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NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSIbN Introduction In the period since the 1979 Surgeon General's report, adolescent smoking behavior has received as much research attention as almost any other health- risk behavior. We know a great deal about the prevalence and natural history of adolescent smoking as well as the correlates and predictors of smoking behavior. In addition, there have been a series of well designed,, theoretically based experiments to evaluate adolescent smoking prevention programs that match or exceed, in number and quality, program evaluation in any other area of health behavior. After a substantial decline in the late 1970's, smoking behavior among adolescents has not decreased appreciably over the past five years, and the most intensive intervention efforts have been judged to be of only modest success.. In this paper we review and summarize what we know about the natural history of adolescent smoking behavior and the results of smoking interventions directed at adolescents. Varied~intervention approaches have been attempted, but the most commonly evaluated programs focus primarily on social influences that are assumed to play a role in smoking initiation. Almost all interventions have placed a heavy emphasis on primary prevention: through the modification of peer influences and other social psychological correlates of smoking. We reexamine the appropriateness of these foci in light of the avaiLable theory and research results and make recommendations on research and public policies relevant to adolescent smoking. We think that the available data suggest a need to reassess the types of research and intervention programs directed at adolescent smoking. Specifically, we think that it is inappropriate to focus almost exclusively on

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSI~ON questionnaire that their saliva would be analyzed for tobacco products. It is not possible to make definitive conclusions about trends among adolescents, but we think the accumulation of evidence showing a decrease in smoking prevalence, and the remarkable similarity of these trends to those among adults, as well as the results of this validity study, support the argument that changes in reported smoking rates reflect real changes. Despite the fact that smoking rates appear to be falling among adolescents in a way that mirrors adult trends, there is sti1L good~reason to be concerned with smoking among adolescents. It is usually assumed that it is better to prevent a disease or unhealthy behavior than to cure the disease or change the behavior once it has been learned (c.f. Johnson, 1982). However, this is not true if the incidence of the disease or behavior in the target population is relatively low or the preventive measures don't have a lasting effect. For smoking, the available data suggest that interest in prevention is justified because of the high risk of intitial use during a relatively brief span of years, and by the relationship that early smoking appears to have with later use of cigarettes. Wong-McCarthy and Gritz (1982) found that a substantial amount of first time smoking occurs after the transitions of entering junior high school or high school. Kandel and colleagues have been conducting longitudinal studies of substance use among adolescents for many years. They recently analyzed results from a ten year follow-up study of 1,325 people who were in the 10th and llth grades in the Fall of 1971 (Kandel and Logan, 1984). They calculated hazard functions for various substances and found that the period of major risk for initiation of cigarettes, alcohol, and marijuana were for the most part complete by age 20. For cigarette smoking, for example, they found that

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION. 13 Moskowitz (1985) has stated that it is premature to conclude that these programs are effective in preventing cigarette smoking. He points out that the studies have yet to demonstrate effects on the more established'habitual smoking that generally does not occur until the high school years. A fourth generation of studies consisted of large scale trials typically involving five or more units per condition. All of these evaluations were based on the social influences approach. Botvin, Renick, and Baker (1983) have asserted that psychosocial smoking prevention strategies are capable of producing initial reductions in smoking behaviors of about 50% and that longer-term~results look promisimg.F1ay (1985b) concludes that the data:from these studies suggest that the social influences approach to smoking prevention can be effective some of the time. He warns, however, that this conclusion is a tentative one because of the inconsistencies in the patterns of results. The importance of viewing some of these results as tentative is emphasized in a review of one of the more successful intervention programs, the Waterloo Study (Best et al., 1984, Flay et al., 1985). Flay (1985b) concludes that the results of the Waterloo study represent one of the most rigorous tests of the social influences approach to smoking prevention. Flay interprets these results as suggesting reasonably good'.maintenance of long term effects and notes the importance of the findimg that the program was most effective for students at high risk. The results from the Waterloo study do indeed appear encouraging. Among students in the experimental program who were not smoking at the beginning of the study, 60% were still non-smokers at the end of the eighth grade, whereas the comparable figure for the control group was 47%. Among students who said they had tried smoking at the beginning of the study, 43% of the students in

