Mediation in a family-directed program for prevention of adolescent tobacco and alcohol use.

BACKGROUND: Family Matters is a universal intervention designed to prevent adolescent tobacco and alcohol use through involvement of family members and by targeting family risk factors for tobacco and alcohol use. Previously reported findings suggest that the program reduced the prevalence of both adolescent smoking and drinking in the 12 months after program completion. This paper reports analyses conducted to identify the mediators through which the program influenced adolescent smoking and drinking. METHODS: One thousand fourteen adolescents ages 12 to 14 years and their families, identified by random-digit dialing, were entered into a randomized trial. Adolescents and their parents provided data by telephone for measuring mediator and behavioral variables at baseline, 3 months, and 12 months after program completion. Repeated-measures logistic regression with generalized estimating equations was used to assess mediation processes. RESULTS: The program resulted in statistically significant changes in several substance-specific aspects of the family, such as rule setting about tobacco and alcohol use. However, the intermediate family effects did not account for the program effects on adolescent behavior. CONCLUSIONS: The variables hypothesized to explain program effects were not identified by direct empirical examination.

Correlates of participation in a family-directed tobacco and alcohol prevention program for adolescents.

This study examined correlates of program initiation and completion in a family-directed program that involved families of adolescents throughout the United States. Correlates varied by whether program initiation, program completion, or the number of activities completed was the indicator of participation. In final regression models, participation was relatively likely by non-Hispanic whites when compared with persons of race/ethnicity other than white, black, and Hispanic; by families with a female adolescent as the program recipient; by families with mothers who had many years of education; and by families with both parents living in the household. There was more participation if parents thought their child would smoke in the future and if the parent thought the adolescent did not smoke currently. Participation was higher if the adolescent felt strongly attached to the parent and if parents did not smoke. The findings are considered in the context of similar programs and future research on family-directed programs to prevent adolescent tobacco and alcohol use.

Trends in parent and friend influence during adolescence: the case of adolescent cigarette smoking.

A common characterization of adolescence is that parent influence decreases and friend influence increases as adolescents age. From that, we hypothesized that the association between parent and adolescent smoking decreases and the association between friend and adolescent smoking increases as adolescents become older. The hypothesis is tested with data from The National Longitudinal Study of Adolescent Health. Adolescent smoking is measured as progressions to more frequent smoking and as continuations from prior smoking levels. There is no support for the hypothesis, a finding consistent with the earlier panel study that tested it. The age-specific findings are discussed in the context of programs designed to influence adolescent cigarette smoking and why the hypothesis that drove this study was not confirmed. Among supplementary findings reported is that adolescent smoking is more influenced by friend smoking than by parent smoking.

The influence of a family program on adolescent tobacco and alcohol use.

OBJECTIVES: This study examined a family-directed program's effectiveness in preventing adolescent tobacco and alcohol use in a general population. METHODS: Adolescents aged 12 to 14 years and their families were identified by random-digit dialing throughout the contiguous United States. After providing baseline data by telephone interviews, they were randomly allocated to receive or not receive a family-directed program featuring mailed booklets and telephone contacts by health educators. Follow-up telephone interviews were conducted 3 and 12 months after program completion. RESULTS: The findings suggested that smoking onset was reduced by 16.4% at 1 year, with a 25.0% reduction for non-Hispanic Whites but no statistically significant program effect for other races/ethnicities. There were no statistically significant program effects for smokeless tobacco or alcohol use onset. CONCLUSIONS: The family-directed program was associated with reduced smoking onset for non-Hispanic Whites, suggesting that it is worthy of further application, development, and evaluation.

Perceived stress, social support, and affectionate behaviors of adolescent mothers with infants in neonatal intensive care.

INTRODUCTION: This article focuses on affectionate behaviors of adolescent mothers with their infants in a neonatal intensive care unit (NICU). Hypotheses derived from behavioral science theory posited the direct influence of social support and perceived stress on affectionate behaviors, the statistical interaction of social support and perceived stress on affectionate behaviors, and perceived stress as a mediator of the relationship between social support and affectionate behaviors. METHOD: Subjects were enrolled from July 1993 through September 1994. Information about perceived stress and social support was obtained twice by means of an interview. Affectionate behaviors were measured by NICU nurse observations. Analyses were conducted on subsamples ranging from 57 to 107 subjects. RESULTS: All hypotheses were rejected. Neither social supports nor perceived stress were related to affectionate behaviors, and no statistical interactions among the 3 variables were identified. DISCUSSION: The findings are considered in the context of the methodology used, stress and social support theory, and implications for practice and future research.

The Safe Dates program: 1-year follow-up results.

