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pyrig ORIGINALoARTICLE N ot C for Pu bli cat ion Impact of Behavioural Interventions on Young te People’s Attitudes Toward Tobacco Use sse nc e
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Eva Hedmana/Ulla Riisb/Pia Gabrea
Purpose: The objective of the present study was to study the ability to influence young at-risk patients’ attitudes toward tobacco use through two intervention methods that were performed by dental health professionals. Materials and Methods: Two interventions, a brief individual motivational interview and an adapted school lecture, were studied, and both were compared with a control group. Before and after interventions, a questionnaire was used. Patients born in 1989 and 1992 who were judged by the dental personnel as potentially at risk for dental diseases, a total of 301 individuals, were included. Results: Both before and after interventions, the results showed a generally negative attitude towards tobacco use. A majority of the participants were positive towards measures that were taken to control the spread of tobacco use, younger participants (born 1992) to a greater extent (73%) than the older participants (born 1989) (54%). Important factors that kept the participants away from tobacco use were the harmful effects and the approaches of parents and friends. The older participants believed to a greater extent that they would try smoking as adults. No change in tobacco use was registered after intervention, although the participants reported an increased use among friends. Conclusions: The two pedagogical methods that were used in the present study influenced the young people’s attitudes towards tobacco use only to a small extent. However, the period between 12 and 15 years old seems to provide a good opportunity to influence attitudes towards tobacco. The adolescents’ demand for interactive learning and their development of attitudes and tobacco use habits in relation to family and friends provide opportunities to use new pedagogical models. Key words: adolescent, attitude to health, health education, intervention study, tobacco use Oral Health Prev Dent 2010; 8: 23–32.
he association between tobacco use and impaired health has been clearly demonstrated (for review, see Doll, 1998). Tobacco use is also associated with an increased risk of oral diseases such as periodontitis and oral mucosa lesions (Papapanou, 1999; Roosaar et al, 2007). In addition, several studies report that smokers, more often than nonsmokers, suffer from dental caries (Hirsch et al,
T
a
Department of Preventive Dentistry, Public Dental Health, Uppsala County Council, Sweden.
b
Department of Education, Uppsala University, Sweden.
Correspondence: Eva Hedman, Department of Preventive Dentistry, Ulleråkersvägen 21, 750 17 Uppsala, Sweden. Tel: +46 18 6116435. Email:
[email protected]
Vol 8, No 1, 2010
Submitted for publication: 15.04.08; accepted for publication: 01.06.09.
1991; Byrappagari et al, 2006). The World Health Organization (WHO) considers tobacco usage as a large health risk and has worked to increase awareness of oral health worldwide as an important component of general health and quality of life (Petersen, 2008). In Sweden, children and adolescents regularly visit the dental clinic for oral health examinations. Thus, dental care, in contrast to medical care, holds a unique position in supporting young people to not start using tobacco and also in providing cessation assistance (Skjöldebrand and Gahnberg, 1997; Carr and Ebbert, 2006). Tobacco use is one of the reasons for the differences in health between various categories of a population. In contrast to the situation that prevailed 30 to 40 years ago in Sweden, today more girls and 23
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more individuals with a low socioeconomic status are using tobacco. Eighteen per cent of the Swedish 15-year-old boys and 30% of the girls were smokers in 2004 (CAN, 2004). While smoking habits have been decreasing since the early 1970s, the use of snuff is increasing, and in 2004, 21% of the boys and 8% of the girls used snuff (CAN, 2004). Swedish snuff is used as a kind of oral snuff that is placed under the upper lip. It is sold as loose snuff and in portion-packed bags. The content of Swedish snuff is largely unknown and the recipe is a production secret. However, in the accessible declaration of contents, it is stated that the amount of water in the snuff totals around 52% and the nicotine level 0.8% to 1% (Swedish Match, 2008). In the western world, many young people start using tobacco between the age of 11 and 16 (Tomar and Giovani, 1998; Galanti et al, 2001). Teenagers need to test the limits and to make autonomous decisions, yet they copy the tobacco habits of their parents and other adults. A recent study suggested that teenagers may become addicted to tobacco even within a couple of days or weeks