilitators who have “Trazando el Camino” activities as part a background in the humanities or of a national campaign to reduce sub- health may be more motivated than stance use among young people. Pub- facilitators who are professors of science licity efforts should be led by the three or math. Unfortunately, the selection of institutions directing the program. facilitators for “Trazando el Camino” is Improved promotion of the program not based on teaching background or and communication of program results even teacher interest; the teachers who will lead to higher acceptance and fuller are selected as facilitators are simply participation by all the stakeholders. those who need to add an additional While partnerships lend an excellent hour of instruction to their teaching mix of resources, expertise, and broad- schedule in order to complete their based support to prevention programs, it is forty-hour work week. important to recognize the inherent dif-

TRAZANDO EL CAMINO: THE COSTA RICAN EXPERIENCE ficulties in sharing the management of addition, representatives from the insti- such programs among collaborating tutions have found that regular meet- institutions. IAFA, CENADRO, and ings where they share evaluation results Ministry of Education staff working on and other information are critical to the “Trazando el Camino” have accom- avoidance of duplication of efforts. plished a great deal in carrying out this Further analysis of the present and collaboration and continue to adopt future evaluations of “Trazando el strategies to improve program imple- camino” will provide direction for the mentation. For instance, since the pro- continued fine-tuning of the program. gram developers represent three separate It is hoped that this life skills tobacco institutions, it was decided that each prevention program will become a per- institution should carry out a separate manent part of the national education- component of the process evaluation. In al curriculum in Costa Rica.

LESSONS LEARNED TO IMPROVE IMPLEMENTATION

• Schools need to be ready to easily incorporate new programs • Directors and teachers must believe that substance use is an important issue • Teachers should volunteer to teach the curriculum • Teachers should be provided with adequate and sufficient training • Teachers should be selected for their commitment and sensitivity • All teachers in the school should be aware of the program • There should be a good relationship between the Ministry of Health and the Ministry of Education • The implementation is done progressively

Evaluation Process

March 1999 August 1999 November 1999

Ministry of Education Training evaluation Implementation surveillance every two months at the regional and school levels

IAFA Pretest with students Post-test with and teachers students and teachers Training evaluation among teachers

CENADRO Implementation evaluation

46 46TOBACCO-FREE YOUTH Bibliography and Suggested Readings

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48 48 TOBACCO-FREE YOUTH Organization of American States, Regional Ruocco G, et al. 1989. Encuesta de prevalen- Educational Development Program. 1990. cia realizada por el Departmento de Med- The Chance to Grow: Education in the icina Preventiva y Social de la Facultad de Campaign against Drug Abuse. Rev. Medicina. Montevideo, Uruguay. ed.Washington, DC: OAS. (Educational Thompson E, Goodstadt M. 1978. Smoking Monograph 12). education programs. Am J Public Health Pan American Health Organization (PAHO). 68:247–250. 1997. Tabaquismo:una amenaza constante UK Secretary of State for Health. 1998 para la salud. Washington, DC: Author. December. Smoking kills: a white paper on (Comunicación para la Salud 12). tobacco. London: The Stationery Office. Pan American Health Organization (PAHO). United Nations Children’s Fund. 1997. Youth 1999 May 31. Policy brief: nicotine addic- health—for a change. A UNICEF note- tion and smoking cessation. Available book on programming for young people’s from:http://www.paho.org/english/hpp/w health and development. New York: ntd_policy.htm. UNICEF. Pan American Health Organization(PAHO). US Department of Health and Human Ser- XXXIII Meeting of the Directing Council vices, Pan American Health Organization. of PAHO, Resolution XXII, Fight against 1992. Smoking and Health in the Ameri- the use of tobacco. In: Final Reports 100th cas: Report of the Surgeon General. and 101st Meetings of the PAHO Exectu- Atlanta, Georgia: Centers for Disease vie Committee, XXXIII Meeting of the Control and Prevention, Office of Smok- Directing Council of PAHO: Washington, ing and Health. (CDC 92-8420). D.C: PAHO. (Official Document 225). US. Department of Health and Human Ser- PP. 141–142. vices. 1994. Preventing tobacco use Pan American Health Organization (PAHO). among young people: a report of the Sur- 1998 November. Plan of action on health geon General. Atlanta, Georgia: Centers and development of adolescents and youth for Disease Control and Prevention, in the Americas, 1998–2001. Washington, National Center for Chronic Disease Pre- DC: PAHO, Division of Health Promo- vention and Health Promotion, Office of tion and Protection, Family Health and Smoking and Health. Population Program. US Department of Health and Human Ser- Pan American Health Organization (PAHO). vices. 1993. Measurements in prevention: 1992. Tobacco or health: status in the a manual on selecting and using instru- Americas. Washington, DC: PAHO. ments to evaluate prevention programs. Pan American Health Organization (PAHO). Rockville, Maryland: Center for Substance 1997 April. Perspectives in health: a world Abuse Prevention. (CSAP Technical without tobacco [videocassette: 25 min.]. Report-8). Washington, DC: PAHO. (Video Perspec- US Department of Health, Education, and tives in Health No. 13). Welfare. 1964. Smoking and health: a report Pandina R. 1996. Risk and protective factor of the Surgeon General. Atlanta, Georgia: models in adolescent drug use: Putting Centers for Disease Control and Prevention, them to work for prevention. Piscataway, Public Health Service. (PHS 1103). New Jersey: Rutgers University, Center for US Substance Abuse and Mental Health Ser- Alcohol Studies. vices Administration. 1999 April. Prelimi- Pollay, et al. 1996. The last straw? Cigarette nary results from the 1997 National advertising and realized market shares Household Survey on Drug Abuse. Avail- among youth and adults. Journal of Mar- able from: http://www.samhsa.gov/oas/ keting 60(2). nhsda/nhsda97/httoc.htm. Research for International Tobacco Control. US Substance Abuse and Mental Health Ser- 1998 August. Report on the Regional vices Administration. (1999b April). The Meeting on Setting Tobacco Control relationship between mental health and Research Priorities for Latin America and substance abuse among adolescents the Caribbean. Rio de Janeiro: IUAC. Rockville, Maryland: Substance Abuse and Roemer R. 1995. Acción legislativa contra la Mental Health Services Administration, epidemia mundial de tabaquismo. 2.a ed. Office of Applied Studies. (Analytic Series: Ginebra: Organización Mundial de la A-9; DHHS publication No. (SMA) 99- Salud. 3286).