OBJECTIVES: An earlier report described desirable 1-month follow-up effects of the Safe Dates program on psychological, physical, and sexual dating violence. Mediators of the program-behavior relationship also were identified. The present report describes the 1-year follow-up effects of the Safe Dates program. METHODS: Fourteen schools were in the randomized experiment. Data were gathered by questionnaires in schools before program activities and 1 year after the program ended. RESULTS: The short-term behavioral effects had disappeared at 1 year, but effects on mediating variables such as dating violence norms, conflict management skills, and awareness of community services for dating violence were maintained. CONCLUSIONS: The findings are considered in the context of why program effects might have decayed and the possible role of boosters for effect maintenance.

Influence of a family-directed program on adolescent cigarette and alcohol cessation.

Programs to reduce adolescent cigarette or alcohol use by users in general populations have only recently been evaluated. Moreover, in spite of the substantial influence families have on their children, few family-directed programs designed to reduce the prevalence of adolescent smoking and drinking have been rigorously evaluated. This paper reports the findings of research designed to determine whether a family program reduced use of cigarettes or alcohol by users. The program consisted of a series of booklets mailed to families and follow-up telephone calls by health educators. A randomized experimental design involved families with children ages 12-14 throughout the United States. Data were collected by telephone at baseline and 3 and 12 months after the program was completed. No statistically significant program effects were observed for cessation or decrease in smoking and drinking by users.

The paucity of effects in community trials: is secular trend the culprit?

BACKGROUND: The most recent major U.S. trials that evaluated community-level programs to influence risk factors and health behaviors identified secular trends in the risk factors and health behaviors among the factors that might have limited community-level effects. The research reported in this paper uses data from one of the trials to examine the secular trend explanation directly. METHODS: Data from the 22-community Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed to test a hypothesis based on secular trend reasoning: program effects for smoking prevalence were larger for treatment communities matched to control communities with small declines in smoking than in treatment communities matched to control communities with larger declines in smoking. RESULTS: Consistent with the secular trend explanation, program effects were larger when control communities had relatively small declines in smoking prevalence. CONCLUSIONS: The findings suggest that secular trends masked community-level program effects in COMMIT.

Measurement of affectionate behaviors adolescent mothers display toward their infants in neonatal intensive care.

This paper describes two studies that had three purposes: (a) to modify a parent-child interaction tool used previously in a neonatal intensive care unit (NICU); (b) to demonstrate interrater reliability, Chronbach's Alpha reliability, and construct validity of the tool with adolescent mothers, and (c) to determine the ability of nurses engaged in usual work duties to observe maternal behaviors. The first study tested interrater reliability. Two NICU nurses were trained, observed adolescent mothers (n = 20) for the same 15 min, and then separately completed the measure. The second study tested internal consistency reliability and construct validity with 107 adolescent mothers with infants in a NICU. Nurses in the neonatal intensive care unit completed the measure, and data on maternal visits were gathered for construct validity. The intraclass correlation coefficient for the first study was r = .83. Results of the second study demonstrated a Chronbach's Alpha of .85 and a significant correlation between ratings of maternal behavior and visits. The instrument obtained acceptably reliable and valid estimates of adolescent mothers' affectionate behaviors toward their infants. In addition, the studies demonstrated that nurses can observe maternal behaviors while performing their usual duties.

An evaluation of Safe Dates, an adolescent dating violence prevention program.

OBJECTIVES: This study assessed the effects of the Safe Dates program on the primary and secondary prevention of adolescent dating violence. METHODS: Fourteen schools were randomly allocated to treatment conditions. Eighty percent (n=1886) of the eighth and ninth graders in a rural county completed baseline questionnaires, and 1700 (90%) completed follow-up questionnaires. RESULTS: Treatment and control groups were comparable at baseline. In the full sample at follow-up, less psychological abuse, sexual violence, and violence perpetrated against the current dating partner were reported in treatment than in control schools. In a subsample of adolescents reporting no dating violence at baseline (a primary prevention subsample), there was less initiation of psychological abuse in treatment than in control schools. In a subsample of adolescents reporting dating violence at baseline (a secondary prevention subsample), there was less psychological abuse and sexual violence perpetration reported at follow-up in treatment than in control schools. Most program effects were explained by changes in dating violence norms, gender stereotyping, and awareness of services. CONCLUSIONS: The Safe Dates program shows promise for preventing dating violence among adolescents.

Predictors of state legislators' intentions to vote for cigarette tax increases.

