The St-Louis du Parc Heart Health Project: a critical analysis of the reverse effects on smoking

Abstract

Objectives: Although some school based smoking prevention programmes have shown positive impacts, others have had only short term effects, no effects, and in some cases reverse effects. The St-Louis du Parc Heart Health Project was a five year heart health promotion programme targeting children in eight elementary schools aged 9-12 years in disadvantaged multiethnic neighbourhoods in Montreal. In a controlled, longitudinal evaluation, the programme produced reverse effects on smoking-children exposed to the programme were more likely to initiate and to continue smoking than control children. This article explores hypotheses to explain the reverse effects. Design: Following work by an in-house committee, a consensus workshop with international experts was conducted to develop hypotheses to explain the reverse effects. This was complemented by an analysis of the programme's concordance with the standard guidelines on the school based prevention of tobacco use, and discussions with experts at the Centers for Disease Control and Prevention. Results: The programme respected most standard guidelines for smoking prevention programmes with respect to content and mode of delivery. Hypotheses to explain the reverse effects include: an unfavourable environment characterised by strong pro-smoking models and resistance to environmental interventions; heightened sensitivity to smoking among children most exposed to the programme; defence mechanisms among children stimulated by cognitive dissonance or anxiety; unanticipated effects associated with the health educator who delivered the programme; inadequate attention in programme development to the diverse cultural origins of the population targeted; and intervention content inappropriately targeted to children's stages of cognitive development. Conclusion: Elementary school based interventions should aim to develop a clear and coherent social norm about the non-use of tobacco, as a precursor to or in close conjunction with having children as their primary target. Programme design should take key student characteristics into consideration and ensure that the modes of communication are adapted to the targeted group's characteristics. Neighbourhood level interventions should be orchestrated to complement regional, provincial, and national programmes.

Adverse effects of a social contract smoking prevention program among children in Québec, Canada

“…Although clear and coherent social norms for non-use of tobacco are benchmarks in school-based prevention programs,11 our results support the notion that smoke-free class competitions, which capitalise on peer pressure not to smoke, may encourage misrepresentation of smoking status among novice smokers, and in addition may contribute to increasing attitudes that may result in marginalising young smokers who do admit to smoking.…”

Predictors of the Onset of Cigarette Smoking

“…Failure to do so could lead to interventions that are fundamentally flawed because they do not address the full range of factors known to be associated with smoking onset. Indeed, the mitigated results of evaluations of even the most carefully conceptualized and well-funded tobacco control interventions [1][2][3][4][5] may reflect a lack of comprehensive action that address relevant risk factors at the individual and environmental levels. It will be important to distinguish modifiable risk factors (e.g., exposure to family and friends' smoking, exposure to films) from those that are not modifiable (e.g., age or sex) but may be helpful in terms of targeting intervention.…”

“…2 Several recent reviews reinforce that the impact of school-based and other types of targeted prevention programs are often short-term, 1,3 and some studies suggest that such prevention efforts may have unanticipated negative effects. 4,5 These observations may reflect a lack of comprehensive understanding of the factors associated with onset such that tobacco control interventions are not conceptualized optimally.…”

Comparing effects of tobacco use prevention modalities: need for complex system models

“…Evaluation challenges aside, the fact that community-wide multi-modality programming provided effects that in a majority of cases was not stronger than single-modality type programming, suggests that either (a) there were key modalities missing from many of these trials, (b) that there were countervailing forces in operation, programming was implemented at inappropriate youth developmental levels, or in an unsupportive larger social environment (e.g., see [67]), or (c) that somehow certain otherwise successful components might have operated negatively together within the system of application.…”