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION 14 the experimental program quit, as opposed to 25% of the comparison group--a statistically significant difference. Even more impressive was the finding that among students classified as being at high social risk, 77.8% of the students in the experimental group remained never smokers, while the figure was only 44.48 for those in the control group. These results appear to suggest that focusing on social influence processes in order to reduce the onset of smoking can be efficacious. However, from a public health perspective, it is important to consider not only the relative differences, but also the total number of students affected and the robustness of the effects. For example, only 44% of the students in the Waterloo study were non-smokers at the beginning of the study and 33% were regular smokers. Partly as a result of this stratification, only one of the 17 contrasts between the experimental and control groups at the end of grade eight was statistically significant.. Similarly, there were only 36 students in the high social risk group who were non-smokers at the beginning of the study. Thus, the difference of 78% versus 44% reported by Best et al. (1984) reflects the fact that 14 smokers in the experimental versus 8 in the control group remained non-smokers--a difference of 6 students. As Flay et al. (1985) assert, these results are "fragile." This is especially true if one takes into account how unstable these reported patterns at the end of gzade eight are likely to be. Most program evaluations conducted to date have been concerned primarily with the efficacy of specific programs. With apologies to McGuire, one might say that the research has focused on finding the best vaccine for inoculating students. In conducting an efficacy trial, it is appropriate to focus on persons at risk. Before preventive measures are implemented, however, it is necessary to ask what the impact on the entire population wi11 be. In the

NOT FOR REPRODUCTION, QUOTATION„ OR CITATION WITHOUT AUTHOR''S'PERMISSION 15 case of adolescent smoking, this means that instead of asking how many non- smokers are prevented from smoking in a six month period of a specific trial,, we should try and estimate what proportion of all adolescents will be prevented from smoking. This is a complex question that cannot be answered definitively with existing data. However, in order to at least sensitize policy makers to this issue we have calculated two statistics for a number of representative intervention studies. The statistic that may be of most interest to public health officials is what we refer to as Attributable Prevention in the Population. This simply refers to the proportion of all students affected by the program. For example, if two schools with 100 students each are assigned to an experimental and control program respectively, and the proportion of new smokers in the experimental school is 10% and the proportion of new smokers in the other is 5%, we say that the Attributable Prevention in the Population is 5%. Therefore, the upper limit of Attributable Prevention in the Population is the prevalence of the behavior. Experimental and control groups often~exhibit different behavior before the start of a study and both groups usually change behavior over the course of time. The methods available for adjusting for such differences are varied and sophisticated (Cleary, 1983) but for simplicity we simply subtract base rates from rates at the end of the study. For example, if in an experimental program~the rate of smoking increased from 4% to 10% whereas the control group increased from 3$' to 5%, we would say the Attributable Prevention in the Population was 4% (10-4 versus 5-3). This is not a statistically correct way of adjusting for group differences„ but in the absence of the original data, it provides a rough way of comparing studies. Data are sometimes reported only for students "at risk." For example, if 70% of both schools already have experimented with smoking, one might

NOT FOR REPRODUCTION, QUOTATION, OR CITATIWWITHOUT AUTHOR'S PERMISSION 16 analyze data for only non-smokers. In the example given above, if only 30% of both schools were used for analyses, the results would indicate that about 33% of the,non-smokers in the experimental school were prevented from~smoking and about 17% were prevented from smoking in the control group--a difference of 16%. To facilitate comparisons among studies, if data are presented only for a "risk group" we calculate what the Attributable Prevention in the Population would be. These types of calculations are a start towards answering the question of what proportion of students would be prevented from smoking for the period of the study if the intervention was applied to that type of population. These figures, along with some description of the studies are presented in Table 1. These studies were drawn from the list compiled and reviewed by Flay (1985a, Table 1).

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION, 18 Washington III 6th 689 6X-9X smoking 2 yrs 4.OX5 (original past week sample) Tennessee 6th-9th 1472 (origiaal sample) 2 yrs FA6 Stanford I l0th 871 2.9X smoking past week 6 mos 3'.SX past month 6 mos 9.7% Stanford II 10th 583 (original sample) cessation 3 mos 11. 3% 0.9X Waterloo 6th 439 33.0X never smoked quit 301 mos 12.9% 5.7X7 regular smoking (among triers). 30lmos 18.OX 6.0% Australia 7th 1964 18.3% smoking initiation 16 mos 5.9% 3.8% smoking cessation 16 sas -1.1X -0:4X Footnotes: 1. Evans included students who wore only exposed to repeated testing in, the experisuentaL group. If those students are considered part of the control group the attributable prevention statistics are5.2Xand 3.6Xrespectively. 2. Estimated: from a published bar graph (Schinke & Blyth, 1982). 3.. Assumes that control and experimental groups were equal at baseline. 6nlypost-test resulits~ were reported. 4. Results from two experimental groups were pooled, assuming that they were of equal size.Bumber of students in each group was not reported. 5.. Estimated from a line.graph. Results frominformation-only group combined with results from.m control group. 6.. Pentz (1984) presents only tests ofsi'gnificance for treatment effects on, cigarette use., 7.. Experimental and control groups assumed to be equal atbaseline..