BIBLIOGRAPHY AND SUGGESTED READINGS Woolcock A, Peat J, Leeder S, Blackburn C. World Health Organization. 1998a June. Cre- 1984. The development of lung function ating health-promoting schools: A strate- in Sydney children: effects of respiratory gic approach to prevent and reduce tobac- illness and smoking—a ten-year study. Eur co use, Proposal for new partnerships and J Respir Dis 65(132 Suppl):1–97. enhanced activities. Geneva: WHO Glob- World Bank/PAHO Partnership for School al School Health Initiative. Health in Latin America and the World Health Organization. 1998b. Tobacco Caribbean. 1999 February. The ten who use prevention: an important entry point go to school: School health and nutrition for the development of health-promoting programming in Latin America and the schools. Geneva: WHO/UNESCO/Edu- Caribbean. Washington, DC: World cation International. (WHO Information Bank, Human Development Department. Series on School Health, Document Five). (LCSHD Paper Series No. 37,). World Health Organization. 1999. The world World Bank/PAHO Partnership for School health report 1999: Making a difference. Health in Latin America and the Geneva: WHO. Caribbean. 1999 July. Situational analysis World Health Organization. 1999 June 16. of existing school health and nutrition Environmental tobacco smoke seriously needs and strategies in Latin America and endangers children’s health [press release the Caribbean: Report of preliminary no. PR-99-35]. Available from: findings. Washington, DC: World Bank. http://www.who.int/inf-pr-1999/en/pr99- World Health Organization. 1993. Life skills 35.html. education in schools. Geneva: Division of World Health Organization. 1999a April. Mental Health and Prevention of Sub- Tobacco—supporting the tobacco indus- stance Abuse. (WHO Publication No. try is bad economics [Fact sheet No. 223]. WHO/MNH/PSF/93. 7A. Rev.2). Available from: http://www.who.int/inf- fs/en/fact223.html. World Health Organization. 1995. Life skills education in schools. Available from: World Health Organization. 1999b April. http://www.who.int/msa/mnh/mhp/mhp Tobacco dependence [Fact sheet No. 222]. 2.htm Available from: http://www.who.int/inf- fs/en/fact222.html. World Health Organization. 1996 August. Trends in substance use and associated World Health Organization, Tobacco-Free health problems [Fact sheet No. 127]. Initiative. 1999 May 31. Some facts on Available from: http://www.who.int/inf- global tobacco use. In: Leave the pack fs/en/fact127.html. behind. Available: http://www.who.org/ toh/worldnotobacco99/english/facts.htm. World Health Organization. 1997a. Tobacco World Health Organization. 1999b May 31. or health: A global status report. Geneva: Tobacco-Free Initiative: The health conse- WHO. quences of tobacco use. Available from: World Health Organization. 1997b. Life skills http://www.who.org/toh/worldnotobac- education in schools. Geneva: WHO Pro- co99/english/consequences.htm. gramme on Mental Health. World Health Organization, International World Health Organization. 1998 April. Children’s Institute, Canada. Guidelines: Skills for life, N 8. Geneva: WHO Pro- Life skills education curricula for schools. gramme on Mental Health. (In press).

TOBACCO-FREE YOUTH Appendix A: Materials Used in Costa Rica’s “Trazando el Camino” Program

Instructional kit • an 8-minute introductory videotape and cassette, • a student workbook, • a teacher’s guide, and • classroom flip charts.

