Tobacco use trends and correlates among students in the Madison Metropolitan School District.

Trends in cigarette use among students in grades 7-12 in the Madison Metropolitan School District were examined using data from the Dane County Youth Survey, which has been conducted every 5 years since 1980. Past year use of smoking tobacco among these students declined from 40% to 45% through 1995 to 32% in 2000. Past month cigarette use declined from 27% in 1995 to 18% in 2000; daily smoking dropped from 15% in 1990 to 8% in 2000. Among 12th grade students, 1999 national data show that 35% smoked in the past month, compared to 30% of Madison 12th graders. Bivariate analyses show significant socio-economic and race/ethnic disparities in cigarette smoking rates. Hispanic, Native American and white students reported higher rates of smoking than Asian and African American students. Students whose parents had more education were less likely to smoke, as were those students who themselves were academically successful and who had college plans. Students who smoked were far more likely than non-smokers to engage in other risky behaviors, including use of alcohol and marijuana, and to be sexually active. Parental monitoring and supervision, support in one's neighborhood, and participation in volunteer and leadership activities were associated with lower rates of smoking. Risk factors associated with increased rates of smoking included other drug use, aggressive behavior, less family disapproval of risky behavior, and self-concerns about one's own behaviors. These data can assist in targeting prevention and cessation efforts for Wisconsin adolescents. Physicians and other care providers should consider cigarette smoking as a sentinel event that signals the need for screening for potential substance abuse, sexually transmitted diseases (STDs) and contraceptive care. School-based preventive efforts should be continued, particularly at the middle school level, with cessation programs added at the high school level.

The Healthy for Life project: sexual risk behavior outcomes.

Sexual risk behavior outcome data from the Healthy for Life (HFL) project is presented. Using a social influences model, the intervention was designed to positively affect the health behaviors of middle school students in five related areas: alcohol use, tobacco use, marijuana use, nutrition, and sexuality. The in-school program was supplemented by parent, community and peer components. The research used self-report data on an initial sample of 2,483 middle school students followed from Grade 6 to Grade 10. Twenty-one schools were assigned to three conditions--age appropriate (program taught in Grades 6, 7, and 8), intensive (program taught in Grade 7) and control--using blocked randomization. Attrition was 20% (by Year 4) and 33% (by Year 5). By ninth grade the lifetime intercourse rate among both groups of HFL subjects was significantly higher than for controls (controlling for baseline substance use risk and involvement with the opposite sex), but reported past month intercourse rates and condom use did not differ. At the tenth grade follow-up, the age appropriate subjects reported higher adjusted rates of lifetime and past month intercourse than did the controls. Intensive subjects perceived significantly lower normative rates of intercourse than controls at ninth grade follow-up, but age appropriate subjects perceived significantly higher norms at tenth grade. Our expectation that this approach would be effective in reducing adolescent sexual risk behavior has not been supported. The influence of social and community norms and contextual factors has a far greater influence on the behavior of students (even 6 years later) than this school-based social influences program targeting only one grade cohort.

Changing nature of physician satisfaction with health maintenance organization and fee-for-service practices.

BACKGROUND: Managed care practice arrangements, or health maintenance organizations (HMOs), are sufficiently mature to examine whether physicians' level of satisfaction has changed as managed care has developed. This study compares Dane County, Wisconsin, physicians' satisfaction with HMO and fee-for-service (FFS) practices in 1986 with that of 1993 and examines factors that contribute to satisfaction in an HMO-dominated environment. METHODS: Cross-sectional surveys were mailed to all Dane County physicians in active practice in 1986 and 1993. Physician overall support for HMO development and satisfaction with work situation was measured with single items. Overall satisfaction and clinical freedom within HMO and FFS practices were measured using statistically reliable scales. RESULTS: Significantly more physicians were supportive of the development of HMOs in 1993 than in 1986, and more than two thirds of physicians in 1993 were satisfied in their current work situation. Primary care physicians were significantly more satisfied than subspecialists across most dimensions of satisfaction. Perceived clinical freedom and satisfaction with income continued to be major predictors of satisfaction in 1993 as in 1986. While physicians' satisfaction with HMO practice remained stable, their satisfaction with FFS practice was significantly lower in 1993 than in 1986. Satisfaction with Medicare practice, which was not measured in 1986, was significantly less than with HMO or FFS practice in 1993. CONCLUSIONS: Analyses suggest that primary care physicians are more satisfied than subspecialists with their HMO practice because of their greater satisfaction with HMO-generated income and the expanded clinical freedom they have in HMO practice. An across-the-board decline in satisfaction with FFS practice may be attributable to diminishing clinical freedom resulting from indemnity carriers' increasing micromanagement of patient care.

Dieting in sixth grade predicts alcohol use in ninth grade.

Recent studies of community-based populations have shown that the comorbidity seen in clinical studies of individuals with eating disorders and substance abuse extends in a graded manner to subclinical levels of each dysfunction as well as to adolescent populations. We hypothesized that frequency of dieting in the sixth grade would predict later alcohol use in middle school students. Data from 1,905 participants in a middle school health promotion project were analyzed. We found a positive, graded relationship between the frequency of dieting in the sixth grade and the frequency of alcohol intake in the ninth grade. We also found that frequency of dieting in sixth grade was a more powerful predictor of future drinking than such parameters as others' approval of alcohol use, perceptions of peer use of alcohol, and personal feelings of shyness and self-satisfaction. Implications of these findings are discussed.