NOT FOR REPRODUCTION, QUOTATION!„ OR CITATION WITHOUT AUTHOR'S PERMISSION 20 There are a number of detailed reviews of the methodological limitations of these issues (Biglan and Ary, 1985; Battjes and'Bell, 1985; Flay, 1985a and 1985b; Lando, 1985; Moskowitz, 1985; Snow, Gilchrist, and Schinke, 1985) and it is not necessary to repeat that material here. Suffice it to say that even the most recent studies suffered problems associated with unit of assignment to experimental conditions, integrity and strength of the treatment as delivered, unit of analysis, attrition, failure to assess treatment interactions, reactive effects of repeated measurements, lack of attention to the differential impact of program in different subsets of students, restricted study populations (e.g. never smokers), and Hawthorne effects. (For reviews of similar problems with drug abuse program evaluations see Schaps et al., 1981 and Moskowitz, 1985.) The observations of methodological problems that numerous authors have made are perceptive, accurate, and noteworthy. However, we disagree with Flay's (1985a) recommendation that we should conduct more large-scale studies;; in effect "bigger and better" studies to address some of the methodological problems mentioned. The experiments he reviews have been carefully developed from sound theoretical work. They have been implemented with great care by some of the best researchers in the field, and the results have been carefully and honestly reported. The methodological shortcomings pointed out by the various reviews cited are important, but these are to be expected givemthe complexity of the research (Lando„ 1985). It is our opinion that evaluations of adolescent smoking prevention programs are among the best evaluation work done on changing health behavior, and that the results are definitive and obvious: the types of programs reviewed can have temporary, small effects on smokingg behavior.

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION' 22 A second assumption apparently motivating much of the current research that focuses only on smoking prevention concerns the relationship between adolescent experimentation~with smoking and the adoption of other problematic behaviors such as alcohol and/or drug abuse. For example, Kandel (1975) and colleagues view the use of various substances as links in a chain of progressively more serious use and abuse., If this is true, then the limited impact of smoking programs on smoking behavior is not as troubling because there will be an effect on many types of substance use. It is important, we think, to critically re-examine some of the research that is used to justify these positions. Social Correlates of Smoking In order to develop public health programs to reduce the prevalence of smoking, it is necessary to understand something about the factors that cause smoking.. By combining theories of behavior and the empirical findings on adolescent smoking, it may be possible to develop a better understanding of the issues that need to be addressed if we are to have an impact on smoking behavior. A key theoretical perspective used to explain the association between peer'smoking and adolescent smoking is social learning theory (Bandura, 1977). Social learning theory describes the importance of vicarious and symbolic learning. That is, adolescents "learn" about smoking and the positive and negative consequences of smoking by watching peers and adults smoke. According to social learning theory,, there are four central processes that determine learning: attention (e.g. watching friends smoke), retention, motor reproduction (e.g. actually trying a cigarette), and motivation or incentive

NOT FOR REPRODUCTION,.QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION' 28 behind white children in early experience and adoption of smoking behavior" (Hunter, Webber and Berenson 1980, p. 701). At all ages, black children who smoked consumed fewer cigarettes than white children. Bachman, 0'Malley and Johnston (1980) reported that black high school seniors smoked less than their white counterparts in 1979--a pattern opposite from that found in 1969. In Covington & D'Onofrio's study (1985) of approximately 6,500 sixth, eighth, and tenth grade students in the San Francisco Bay area, Asian students reported the lowest prevalence of smoking (1.4%, 11.5%, 13.0%, respectively, for Grades 6, 8 & 10). Hispanics students reported consistently higher prevalence for the same grade levels: 9.4$, 22.58,and 20.0%. Black and white students had about same prevalence at Grade 6(4.6$ and 4.5%) and at Grade 8 (18.78 and 18.98).. By 10th grade, however, the black students in this sample had the highest prevalence of all age and ethnic groups, 25.2%. There are a number of other findings that are not easily explained by viewing smoking among adolescents solely as a socially learned behavior. For example, children from "broken homes" smoke more than children from intact two-parent homes (Green, 1979; Bachman, 0'MaILey and Johnston, 1980,, p. 12). The Monitoring the Future Study has also found greater drug and cigarette use among the high school seniors who worked a substantial number of hours at a job, had higher incomes, dated more often, and spent more evenings out of their families' home (Bachman, O'Malley and Johnston, 1980)., These correlations were strongest for females. Banks, Bewley, Bland, Dean and Pollard (1978) found very similar patterns: "Having more money to spend, working at a part-time job, spending more evenings out with a mixed-sex peer group, at a youth club, or out dancing ...were all associated with an increased risk of smoking... The best predictor of smoking and experimenting with cigarettes for both boys and girls was attending youth clubs..."'(p. 16).