of smoking (Di Franza et al, 2002). The process of establishing a tobacco habit consists of several steps such as preparation, experimental stage, regular use and addiction (Mayhew et al, 2000). Values, attitudes and norms are important factors for the initiation of tobacco use among adolescents (Koval and Pederson, 1999). In addition, approaches of the family, school, friends and society influence the decision of the young individual as to whether or not to start using tobacco (Di Franza et al, 2002). A meta-analysis of 23 controlled trials of schoolbased programmes that were conducted to prevent tobacco use showed only weak evidence that the programmes were effective (Thomas and Perera, 2006). The programmes included giving information, social influences, approaches, social skills training and community interventions. According to Rubak et al (2005), if the purpose were to change people’s health behaviour, a shift from an authoritarian to a more collaborative model must take place. Motivational interviewing is a method involving exploring ambivalence, reflective listening and building confidence in people’s own ability to change. Methods to guide the process of building confidence and influence valuations can be used to change the health behaviour of young people (Rogers, 1973). In recent years, programmes aimed at tobacco prevention have been influenced by the empowerment model and psychosocial methods that focused on the individual’s self-confidence and social skills training (Peterson et al, 2000).
pyrig No Co t fo r Pto study The aim of the present investigation was ub the ability to influence young at-risk patients’ lica attitudes toward tobacco use through two interven-tion te and an tion methods: a brief motivational interview ss e n c e
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adapted lecture in school, performed by dental health professionals.
METHODS The study was approved by the Ethics Committee, Faculty of Medicine, Uppsala University, Sweden. Informed consent was obtained from all of the participating adolescents and their parents before the study began.
Subjects The present study focused on the effects of two interventions aimed at adolescents who were 12 and 15 years old. All of the children in Uppsala County born in 1989 and 1992 who were assessed by a clinician or dental hygienist during the period January 2003–March 2004, being at high risk of oral diseases, were invited to participate. The risk assessment used data from the clinical examination in addition to a medical and odontological anamnesis and information about social conditions. Risk factors, and also factors supporting health, were identified. The balance between risk and healthy factors was judged and an individual was assessed as at high risk when the risk factors dominated. Of the total number of individuals born in 1989 and 1992 (5442), 7% were assessed as at high risk of dental diseases. Thus, 382 adolescents received the invitation. Twenty-one per cent of the adolescents, 79 individuals, declined to participate in the study from the beginning. Two individuals moved from the county and therefore interrupted participation, resulting in 301 participants in the study. The subjects were divided into groups based on intervention: a school lecture group, a motivational interview group and a control group (Fig 1).
Grouping Adolescents residing in the same geographical area had the same intervention, with the purpose of preventing persons belonging to the control or interview group from being present at school when the lecture was delivered. The 17 dental clinics in Oral Health & Preventive Dentistry
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Control group n=120 Refused to participate n=13
Lecture group n=120 Refused to participate n=29
Motivational interview group n=142 Refused to participate n=39
Participants n=107 Boys/girls n=54/53 Born1989/1992 n=55/52 Born abroad n=9
Participants n=91 Boys/girls n=47/44 Born1989/1992 n=48/43 Born abroad n=9
Participants n=103 Boys/girls n=45/58 Born1989/1992 n=42/61 Born abroad n=10
Questionnaire
Questionnaire
Questionnaire
No intervention
Lecture in school
A brief motivational interview
Questionnaire
Questionnaire
Questionnaire
Fig 1 Schedule of the study showing groups and the working process from the first questionnaire to the second.
the county each have responsibility for a certain geographical area, and all of the participants were patients at these clinics. The patients from each specific dental clinic were chosen as participants in one of the interventions or as controls, so that each group of clinics had an equal number of subjects and distribution of urban/rural inhabitants. After the clinics had been divided into three groups, it was decided by drawing lots which group of clinics should perform lectures (91 patients), conduct motivational interviews (103 patients) or be in the control group (107 patients).
