标题：The Linking Lives Health Education Program: A Randomized Clinical Trial of a Parent-Based Tobacco Use Prevention Program for African American and Latino Youths
摘要：Objectives. We evaluated the effectiveness of a parent-based add-on component to a school-based intervention to prevent cigarette smoking among African American and Latino middle school youths. Methods. Mother–adolescent dyads (n = 1386) were randomly assigned to 2 groups: (1) a school-based smoking-prevention intervention or (2) the same intervention with a parent-based add-on component called Raising Smoke-Free Kids. Mothers in the experimental condition received the parent add-on component. Mothers in the control condition received information on selecting a high school. All adolescents received a version of Project Towards No Tobacco Use (TNT). The primary outcome was a reduction in adolescent cigarette smoking. Follow-up data were obtained from 1096 mother–adolescent dyads at 15 months postintervention. Results. At follow-up, the odds of smoking cigarettes were reduced by 42% for adolescents in the parent add-on condition versus the TNT-only condition. Mothers in the parent add-on condition were more likely than were mothers in the TNT-only condition to set rules about risk-sensitive social activities and to be perceived as trustworthy by their child. Group differences also were found in the frequency and quality of mother–adolescent communication. Conclusions. Including parent add-on components in school-based smoking prevention programs can reduce smoking behavior on the part of inner-city middle school youths. Each day in the United States, more than 4000 adolescents aged 12 to 17 years try their first cigarette. 1 If current smoking patterns continue, an estimated 6.4 million of today's children can be expected to eventually die from a smoking-related disease. 2 Ethnic and racial disparities in smoking-related morbidity and mortality are well-documented. Data suggest that African Americans and Latinos are particularly vulnerable to the negative consequences of tobacco use. 3 , 4 Research suggests that parents can play an important role in preventing cigarette smoking among African American and Latino youths. 5 – 8 Parenting processes associated with protective effects include parent-adolescent communication about tobacco use, 9 parental disapproval of smoking, 8 and the institution of parental rules that discourage smoking. 10 , 11 In addition, studies have documented inverse relationships between high levels of parent–adolescent connectedness and involvement with adolescent smoking. 12 – 14 In recent years, a number of interventions have involved parents to prevent adolescent tobacco use. 15 – 19 A recent systematic review identified 22 randomized clinical trials of family-based interventions to prevent smoking; of these, the reviewers deemed 17 to be methodologically sound. 20 Of these 17 studies, 9 tested a family intervention against a no-treatment control group, and 4 of those 9 yielded statistically significant positive effects; 1 study that compared a family-based intervention with a school-based intervention found the family-based intervention to be more effective, and of the 7 studies that evaluated whether a family-plus-school program had incremental effects as compared with a school program alone, none yielded significant effects. 20 Most of the intervention studies that used parent-based add-on components were not realistic from a practical standpoint, lacked a theoretical basis, or suffered from methodological limitations. When tests evaluate whether parent-based add-on components have incremental effects over and above a nonparent intervention, a demanding standard is being set. This is because the parent add-on component is judged to be effective only to the extent that it affects youths whom the original program was unable to affect, and such youths are likely to be more resistant to change than were those affected by the original program. Although none of the tobacco-focused programs in the systematic review showed incremental effects, 20 we located 2 HIV-prevention programs that found a parent add-on component to have incremental effects on cigarette smoking. Wu et al. 19 tested whether a parental monitoring add-on incrementally affected multiple risk behaviors, including cigarette smoking, as compared with an HIV-prevention program alone. The researchers reported an incremental effect on whether the adolescent had ever smoked a cigarette at the 6-month follow-up but not at the 12-month follow-up. 19 Prado et al. 18 evaluated an incremental effect of a parent add-on for an HIV-prevention program aimed at sexual risk behavior and for a program aimed at cardiovascular health that directly addressed smoking (HeartPower! for Hispanics; the HEART program). They found no evidence for incremental parent add-on effects on smoking for the HEART program, but they reported that the HIV program plus the parent add-on had a surprising long-term effect (36 months) on smoking, compared with the HIV program alone. 18 It is unclear whether this is a reliable result. Overall, previous studies of parent add-on programs have found limited evidence of incremental effects on smoking relative to existing school-based programs aimed at preventing smoking in adolescence. For our study, we conducted a randomized clinical trial of a parent-based intervention to prevent cigarette smoking among inner-city African American and Latino youths in middle school. In contrast to past efforts, we used an add-on that was based on strong theories of behavior, extensive formative data yielding both adolescent and parental input for program design and delivery, and a structure that made parental involvement practical. The intervention was developmentally appropriate and was tailored to the ethnicity and urban context of the target population. The parent add-on program was called Raising Smoke-Free Kids and was developed as part of the Linking Lives Health Education Program, which was developed by V. G. R., J. J., and P. D. The theories and formative work that were the basis of the intervention are described elsewhere. 7 , 9 , 21 The stand-alone program we chose was the school-based Project Towards No Tobacco Use (TNT), 22 a well-known intervention with considerable efficacy data. 23 , 24