NOT FOR REPRODUCTION, QUOTATION, OR CITATION'WITHOUT AUTHOR'S PERMISSION 29 Similarly, Murray et al. (1983) found that both initiation and changes in smoking were related to having friends of the opposite sex. Green (1979) also found a pattern of greater smoking on the part of students who worked. Other Theoretical Perspectives. Clearly, a social influences model of smoking acquisitiomis not adequate to explain these disparate findings. However, there are a number of other important behavioral theories that can be brought to bear on the issue of adolescent smoking. For example, although smoking is almost normative among adolescents, from an adult perspective it can be considered a "deviant behavior" and there is a large amount of theory and empirical research to explain why adolescents adopt deviant behaviors. Another major research paradigm is that developed by Jessor and Jessor (1977). They describe socio-cultural, personality, and social systems and describe how these affect behavior. Their work is especially interesting because they hypothesize that there are behavior syndromes that consist of groups of behavior with a common social genesis. To the extent that general social factors are operative, specific interventions focused on smoking behavior will not be very effective. Skinner and colleagues (Skinner, Massey, Krohn, and Lauer, 1985; Krohn, Massey, Skinner, and Lauer, 11983) have tested the hypothesis that social bonding theory and differential association theory explain smoking behavior. Social bonding theory (Hirschi, 1969) posits that individuals will tend to behave in individualistic and "deviant" ways unless constrained by ties to conventional society. These constraints are maintained througi3 four types of bonds to conventional society: attachment, commitment, involvement, and belief. This theoretical perspective does not focus on the learning of behavior, but rather on the mechanisms of social control. Skinner, Massey, Krohn, and Lauer (1985; Krohn, Massey, Skinner, and Lauer, 1983) tested this

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION 30 theory using data from a two-wave panel study of 1405 students in 7th through 12th grade. The findings generally supported the hypothesis that adolescents' ties to conventional society are important in constraining deviant behavior. Commitment to education, attachment to father and mother, and association with female smoking friends were the variables most strongly associated with differences in rates of smoking initiation, whereas attachment to father, beliefs about smoking, and association with both male and female smoking friends were important for cessation. The Muscatine study has also reported important results on parental and peer influence and ties to conventional social order. Although we tend to assume that adolescents smoke for reasons that are different from the reasons that motivate adults, this may not be the case. A good example of this is regulation of emotional states. Recent analyses of data from the West German study of adolescent smoking indicate that beliefs about the effect of smoking on affective states are predictors of changes in smoking behavior (Semmer, Cleary, Dwyer et a1., 1986). Similarly, Wills (1985) found that stress was related to an increased probability of cigarette use among two cohorts of public school students who were in the seventh grade when first interviewed. These various findings do not imply that social influences are not important. For example, regional or racial differences could simply be a function of the salience of different models. Furthermore, social influences are probably major mechanisms for maintaining these differentials. Thus, social influence is undoubtably extremely important in influencing the anticipation of, the experimentation with, and the adoption of smoking. However, social influence models explain transmission and cannot account for the important class, race, and regional differentials that have been observed.

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION 31 Surprisingly, only the most recent, sophisticated programs programs take into account the various processes that theory would predict to be important in the initiation and maintenance of smoking. One example is the work conducted by Glynn, LeventhaL, and Hirschman (1985). In the program that they have developed, they explore, in some depth, the nature of the user's physical as well as psychological response to cigarettes and attempt to provide knowledge that promotes a negative evaluation of those reactions. They speculate that such an approach will be especially effective with experimental smokers who are evaluating the efficacy of smoking for themselves. Public Health Policy Considerations We think that there may be very little utility in conducting further large scale school smoking prevention research and demonstration programs based primarily on social learning theory and focused almost exclusively on prevention. Our conclusions are consistent with the directions adpoted by some of the most recent programs that are currently in planning or implementation stages. The most innovative programs have adopted a much broader theoretical perspective and focus on~a full range of smoking behaviors. To be effective, a public health program aimed at reducing smoking, or alcohol and drug abuse among adolescents nationwide, ideally would utilize a program model or models with attributable prevention rates considerably higher than those we have reviewed here. However, even if one were to accept these moderately successful models as the best available for a broad school-based prevention strategy there are a number of other important criteria that must be considered. First, regardless of the relative effectiveness of any prevention model, it must be "marketable" in the sense that it can be easily and rapidly