Student workbook The workbook contains activities organized by session: Session # 1: Analysis of student expectations Session # 2: Comparison of primary and secondary school experiences Session # 3: Identification of positive and negative characteristics Session # 4: Decision making case study Session # 5: Analysis of decision making practices Session # 6: Influence of advertising Session # 7: Stress management Session # 8: Characterizing family members Session # 9: Opinion poll on smoking Session # 10: Monetary consequences of cigarette consumption Session # 11: Rights of non-smokers Session # 12: Myths associated with alcohol Session # 13: Review of skills Session # 14: Beliefs statement Session # 15: Development of a prevention project

Instructor’s guide The instructor’s guide contains a letter of endorsement from the President of Costa Rica, a brief explanation of the theoretical basis of the program, expected outcomes, and strategies for developing session activities.

51 Appendix B: Life Skills Training: Summary of Selected Evaluation Results

Source Location No. of Students Design Content Results

Botvin, Eng, New York 281students from A O1 X O2 X: 10 sessions (once a A: onset rate 4%, and Williams, 2 schools 8th, 9th and 10th C O1 O2 week) C: onset rate 16% C. (1980) suburban grades; 121 in inter- No objective “self improvement Overall 75% reduction middle class vention group and measure project” in incidence; increase 160 in control group Outside specialist used in knowledge Tobacco

Botvin and New York 426 7th graders; A O1 X O2 O3 X: 12 sessions (once Reduction in incidence Eng, (1982) 2 schools 357 completed B O1 O2 O3 a week) by 58%; increase in suburban intervention 0m 3m 1y Led by paired peer leaders knowledge. middle and Saliva samples who had 4 h. training plus After one year: 25% upper class 1 h. briefing each week fewer non-smokers in >90% white Tobacco experimental group

Botvin, et al., New York 902 7th graders A O1 X O2 O3 X: 15 sessions At one year follow up (1983) 7 schools B O1 X O2 O3 b: 8 booster sessions Intensive minicourse suburban D O1 X O2 b O3 Implemented by teachers reduced new smoking middle and C O1 O2 O3 A: 1 session per week onset by 50% the first upper class 0m 4m 16m B: Intensive minicourse = year and by 55% the 91% white Saliva samples Sessions everyday for one second year. month New smoking was D: Minicourse plus 8 reduced by 87% in weeks of booster sessions the 2nd year when C: control group = no booster applied. intervention Tobacco

Botvin, Dusen- New York 471 7th graders 2A: O X O (156) 15 sessions Level of implementa- bury, Baker, 8 urban 2B: O X O (99) A: high implementation tion is related to the James-Ortiz, schools 4C: O O B: low implementation by efficacy of the inter- and Kerner, >70% Hispanic 3.5m teachers vention; teachers in (1989) Breath samples Tobacco high implementation group were younger and less experienced, and reported feeling better prepared than teachers in the low implementation group.

TOBACCO-FREE YOUTH Appendix B, cont.: Life Skills Training: Summary of Selected Evaluation Results

Source Location No. of Students Design Content Results

Botvin, G., New York Year 1: A O1 X O2 O3 X: 20 sessions in 7th grade At one year follow up: Baker, Filazolla 10 schools 1311 7th graders B O1 X O2 b O3 b: 10 sessions in 8th grade Peer-led sessions and Botvin, E., suburban Year 2: D O1 X O2 O3 A: implemented by older 79% lower weekly and (1990) middle class 1185 8th graders E O1 X O2 b O3 students (4 h. training); no 82% lower daily smok- 80% white Year 3: (one-year fol- C O1 O2 O3 booster ing; 69% lower marijua- low up): 4m 1y B: implemented by older na use 998 or 76% of initial Saliva samples students (4h. training) with Teacher-led sessions sample booster in 8th grade 44% lower weekly D: implemented by teach- smoking and daily ers (one day training); no smoking reduced by booster 50% among females E: implemented by teachers (one day training) with booster C: control group = no intervention Tobacco, alcohol, marijuana

Botvin, et al., New York 5954 7th graders in A O1 X1 X2 X3 O2 X1: 15 sessions in Long-term follow up: (1995) 56 public 1985 B O1 X1 X2 X3 O2 7th grade Intervention group had schools Six-year follow up: C O1 O2 X2: 10 sessions in 15% lower monthly and middle class 3597 students in Breath CO samples 8th grade 27% lower weekly smok- mostly white 1991 (60% of original X3: 5 sessions in 9th grade ing. Also had 25% lower sample) Implemented by teachers heavy tobacco use (>=1 A: teachers attended one- pack/day) and 66% lower day workshop; implemen- multiple substance use tation feedback given B: teachers were trained with a 2 h. videotape (no feedback) Tobacco, alcohol, marijuana

APPENDICES