Lecture in school Participants in the lecture intervention attended an interactive session in the school lasting for 40 min. Values and attitudes toward health and tobacco from a health-promoting perspective were presented by a dental hygienist or a dental nurse and discussed with the teacher and students. The aim of this session was to increase the adolescents’ self-confidence and, through interaction with their classmates, clarify their own attitudes and thoughts with regard to tobacco use and oral health. The lecture also described the content of tobacco, effects on the body, addiction, expense of using tobacco, risks of passive smoking and environmental pollution associated with Vol 8, No 1, 2010
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Patients at risk of oral diseases born 1989 and 1992 (total n=382)
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tobacco. The attitude and values training dealt with reasons for using or not using tobacco, the importance of peer pressure, values and attitudes toward tobacco users, and legislation and tobacco prohibition in society. All of the students in the class participated in the lecture, even those who did not participate in the study. Six hygienists and nurses visited a total of 32 schools and 63 classes. Before the study began, the dental nurses and dental hygienists took an 8-hour preparatory course in ‘values clarification’. Props were produced for the lectures: a model of teeth, photographs of the effects of tobacco on teeth and mucosa, a tube with cigarette butts illustrating one year’s consumption and a wallet with money showing the high cost of using tobacco.
Motivational interview The individuals in the interview group participated in a one-on-one brief motivational interview with a dental hygienist. The interview took place at the dental clinic and lasted for about 10 min. Motivational interviewing is a method involving both patient and practitioner, and together they define the problem. The patient-centredness involves careful reflective listening, exploring the patient’s ambivalence and the ability to make changes. The practitioner uses open questions to chart the patient’s attitudes and 25
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When the participants came to the dental clinic for regular oral health examinations, they answered a questionnaire. The interventions were then performed and 8 to 10 months later, when it was time for the next oral health examination, the same questionnaire was answered again (Fig 2). The questionnaire consisted of nine structured questions with fixed answers. The questions have been used in other studies (Marklund and Törnell, 1996; Östberg, 2002) and referred to the tobacco habits of the participant, family and friends. In addition, attitudes toward tobacco use and oral health, and future perspective were elucidated.
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knowledge pertaining to tobacco use and how it affects oral health and to guide the patient towards a decision, showing sensitivity to the patient’s ability and readiness to change, or to not start, tobacco use. Prior to the study, the nine dental hygienists who were involved in the study were trained in ‘motivational interviewing’ at a 2-day course with both theoretical input and interview practice.
pyrig No Co t fo r P use. sex, year of birth, country of birth and tobacco u Ten per cent of the participants came from bimmilica grant backgrounds (Fig 1). Tobacco habits of the par-tion t ticipant, family and friends, attitudes eand ss e nfuture ce
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perspective were also similar in the groups on the first response occasion (Table 1). The participants’ use of tobacco was low. More individuals in the control group reported that at least half of their friends smoked compared with the intervention groups. In the lecture group, few individuals stated that they had good oral health compared with the control and interview groups (Table 1). Boys and their best friends used snuff more often than the girls and their best friends, whereas the girls had more friends who smoked. The girls asked for more information on tobacco in school. Several differences were found between the 12- and 15-year age groups: the older participants used tobacco to a greater extent than their younger counterparts and so did their relatives and friends. The younger participants were more positive about tobacco bans, and a few of them believed that they would smoke in the future (Table 2). When it came to factors that influenced the adolescents to avoid tobacco, younger participants felt that all of the factors were more important compared with the older participants, except ‘costs’, and that it is not popular to smoke (Table 2).