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION Perry, C. (Eds.) Promoting adolescent health: A dialog on research and practice. New York: Academic Press, 1982. 46 Evans, R.I.; Rozelle, R.M.; Mittelmark, M.B.; Hansen, W.B.; Bane, A.L.; Havis, J. Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. Journal of Applied Social PsychologX, 8(2): 126-135, 1978. Evans, R.I.; Rozelle, R.M.; Maxwell, S.E.; Raines„ B.E.; Dill, C.A.; Guthrie, T.J.; Henderson, A.H.; Hill, P.C. Social modeling films to deter smoking in adolescents: Results of a three-year field investigation. Journal of Applied Psychology, 66(4): 399-414, 1981.. Evans, R.I.; Smith, C.K.; Raines, B.E. Deterring cigarette smoking in adolescents: A psycho-social-behavioral analysis of an intervention strategy. In Baum, A.; Singer, J.; Taylor, S. (Eds.) Social psycholo ical aspects of health. Hillsdale, N.J.: Lawrence Erlbaum Associates, Inc., 1984. Fisher, E.B. Progress in reducing smoking behavior. American Journal of Public Health, 70: 678-679, 1980. Fisher, E.B.; Gritz, E.R.; Johnson, C.A. Cessation of Smoking. In U.S. Public Health Service. The Health Consequences of Smoking: Cancer A Report of the Surgeon General. DHHS Pub. No. (PHS) 82-50179. Washington, DC: Superintendant of Documents, U.S. Government Printing Office, 1982. Flay, B.R. Psychosocial approaches to smoking prevention: A review of findings., Health Psychology, 4(5): 449-48'8,, 1985a. . Flay, B.R. What we know about the social influences approach to smoking prevention: Review and communicaions. In Bell, C.S. and Battjes, R. (Eds.) Prevention Research: Deterring Drug Abuse Among Children and Adolescents. National Institute on Drug Abuse Research Monograph 63. DHHS Pub. No. (ADM) 85-1334. Washington, D.C.: Superintendant of Documents, U.S. Government Printing Office, pp. 67-111, 1985b. Flay, B.R. Personal Communication, August 15, 1986. Flay, B.R.; d'Avernas, J.R.; Best, J.A.; Kersell, M.W.; Ryan, K.B. Cigarette smoking: Why young people do it and ways of preventing it. In Firestone,. P. and McGrath, P. (Eds.) Pediatric and Adolescent Behavioral Medicine. New York: Springer Verbig, pp. 132-183, 1983. Flay, B.R.; Ryan, K.B.; Best, J.A.; Brown, K.S.; Kersell, M.W'.; d'Avernas, J.R.; Zanna, M.P. Are social-psychological smoking prevention programs effective?: The Waterloo Study. Journal of Behavioral Medicine, 8(1): 37- 59, 1985. Friedman, L.S.; Lichtenstein, E.; and Biglan, A. Smoking onset among teens: An empirical analysis of initial situations. Addictive Behaviors, 10:L-13', 1985.