BACKGROUND: This study analyzed influences on state legislators' decisions about cigarette tax increase votes using a research strategy based on political science and social-psychological models. METHODS: Legislators from three states representing a spectrum of tobacco interests participated in personal interviews concerned with tobacco control legislation (n = 444). Measures of potential predictors of voting intention were based on the consensus model of legislative decision-making and the theory of planned behavior. Multiple logistic regression methods were used to identify social-psychological and other predictors of intention to vote for cigarette tax increases. RESULTS: General attitudes and norms concerning cigarette tax increases predicted legislators' intention to vote for cigarette tax increases. More specific predictors included perceptions of public health impact and retail sales impact of cigarette tax increases. Constituent pressure was the strongest perceived social influence. Political party and state also were strong predictors of intention. Results were consistent with related research based on political science models. CONCLUSIONS: Legislators' votes on cigarette tax increases may be influenced by their perceptions of positive and negative outcomes of a cigarette tax increase and by perceived constituent pressures. This research model provides useful insights for theory and practice and should be refined in future tobacco control research.

State-level infant, neonatal, and postneonatal mortality: the contribution of selected structural socioeconomic variables.

Reducing infant mortality in the United States is a national priority. States' infant mortality rates vary substantially. Public health researchers, practitioners, and leaders have long argued that social and other structural factors must be addressed if health outcomes are to be improved. A knowledge of which structural variables are most strongly related to state-level infant mortality is needed to guide the development of policies and programs to reduce this mortality. The authors examine the importance of several structural (social, economic, and political) variables for state-level infant, neonatal, and postneonatal mortality. With the state as the unit of analysis, data for all 50 states were analyzed using multiple regression. Together, the structural variables accounted for two-thirds of the variance in infant and neonatal mortality rates and over half of the variance in postneonatal mortality rates. States with proportionately larger black populations had higher infant, neonatal, and postneonatal mortality rates. States with greater percentages of high school graduates had lower neonatal mortality rates but higher postneonatal mortality rates. The findings suggest that a better understanding of the relationship between states' social structure and infant health outcomes is needed if state-level infant mortality is to be reduced.

Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health.

CONTEXT: The main threats to adolescents' health are the risk behaviors they choose. How their social context shapes their behaviors is poorly understood. OBJECTIVE: To identify risk and protective factors at the family, school, and individual levels as they relate to 4 domains of adolescent health and morbidity: emotional health, violence, substance use, and sexuality. DESIGN: Cross-sectional analysis of interview data from the National Longitudinal Study of Adolescent Health. PARTICIPANTS: A total of 12118 adolescents in grades 7 through 12 drawn from an initial national school survey of 90118 adolescents from 80 high schools plus their feeder middle schools. SETTING: The interview was completed in the subject's home. MAIN OUTCOME MEASURES: Eight areas were assessed: emotional distress; suicidal thoughts and behaviors; violence; use of 3 substances (cigarettes, alcohol, marijuana); and 2 types of sexual behaviors (age of sexual debut and pregnancy history). Independent variables included measures of family context, school context, and individual characteristics. RESULTS: Parent-family connectedness and perceived school connectedness were protective against every health risk behavior measure except history of pregnancy. Conversely, ease of access to guns at home was associated with suicidality (grades 9-12: P<.001) and violence (grades 7-8: P<.001; grades 9-12: P<.001). Access to substances in the home was associated with use of cigarettes (P<.001), alcohol (P<.001), and marijuana (P<.001) among all students. Working 20 or more hours a week was associated with emotional distress of high school students (P<.01), cigarette use (P<.001), alcohol use (P<.001), and marijuana use (P<.001). Appearing "older than most" in class was associated with emotional distress and suicidal thoughts and behaviors among high school students (P<.001); it was also associated with substance use and an earlier age of sexual debut among both junior and senior high students. Repeating a grade in school was associated with emotional distress among students in junior high (P<.001) and high school (P<.01) and with tobacco use among junior high students (P<.001). On the other hand, parental expectations regarding school achievement were associated with lower levels of health risk behaviors; parental disapproval of early sexual debut was associated with a later age of onset of intercourse (P<.001). CONCLUSIONS: Family and school contexts as well as individual characteristics are associated with health and risky behaviors in adolescents. The results should assist health and social service providers, educators, and others in taking the first steps to diminish risk factors and enhance protective factors for our young people.

State legislators' intentions to vote and subsequent votes on tobacco control legislation.

The predictive validity of state legislators' behavioral intentions in relation to their votes on tobacco control legislation was assessed by using the theory of planned behavior (I. Ajzen, 1991). Intentions to vote for cigarette tax increases were measured through interviews in the summer of 1994. A bill containing cigarette tax increases was considered about 8 months later. Votes were compared with intentions and were found to be consistent for 78% of these legislators (N = 120). Multiple logistic regression analyses showed a strong independent relationship between intentions and voting and a similar effect of political party; results suggested but did not confirm that votes were predicted by interactions between intentions and perceived control. Legislator surveys that use this conceptual model can provide results relevant to understanding tobacco policy development.

State legislators' attitudes and voting intentions toward tobacco control legislation.