Statistical analyses A power assessment was performed to determine the sample size in the interventions and control group. The results of the questionnaires were transferred to a database and logical checks were made on individual and group levels. Quality controls of the transfer process showed a margin of error of 0.2%. Descriptive analyses of the answers to the questionnaires were shown in frequency tables, split into intervention groups, occasion and age. The statistical analyses of the variation in frequency over time within a group were tested by McNemar’s test. Between the groups, chi-square tests analysed the answers from the same occasion. Performing a large number of statistical tests increased the risk of mass significances. This risk was limited by a conservative interpretation of the analyses. A P value < 0.05 was considered statistically significant.
RESULTS Before intervention In the pre-test, the intervention groups and control group showed similar distributions with regard to 26
After intervention No change in the use of tobacco among the participants was registered. In the second response occasion, respondents in the interview and lecture groups had more friends who smoked than in the first response occasion (Table 3). The results generally showed the same negative attitude towards the use of tobacco both before and after interventions. The majority of the participants were positive towards measures adopted to control the spread of tobacco use, such as bans on smoking and rises in prices (Table 3). After the intervention period, the participants in both control group and lecture group were less interested in collecting more information on tobacco in school. The participants in the interview group were more positive towards smoking bans in all of the discotheques after intervention compared with those in the other groups. Statements like ‘Mum and Dad (or ‘‘My girlfriend/boyfriend’’) do not want me to use tobacco’ influenced the participants in the intervention groups more than in the control group, and the difference was reinforced between the first and second response occasions (Table 3). Other differences between the intervention groups Oral Health & Preventive Dentistry
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2. Do you use snuff? – Yes / No
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Questionnaire:
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3. Do any of the following people smoke? – Yes / No a) Mother c) Best friend b) Father d) Half of all friends 4. Do any of the following people use snuff? – Yes / No a) Mother c) Best friend b) Father d) Half of all friends 5. What might influence you to not start smoking/using snuff? a) It is expensive b) It smells bad c) It is harmful d) Parents do not want me to use tobacco e) It is not popular to use tobacco f) My friends do not use tobacco g) My boy/girlfriend does not want me to use tobacco 6. Do you agree with the following statements? a) Yes, I am in favour of tobacco bans in all discotheques b) Yes, I am in favour of tobacco bans in the schoolyard c) Yes, I am in favour of tobacco bans in all media d) Yes, I am in favour of more education about tobacco in school e) No, I am not in favour of cheaper tobacco 7. Pick the alternative that best describes you? a) As an adult I think I would not have tried smoking b) As an adult I think I would have tried smoking c) As an adult I think I will smoke sometime d) As an adult I think I will smoke everyday e) I don’t know 8. I have good oral health a) I agree b) I fairly agree c) I don’t agree d) I don’t know
Fig 2 The questionnaire used in the study.
9. I brush my teeth a) Once a day b) Twice a day c) Once a week d) I don’t know
and the control group were associated with how they viewed their tobacco habits in the future. The participants in the control group believed to a greater degree than the others that they would have tried smoking as adults. A majority of them rated their oral hygiene as good or fairly good both before and after interventions. Most of the adolescents spoke of the importance of good oral hygiene and three out of four brushed their teeth at least twice a day (Table 3).
