National Cancer Institute

The Hutchinson Smoking Prevention Project (HSPP) was a 15-year randomized trial conducted by the Fred Hutchinson Cancer Research Center in Seattle, Washington, and supported by the National Cancer Institute (NCI) in Bethesda, Md. The purpose of the study was to determine the long-term impact on youth smoking of a school-based intervention from the third through 12th grade.

The intervention used a social-influences approach and included HSPP-developed anti-smoking curriculum units taught by HSPP-trained classroom teachers for students in grades three through 10. Supplemental high school components were implemented and available to students in grades nine through 12. These included motivational and self-help cessation materials, faculty training on how to encourage and support teen smoking cessation efforts, as well as posters and school newspaper advertisements with anti-smoking elements.

The primary outcomes of the trial were the number of participants in the control and intervention groups who smoked daily at grade 12 and at two years after high school (Plus Two).

Forty school districts in Washington state took part in the project from 1984 to 1999; 20 districts were randomly assigned to implement the HSPP intervention and 20 continued their health promotion and tobacco prevention activities already in place, to serve as a means of comparison (control).

Researchers enrolled 8,388 third-grade students in these 40 collaborating districts. The students in the intervention school districts received HSPP curriculum or materials from the third through the 12th grade.

The 40 school districts were situated in demographically and geographically diverse communities in rural or suburban settings. Intervention and control districts were similar at baseline for all child and parent characteristics that were measured, including child's early experimentation with cigarettes, parent's education level, parent's smoking, and single-parent households.

Of the 8,388 students who were enrolled as third-graders, 7,798 (93 percent) completed a grade 12 survey and 7,865 (94 percent) completed a Plus Two survey.

Researchers were interested in two main outcomes: current daily smoking at grade 12 and at Plus Two. For those students who were still enrolled as 12th-graders in an HSPP school district (49 percent of the original group), the grade 12 survey was conducted in class. HSPP-trained staff promised confidentiality and emphasized the need for accurate reports. For those students who were no longer enrolled (51 percent), the grade 12 survey was done primarily over the phone. For all study participants, the Plus Two survey was conducted through the mail, with telephone and mail follow-up to students who did not initially respond.

Because the surveys were based on self-report, and misreporting of tobacco use is a possibility among teens, each 12th-grader was also asked to provide a saliva specimen for cotinine analysis. Students were provided with an explanation of the saliva cotinine test and a demonstration of its collection. Cotinine is made in the body from nicotine, which is found in cigarette smoke. Since cotinine can only be made from nicotine, cotinine measurements from blood, urine, or saliva can show how much cigarette smoke enters the body.

The intervention did not show any impact on youth smoking, either at grade 12 or at Plus Two. The number of both boys and girls who smoked or who started to smoke during the project, as well as their ages when they started to smoke, were approximately the same between the intervention counties and the control counties. At grade 12, 25.7 percent of adolescents in the control group were daily smokers and 25.4 percent in the intervention group were daily smokers. At Plus Two, 29.1 percent in the control group were daily smokers and 28.4 percent in the intervention group were daily smokers.

A small difference was found in the number of cigarettes smoked per day among daily smokers: 10.4 by students in districts without the intervention and 9.6 in the intervention districts. The authors concluded that the HSPP intervention had little or no impact on smoking prevalence.

This study shows that a curriculum-based social influences program aimed at smoking prevention was ineffective. These findings indicate that more research is needed to define the components of effective smoking prevention efforts.

Other approaches, such as Life Skills Training, have been shown to be more effective in preventing smoking among youth. Smoking prevention approaches that have demonstrated effectiveness should be encouraged in the context of a comprehensive tobacco control program that includes strictly enforced school tobacco-free policies, active parent and community involvement, cessation services for students and staff, and coordination with community and media efforts to reduce tobacco use.

The social-influences approach focuses on helping youth to identify and resist social influences to smoke. The HSPP program incorporated such social influence components as: bolstering skills to recognize the social influences of smoking, including advertising and peer pressure; fostering skills for resisting those influences to smoke; and increasing awareness of and promoting tobacco-free social norms.

The HSPP began 16 years ago, in 1984. When the NCI and the Centers for Disease Control and Prevention (CDC) developed recommendations for effective school-based prevention programs in 1987 and 1994, respectively, researchers sought to include recommended curriculum elements from those guidelines in the HSPP curriculum. However, both the CDC and the NCI stressed that those recommendations were based on the best prevention knowledge at that time and emphasized the need for continued research.

The national efforts to prevent nicotine addiction among this country's youth must be focused on the most effective strategies. The 1999 Youth Risk Behavior Survey showed that 34.8 percent of U.S. high school students smoke at least once a month. Studies suggest that those who begin smoking at young ages are more likely to become heavy smokers and have a higher risk of dying from smoking-related diseases. The CDC has estimated that if current rates of smoking persist, over 5 million youth in this country below age 18 will die prematurely of a smoking-related disease.

The Hutchinson Smoking Prevention Project cost approximately $15 million over 15 years.

The Hutchinson study is the first of its kind in terms of the quality of the science and the length of follow-up. Although NCI does not have plans to support a similar, long-term intervention study at this time, NCI is currently supporting 50 research grants addressing youth tobacco. These grants encompass a broad range of topics including: research examining initiation, experimentation, and progression to regular tobacco use; testing and implementing prevention interventions such as media and policy; studying dependence to, and withdrawal from, nicotine; and assessing treatment and tobacco cessation such as behavioral and pharmacological interventions. In addition, NCI is funding 12 community-based tobacco control studies.