OBJECTIVES: This study describes state legislators' knowledge, attitudes, and voting intentions with regard to tobacco-related issues. METHODS: A cross-sectional survey of state legislators was conducted in North Carolina, Texas, and Vermont in 1994. RESULTS: Most legislators agreed that secondhand smoke can cause lung cancer in nonsmokers, and a majority believed that smokers are addicted to nicotine. More than 75% stated that they would support a measure to enforce laws preventing tobacco sales to youth. A majority of Texas and Vermont legislators supported an increase in the state cigarette excise tax; 43% of North Carolina legislators would support an increase if revenues were directed toward tobacco farmer diversification. CONCLUSIONS: State legislators believe tobacco to be addictive, and they support policies to protect youth from tobacco. Support for other legislative measures differs significantly across states.

Urinary cotinine and parent history (questionnaire) as indicators of passive smoking and predictors of lower respiratory illness in infants.

Studies of the effects of passive smoking on lower respiratory illness (LRI) have relied on questionnaires to measure exposure. We studied the association between two measures of passive smoking and the incidence of acute LRI in infants. We analyzed data from a community-based cohort study of respiratory illness during the first year of life in North Carolina. The incidence of LRI was determined by telephone calls at 2-week intervals. Environmental, demographic, and psychosocial risk factors for LRI were measured during home interviews. Tobacco smoke exposure was measured as the mean number of cigarettes smoked per day in the infant's presence. Smoke absorption by the infants was measured by the urinary cotinine/ creatinine ratio. Of the 485 infants in the study, 325 (67%) had telephone follow-up and at least two home interviews. In bivariate analyses, reported tobacco smoke exposure and urinary cotinine were associated with LRI. Only the association between reported exposure and LRI remained significant after adjusting for confounders, [adjusted incidence of LRI (episodes/child-year) non-exposed: 0.6; < or = 10 cigarettes/day: 0.9 (RR 1.5, 95% CI: 1.1, 2.0); > 10 cigarettes/day: 1.3 (RR 2.2, 95% CI: 1.3, 3.8)]. We conclude that infants reportedly exposed to tobacco smoke have an increased incidence of LRI. There are differences between questionnaire and biochemical measures of passive smoking. Urinary cotinine will not necessarily improve the validity of studies of the relationship of passive smoking to LRI in infants.

The effectiveness of family planning programs evaluated with true experimental designs.

OBJECTIVES: This paper describes the magnitude of effects for family planning programs evaluated with true experimental designs. METHODS: Studies that used true experimental designs to evaluate family planning programs were identified and their results subjected to meta-analysis. RESULTS: For the 14 studies with the information needed to calculate effect size, the Pearson r between program and effect variables ranged from -.08 to .09 and averaged .08. CONCLUSIONS: The programs evaluated in the studies considered have had, on average, smaller effects than many would assume and desire.

The Safe Dates Project: theoretical basis, evaluation design, and selected baseline findings.

Approximately 20% of adolescents have experienced violence from a dating partner. The Safe Dates Project tests the effects of a program on the primary and secondary prevention of dating violence among adolescents living in a rural North Carolina county. The program being evaluated aims to prevent dating violence by changing dating violence norms, gender stereotyping, conflict-management skills, help-seeking, and cognitive factors associated with help-seeking. School activities include a theater production, a 10-session curriculum, and a poster contest. Community activities include special services for adolescents in violent relationships and community service provider training. A pretest-posttest experimental design with random allocation of 14 schools to treatment condition was used to test study hypotheses. Data were collected in schools using self-administered questionnaires. Eighty-one percent (n = 1,967) of the eighth- and ninth-graders in the county completed baseline questionnaires, and 91% of those adolescents completed follow-up questionnaires. The sample is 75.9% Caucasian and 50.4% female. Baseline data indicate that 25.4% and 8.0% of this sample have been victims of nonsexual and sexual dating violence, respectively, and 14.0% and 2.0% have been perpetrators of nonsexual and sexual dating violence, respectively. Consistent with other adolescent dating violence studies, both boys and girls report being victims and perpetrators of dating violence. Control and treatment groups are similar at baseline on all demographic, mediating, and outcome variables. Findings suggest that dating violence is prevalent among adolescents and that prevention programs are warranted.

On the importance of peer influence for adolescent drug use: commonly neglected considerations.

Peer influence is generally believed to be a major cause of adolescent drug behavior. This paper reviews research findings on friend selection and projection to suggest that the magnitude of friend influence may be overestimated. This paper also observes that, although adolescent drug use is assumed to begin in response to peer group influence, peer groups have rarely been measured in studies of drug behavior. Social network analysis is identified as a promising method for measuring peer groups. The implications of this review for research and programs are considered.