DISCUSSION The present study showed few significant differences associated with the two interventions. Vol 8, No 1, 2010
In line with other investigations, the adolescents’ overall attitude towards tobacco use was negative both before and after interventions (Skjöldebrand and Gahnberg, 1997; Nilsson et al, 2006). They were not in favour of lower prices, and they recognised the benefits of the ban on smoking and of political actions to restrict the use of tobacco. The adolescents in the present study wanted more information on tobacco in school, but after the interventions fewer participants expressed this request. One possible explanation could be that the interventions had satisfied their desire for information. A clear difference was found pertaining to the attitudes between 12- and 15-year-old adolescents, and this can be verified in other studies (Skjöldebrand and Gahnberg, 1997; Nilsson et al, 2006). The younger 27
pyrig No Co t fo r test Table 1 Distribution of answers before interventions: questions 1–9, with statistical analyses and chi-square P ub lica Answer-alternative Lecture Interview Control Difference tio te groups n (n = 91) % (n = 103) % (n = 107) % between ss e n c e
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4 6 24 8 25 26 12 8 11 16
4 4 23 1 28 30 12 8 7 10
8 5 17 5 25 21 14 11 21 19
NS NS NS NS NS NS NS NS < 0.01 NS
5a. Tobacco is expensive 5b. It smells bad 5c. It is harmful 5d. Parents do not want me to use tobacco 5e. It is not popular 5f. My friends do not use tobacco
52 63 76 51 28 30
64 72 83 63 22 35
53 66 81 61 22 24
NS NS NS NS NS NS
6a. Yes, I am in favour of tobacco bans in all of the discotheques 6b. In the schoolyard 6c. In all media 6d. I am in favour of more education about tobacco in school 6e. I am not in favour of cheaper tobacco
70
71
70
NS
80 66 49
84 56 46
82 69 55
NS NS NS
71
71
74
NS
7a. As an adult I think I would not have tried smoking 7b. I would have tried smoking 7c. I smoke sometimes 7d. I smoke everyday 7e. I don’t know
46
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49
NS
21 9 1 22
27 4 1 14
24 10 2 15
NS NS NS NS
8a. I have good oral health 8b. My oral health is fairly good 8c. I don’t have good oral health 8d. I don’t know
21 49 9 21
39 48 5 8
38 47 7 8
< 0.05 NS NS < 0.05
9a. I brush my teeth once a day 9b. Twice a day 9c. Once a week 9d. I don’t know
15 80 0 4
20 77 1 2
25 70 2 3
NS NS NS NS
participants were more positive towards the legislative restriction of tobacco use and price regulation, they had a more positive belief in a tobacco-free future and ranked the negative consequences of tobacco use higher than the older participants. The period between 12 and 15 years seems to be a period when the chance to influence attitudes is significant. Therefore, an important issue for tobacco prevention would be to maintain the younger persons’ opinions about tobacco. 28
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1. Participants who smoke 2. Participants who use snuff 3a. Mother is smoking 4a. Mother uses snuff 3b. Father is smoking 4b. Father uses snuff 3c. Best friend smokes 4c. Best friend uses snuff 3d. Half of all friends smoke 4d. Half of all friends use snuff
The dropout rate in the present study was 33%. The reasons for refusing to take part in the study are not known. Possible explanations could be difficulties with the Swedish language, unwillingness to expose tobacco use or doubtfulness about anonymity. The number of persons with immigrant backgrounds was 10%, roughly proportional to persons with immigrant background in the Swedish population. However, among people at high risk of oral diseases, persons with immigrant backgrounds are often Oral Health & Preventive Dentistry
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1989 (n = 145) %
1992 (n = 156) %
Difference between groups
Boys (n = 146) %
Girls (n = 155) %
1. Participants who smoke 2. Participants who use snuff 3a. Mother is smoking 4a. Mother uses snuff 3b. Father is smoking 4b. Father uses snuff 3c. Best friend smokes 4c. Best friend uses snuff 3d. Half of all friends smoke 4d. Half of all friends use snuff
10 11 27 5 29 40 25 18 27 31
1 0 16 8 24 36 1 1 1 1
< 0.001 < 0.001 NS NS NS NS < 0.001 < 0.001 < 0.001 < 0.001
3 8 19 3 26 24 6 13 8 17
8 1 22 5 27 27 19 5 18 13
NS < 0.01 NS NS NS NS < 0.05 < 0.05 < 0.05 NS
