Smoking-prevention strategy targets fourth-graders in Georgia

A smoking-prevention strategy that targets black fourth-graders and their parents is under study in urban and rural Georgia.

Researchers want to know if they can keep these children from smoking and help smoking parents quit, according to Dr. Martha S. Tingen, nurse researcher at the Medical College of Georgia's Georgia Prevention Institute, and Interim Program Leader for Cancer Prevention and Control, MCG Cancer Center.

Dr. Tingen is principal investigator on a $2.5 million National Cancer Institute grant to determine if this novel strategy of concurrent intervention in the classroom and at home reduces smoking and related disability and death in blacks. Blacks tend to have higher rates of second-hand smoke exposure and more adverse health effects than whites.

“Every day in Georgia, 84 kids between 10 to 13 years of age start smoking cigarettes,” says Dr. Tingen. “Ninety percent of all smokers start before they are out of high school. If we can help keep kids from smoking before they get out of high school, they probably won't ever start. I am hoping the fourth graders haven't started smoking, but I am thinking a lot of them still are exposed to tobacco use and second-hand smoke in the home.”

Researchers are enrolling 350 students and their parents or guardians in 16 elementary schools in Augusta, Ga., and rural Jefferson County, Ga., about 60 miles away. During the fourth and fifth grades, half the children will get two intense learning sessions per week over four weeks of Life Skills Training, developed by Dr. Gilbert J. Botvin, director of the Institute for Prevention Research at Cornell University Medical College.

Children will learn basics such as communication skills, decision-making and assertiveness. Their parents/guardians will get similar instruction as well as additional information on topics such as being a good role model and effective parenting skills.

Pilot studies in 60 families showed Life Skills Training increased refusal skills and self-esteem, better-equipping kids to say no to a friend's offer of a cigarette, Dr. Tingen says. Parents and guardians also liked working with their children on the project. In those studies, 40 percent of the parents said they smoked, 80 percent of children reported that their parents smoked and all children had saliva testing that showed they were exposed to second-hand smoke.

Dr. Tingen estimates that 30-40 percent of the parents/guardians in the new study will be smokers. They also will receive self-help information, motivational interviewing and the nicotine patch. Motivational interviewing focuses on an individual's strengths in prior situations to help quit smoking.

Children in the control group will receive the standard health curriculum in Georgia and their parents/guardians will receive general health education information on nutrition, physical activity and risk factors for cancer and cardiovascular disease.

Levels of cotinine, a breakdown product of nicotine readily measured in saliva, will be documented in both groups at baseline, at two years and as a follow-up at three years. “Cotinine levels can be measured so precisely, it can tell if you are a smoker, if you are not a smoker but are exposed to second-hand smoke, or if you are not a smoker and not exposed,” Dr. Tingen says.

“We are trying to create this environment where parents work with kids on expectations at home so they can say, ‘We are just not going to be one of those families that have smoking going on,'” she says. “Young children are greatly influenced by what their parents do. When parents role model cigarette-smoking, it has a dramatic effect on their children. In fact, most children who smoke got their first cigarettes from their parents.”

Her goals include turning things around so that children become change agents for parents. Having Life Skills Training as a part of the standard curriculum would help, she says, noting the courses offered through the grant would be an easy permanent fit since they meet 70 percent of mandated state health education requirements. Dr. Tingen, a certified Life Skills trainer, will teach health teachers, school nurses and counselors to lead the programs. Children will start taking classes in January.

“Tobacco has been and still is the number-one cause of premature death and disability,” Dr. Tingen says. “It's directly linked to many cancers, not just the lungs, but also the jaw, the stomach, the bladder, as well as cardiovascular disease, high blood pressure and stroke.” As long as nicotine is in the body, it's doing damage, she says. “That's in addition to the other 4,000 chemicals in cigarettes that you are huffing and puffing on or that you are exposed to.”

Whites tend to metabolize and excrete nicotine more quickly than blacks, resulting in more adverse effects in blacks, according to her previous studies looking at four genes that metabolize nicotine. Smoking rates among all Georgia students have increased since 1991, with black students experiencing the highest increase at 80 percent. Black youths also tend to have high exposure rates to second-hand smoke, MCG researchers say.

“Every child at some point in his/her life, is given the opportunity to start smoking,” Dr. Tingen says. “Study after study has been done on kids in the ninth and 10th grades, asking if they could quit and they all say they could easily quit before graduation if they want. But you go back and survey them and they can't quit. Quitting smoking is incredibly difficult; the average person tries five times before they are successful. Our goal is that children never start and that parents role model this expectation.”