Predicting adolescent problem use of marijuana: development and testing of a Bayesian model.

This paper reports on the development and testing of a risk assessment index for problem marijuana use designed to guide teenagers through an extensive computer-based support system intended to help them improve marijuana-related behaviors. Bayesian decision theory, used as the basis of the index development process, offers the advantage of building the index on subjective judgments of experts and does not require a large empirical data base. The index was found to predict an independent panel's ratings of teenager risk, and predict the marijuana use of 10th graders using self-reports of their profiles in the 7th grade. Implications for future risk assessment developments are discussed.

"US Planning Prevention for Them": The Social Construction of Community Prevention for Youth.

Recently, prevention programs for youth have been aimed at the social spheres presumed to influence health behavior decisions. Community-level programs have emerged as part of this trend. Communities are, however, dynamic, complex, and fluid. Describing community prevention efforts within the bounds of "normal" science has rendered invisible certain important features. We combined open- and close-ended research methods to study the grassroots prevention efforts of ten communities in the upper midwest. Three basic questions formed our inquiry: 1) how were community prevention actions constructed or planned?; 2) toward whom were these actions aimed?; and 3) what were the major success and problems in carrying out prevention actions? A central finding was the existence of an automatic yet tacit "filtering" process whereby certain people became involved in prevention while others did not. This "us versus them" pattern was expressed as a major barrier to the effectiveness and sustainability of community prevention efforts. Existing as informal, "everyday" knowledge, this problem has largely been rendered invisible by the heavy reliance on close-ended, "check the box" communication between the researcher and the researched.

An outcome evaluation of project model health: a middle school health promotion program.

This article reports findings from the outcome evaluation of Project Model Health (PMH), an intensive in-school health promotion program for middle school students. Promising prevention strategies identified in past research based on social influences theory were combined in PMH, targeting multiple health behaviors in the areas of nutrition, marijuana use, tobacco use, drinking and driving, and sexuality. Results reported in this paper are based on an experimental group of 115 eight graders who were exposed to the 32 hour program, taught by college-age "role models." The evaluation included both an extensive qualitative process evaluation and a quasi-experimental outcome evaluation. The outcome evaluation used both a prior year's cohort and students from a similar untreated school for comparison purposes. While an immediate post-test showed only inconsistent results, a 20-month follow-up resulted in clear positive outcomes for experimental students on measures of cigarette smoking and improved food choices, and ambiguous but positive results on rates of intercourse. Limitations of the methodology (nonexperimental assignment to conditions, reliance only on self-report data) are such that further more rigorous testing of this program model is called for. However, PMH shows significant promise as an effective adolescent health promotion approach.

Correlates of smokeless tobacco use in a male adolescent population.

This paper identifies the correlates of smokeless tobacco use in a sample of 1,030 males representative of 7th through 12th grade students of Dane County (Madison), Wisconsin. Variables independently associated with frequent use of smokeless tobacco were: being White; living in other than a two-parent home; performing poorly in school; smoking cigarettes; consuming beer, wine, or hard liquor; and deviant/delinquent behavior. Participation in team sports was associated with some "experimentation" with smokeless products.

Identifying adolescents with alcohol problems. A field test of the Adolescent Alcohol Involvement Scale.

A modified version of the Adolescent Alcohol Involvement Scale (AAIS) was administered in a telephone survey and in a longitudinal study. Results indicated acceptable reliability and validity in the AAIS but scores may be unstable in the long run because of the transient nature of alcohol misuse among many adolescents.

Posttreatment drinking behavior among inpatients from an industrial alcoholism program.

Findings from a follow-up study of inpatients from an industrial alcoholism program are presented. At 3-month follow-up, 46% were abstinent and 22% drinking moderately; at 9 months, 37% were abstinent and 20% drinking moderately. Moderate drinkers at 3 months had a high relapse rate by 9 months. In comparing moderate drinkers at 9 months to abstainers and to those drinking destructively, it was found that moderate drinkers were more similar to abstainers than to destructive drinkers on most variables. Relationships between drinking outcomes and several sets of predictor variables are presented and discussed. From these data it is evident that social support (being married, family involved in treatment, AA and/or religious involvement) is crucial in recovery from alcoholism, that employer's involvement had a positive influence, that coercion for treatment did not have a negative impact, that prior job problems had a delayed negative impact, and that treatment outcome for earlier-phase alcoholics was relatively poor in comparison to "chronic" cases in this program.

Treatment outcome for earlier-phase alcoholics.

Employed alcoholics treated in a traditional inpatient alcoholism treatment program were classified by their alcoholism counselors as being in either the chronic phase or in earlier phases of alcoholism. Three-month follow-up data indicated that a significantly smaller proportion (41%) of the earlier-phase alcoholics than of the chronics (59%) were maintaining abstinence. Given abstinence as the primary success criterion, it must be concluded that earlier-phase alcoholics treated in this program were less successful than chronics. However, follow-up data also indicated that earlier-phase alcoholics were more likely than chronics to be controlling their drinking. These findings are discussed in light of the newly emerging paradigm of alcohol problems as a multidimensional rather than a unidimensional problem; it is suggested that success criteria be relaxed to include controlled or responsible drinking as acceptable treatment objectives and that experimental treatment programs, specifically for earlier-phase alcoholics, be initiated.