5a. Tobacco is expensive 5b. It smells bad 5c. It is harmful 5d. Parents do not want me to use tobacco 5e. It is not popular 5f. My friends do not use tobacco 5g. My boy/girl friend does not want me to use tobacco
50 58 57 42
63 76 93 73
NS < 0.01 < 0.001 < 0.001
57 63 80 62
56 71 81 55
NS NS NS NS
11 17 44
36 42 49
NS < 0.001 < 0.01
25 31 50
23 29 43
NS NS NS
6a. Yes, I am in favour of tobacco bans in all of the discotheques 6b. On the schoolyard 6c. In all media 6d. Of more education about tobacco in school 6e. Not in favour of cheaper tobacco
61
79
< 0.001
74
67
NS
13 54 48
8 73 52
< 0.01 < 0.001 NS
87 61 44
78 66 56
NS NS < 0.05
66
78
NS
69
75
NS
7a. As an adult I think I would not have tried smoking 7b. I would have tried smoking 7c. I smoke sometime 7d. I smoke every day 7e. I don’t know
34
64
< 0.001
48
51
NS
34 15 3 15
16 1 0 19
< 0.001 < 0.001 NS NS
26 6 1 20
23 10 2 14
NS NS NS NS
8a. I have good oral health 8b. My oral health is fairly good 8c. I don’t have good oral health 8d. I don’t know
25 54 9 11
40 42 4 13
< 0.05 NS NS NS
37 48 6 9
29 49 7 15
NS NS NS NS
9a. I brush my teeth once a day 9b. Twice a day 9c. Once a week 9d. I don’t know
17 79 1 4
24 73 1 2
NS NS NS NS
23 73 1 3
18 78 1 3
NS NS NS NS
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Difference between groups
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pyrig No Co t fo r Table 3 Distribution of answers after interventions: questions 1–9, with statistical analysis between groups Pand ubchilica square test; before versus after, McNemar’s test tio tDifference ess c e n Answer-alternative Lecture Interview Control Difference en before versus (n = 91) % (n = 103) % (n = 107) % between
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groups
after intervention
1. Participants who smoke 2. Participants who use snuff 3a. Mother is smoking 4a. Mother uses snuff 3b. Father is smoking 4b. Father uses snuff 3c. Best friend smokes 4c. Best friend uses snuffs 3d. Half of all friends smoke 4d. Half of all friends use snuff
5 5 21 5 26 22 8 12 21 20
4 4 20 1 24 30 13 6 18 7
7 7 18 6 26 20 14 17 24 18
NS NS NS NS NS NS NS < 0.05 < 0.05 NS
NS NS NS NS NS NS NS NS < 0.001 NS
5a. Tobacco is expensive 5b. It smells bad 5c. It is harmful 5d. Parents do not want me to use tobacco 5e. It is not popular 5f. My friends do not use tobacco 5g. My boy/girl friend does not want me to use tobacco
53 58 74 49
51 71 81 60
49 65 76 43
NS NS NS < 0.05
NS NS NS NS
22 29 57
23 30 51
16 21 35
NS NS < 0.05
NS NS < 0.05
73
81
71
NS
< 0.05
80 60 38
81 62 49
83 62 43
NS NS NS
NS NS < 0.05
80
74
70
NS
NS
7a. As an adult I think I will not have tried smoking 7b. I will have tried smoke 7c. I smoke sometime 7d. I smoke every day 7e. I don’t know
45
53
41
NS
< 0.05
25 8 2 20
30 4 2 11
32 10 2 15
NS NS NS NS
NS NS NS NS
8a. I have good oral health 8b. My oral health is fairly good 8c. I don’t have good oral health 8d. I don’t know
21 56 8 15
35 49 1 15
33 49 5 14
NS NS NS NS
NS NS NS NS
9a. I brush my teeth once a day 9b. Twice a day 9c. Once a week 9d. I don’t know
19 79 0 0
18 80 0 2
22 71 2 5
NS NS NS NS
NS NS NS NS
6a. Yes, I am in favour of tobacco bans in all of the discotheques 6b. On the schoolyard 6c. In all media 6d. Of more education about tobacco in school 6e. Not in favour of cheaper tobacco
over-represented (Julihn et al, 2006). The fact that the individual responded to the questionnaire at
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the dental clinic and could get assistance from the dental hygienist decreased the risk of language
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difficulties. At the same time, the collaboration with the dental hygienist reduced anonymity. Compared with the prevalence of tobacco use in the actual age reported in other investigations (CAN, 2004), fewer participants in the present study reported tobacco use, indicating that tobacco use was the reason for refusing to participate in the study. Another reason for reporting a low tobacco use could be an unwillingness to reveal tobacco habits. Such a suspicion is supported by the fact that the participants report a higher tobacco use among their best friends compared with themselves. If adolescents with tobacco use were more likely to decline participation in the study, the results may have been influenced. Also the selection process, where geographical areas rather than