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION 48' Hunter, S.M.; Webber, L.S.; and Berenson, G.S. Cigarette smoking and tobacco usage behavior in children and adolescents: Bogalusa Heart Study. Preventive Medicine, 9:701-712, 1980. Iverson, D.C. Promoting health through the schools: A challenge for the eighties. HeaLth Education OuarterlX, 8(1): 6-10, 1981. Jessor, R. and Jessor, S.L. Problem Behavior and Psychosocial DeveLopment: A Longitudinal Study of Youth. New York: Academic Press, 1977. Johnson,, C.A. Prevention and control of drug abuse. In Last, J.M. (Ed.). Maxcy-Rosenau Public Health and Preventive Medicine. 12th ed., Norwalk, Conn.: Appleton-Century-Crofts, 1986. Johnson, C.A. Untested and erroneous assumptions underlying anti-smoking programs. In Coates, T.; Peterson, A.; Perry, C. (Eds) Promoting Adolescent Health: A Dialog on Research and Practice. New York: Academic Press. 1982. Johnson, M.R.D.;- Bewley, B.R.; Banks, M.H.; Bland; J'.M~.; and Clyde, D.V. Schools and smoking: School features and variations in cigarette smoking by children and teachers. British Journal of Educational Psychology, 55: 34,- 44, 1985. Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. Drugs and American High School Students: 1975-1983. National Institute on Drug Abuse. DHHS Pub No. (ADM) 85-1374. Washington, D.C.: Superintendant of Documents, U.S. Government Printing Office, 1984. Johnston, L.D.; O'Malley, P'.M.; and Bachman, J.G. Use of licit and illicit drugs by America's high school students: 1975-1984. National Institute on Drug Abuse. DHHS Pub. No. (ADM) 85-1394., Washington D.C.: Superintendant of Documents, U.S. Government Printing Office, 1985. Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. Drug_Use among American high school students, college students. and other young adtults: National trends through 1985. Rockville, MD: National Institute on Drug Abuse. DHHS Pub. No. (ADM) 86-1450. Washington, D.C.: Superintendant of Documents, U.S. Government Printing Office, 1986. Jones, E.L.; Kanouse, D.E.; Kelley, H.H.; Nisbett, R.E.; Valins, S.; Weiner, B. Attribution: Perceiving the causes of behavior. Morristown, N.J.: General Learning Press. 1972. Kandel, D.B. Homophily, selection, and socialization~in adolescent friendships. American Journal of Sociology, 84: 427-436„ 19Z8. Kandel, D.B. Stages in adolescent involvement in drug use. Science, 190:' 912-914, 1975.

NOT FOR REPRODUCTION, QUOTATION, OR CITATION WITHOUT AUTHOR'S PERMISSION 50 Moskowitz, J.M. Preventing adolescent substance abuse through drug education. In Glynn, T.J.;, Leukefeld, C.G.; Ludford, J~.P. (Eds.) Preventine Adolescent Drug Abuse: Intervention Strategies. National Institute on Drug Abuse Research Monograph 47. DHHS Pub. No. (ADM) 85-159663. Washington, D.C.: Superintendant of Documents, U.S. Government Printing Office, pp. 170-195, 1985. Murray, M.; Swan, A.V.; Bewley, B.R.; Johnson, M.R.D. The development of smoking during adolescence - The MRC/Derbyshire smoking study.I'nternational Journal of EnidemiologX, 12: 185-192, 1983. National Center for Health Statistics: Provisional Data from the Health Promotion and Disease Prevention Supplement to the National Health Interview Survey: United States, January-June 1985, Advance Data from Vital and Health Statistics. No. 119. DHHS Pub. No. (PHS) 86-1250. Public Health Service, Hyattsville, Md., May 14, 1986. Newman, I.M. Capturing the energy of peer pressure: Insights from a longitudinal study of adolescent cigarette smoking. Journal of School ea h, 54: 146-48, 1985. O'Malley, P.M.; Bachman, J.G.; and Johnston, L.D. Period, age, and cohort effects on substance use among American youth, 1976-82. American Journal of Public Health, 74(7): 682-688, 1984. O'Rourke, T.;, Nolte, A.E.; Smith, A.J. Improving anti-smoking education: Profiling the ex-smoker. Journal of Drug Education, 15(1): 7-22, 1985. Pechacek, T.F. and McAlister, A.L. Strategies for the modification of smoking behavior: Treatment and prevention. In Ferguson~„ J.ff. & Taylor, C~.B. (Eds.) A comRrehensive handbook of behavioral medicine Extended' a4plications and issues: Vol. 3. New York: SP Medical and Scientific, 1980. Pentz, M.A., Differences in research and secular trends in prevention.. Manuscript in preparation. Pentz, M.A. Social competence skills and self-efficacy as determinants of substance use in adolescence. In Shiffman, S.; Wills, T.A. (Eds.) Coping and substance abuse. New York: Academic Press, 1985. Perry, C.; Killen, J.; Telch, M.; Slinkard, L,A.; Danaher, B.G. Modifying smoking behavior of teenagers: A school-based intervention. American Journal of Public Health, 70(7): 722-725, 1980. Reed, Charles E., What are Schools Doing..to Discourage Cigarette Smoking? Health Education, 16-17, Mar./Apr. 1981. Schaps, E.;. DiBartolo, R.; Moskowitz, J.M.; Palley, C.S.; Churgin, S. Primary prevention evaluation research: A review of 127 impact studies. Journal of Drug Issues, 11: 17-43, 1981.

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