individuals were randomised into intervention groups, decreases the ability to make generalisations. However, it was not possible to perform the intervention in school with another study design. The fact that all variables, including background factors, tobacco habits, attitudes and future perspectives, with the exception of data pertaining to tobacco habits among the majority of the friends, showed an equal distribution between the groups before interventions indicates that the sampling procedure had resulted in three comparable samples. In addition, the pre-test, post-test design nevertheless is a valid method for revealing the differences among pedagogical methods, despite initial group differences. The sample consisted of the 7% assessed as having the highest risk of oral diseases. Despite this fact, the majority of the adolescents estimated their oral health as good or fairly good and considered their teeth important to them. This is in line with previous studies (Östberg, 2002; Hedman et al, 2006). In the study of Östberg (2002), almost 90% of a random sample of 13- to 15-year-olds estimated their oral health as good. As the majority of the adolescents in the present study were non-tobacco users, the authors’ interventions focused on encouraging and maintaining the existing positive behaviour. Motivational interviewing is a structured and teachable method to help individuals consider lifestyle issues (Rollnick et al, 1997; Miller and Rollnick, 2002). The school lecture was based on communication and dialogue, but with the classmates involved in the interactive process. The adolescents’ valuations were related to a context and their individual positions were revealed with the purpose of creating an interaction between the young people in the classroom. Both methods give young people the opportunity to take responsibility for their
pyr Co etigal No Hedman tf rP own health and to build confidence. As a o classroom ub at intervention reaches a large group of individuals lica the same time, this method may be preferable from tion te motivaan economic point of view. In contrast, the ss e n c e tional interview can be implemented within an existing dental care organisation as a part of regular clinical practice. However, classroom interventions aim to promote health for the whole population. Population strategies have, in favour of individual high-risk strategies, become a more recommended method. Since the number of people at low risk of disease is so much higher than that with high risk, the majority of caries lesions occur among the low risk population. This situation seems to limit the utility of a ‘high-risk’ approach to prevention (Rose, 1985). Two different pedagogical methods were compared in the present study. The use of tobacco was rare among the participants before the interventions. Mainly the attitudes toward tobacco use were negative. Small effects of the interventions could be registered, but the follow-up period was short and the effects on smoking uptake among the adolescents need to be evaluated later. The period between the ages of 12 and 15 seems to provide opportunities to influence tobacco habits. The adolescents’ needs for interactive learning and their development of attitudes and tobacco habits in relation to family and friends provide opportunities to use new pedagogical methods.
ACKNOWLEDGEMENTS We would like to thank Uppsala County and Public Dental Health for the financial support. We also thank Lars Berglund and UCR (Uppsala Clinic Research) for help with statistical analysis and Linda Schenk for revising the English text.
REFERENCES 1. Byrappagari D, Mascarenhas AK, Chaffin JG. Association of caries and tobacco risk with dental fitness classification. Mil Med 2006;171:415–419. 2. CAN—Swedish Council for Information on Alcohol and Other Drugs. Drogutvecklingen i Sverige. Report No. 82. Stockholm, Sweden, 2004. 3. Carr AB, Ebbert JO. Interventions for tobacco cessation in the dental setting. Cochrane Database Syst Rev 2006;25: CD005084. 4. Di Franza JR, Savageau JA, Fletcher K, Ockene JK, Rigotti NA, McNeill AD et al. Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study. Arch Pediatr Adolesc Med 2002;156:397–403. 5. Doll R. Uncovering the effects of smoking: historical perspective. Stat Methods Med Res 1998;7:87–117.
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