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EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY RECRUITS BY THOMAS LEE POKORSKI A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1992 ACKNOWLEDGEMENTS I wish to express my sincere gratitude to Dr. W. William Chen, chairman of my dissertation committee. His guidance during the past three years, especially during the dissertation process, has been invaluable. I would also like to extend my appreciation to Dr. R. Morgan Pigg, Dr. Claudia Probart, Dr. Steve Dorman, and Dr. Marc Branch for serving as members of my doctoral committee. Without the guidance and assistance of my committee I would never have been able to complete this work, nor retain my sanity. I also appreciate the statistical assistance provided by Dr. David Miller, and the help of Dr. Roger Bertholf in cotinine analysis. I wish to thank my parents, Pat and Joe Pokorski, for lifelong support of all my endeavors. I'd like to acknowledge the patience my children, Mike and Nicole, have shown over the past few years while having to deal with a "part-time" dad. I would especially like to thank my wife Liz for her understanding, patience, editorial assistance, and completion of over 600 scantron forms. I'd like to recognize the assistance provided by the Navy's Office of Health and Physical Readiness. Without the financial assistance provided by this office the study could not have been as comprehensive. I'd like also to thank the 11 American Cancer Society, especially Roberta Moss and Marsha Nenno, for providing the shirts, pamphlets, and posters used in the study. I would like to thank Captain Kathleen M. Bruyere, U.S. Navy, and her fine staff at Recruit Training Center, Orlando, Florida. The assistance I received while conducting this study was tremendous. I am especially grateful for all the efforts of PHCM Breece, without which this study could not have been done. Finally, I would like to thank all the fine Navy recruits who participated in this project and made the study the success it was. 111 TABLE OF CONTENTS page ACKNOWLEDGEMENTS ii LIST OF TABLES vi ABSTRACT vii INTRODUCTION 1 Statement of the Research Problem 6 Purpose of the Study 7 Hypotheses 8 Significance of the Study 8 Delimitations 11 Limitations 12 Assumptions 13 Definition of Terms 13 REVIEW OF LITERATURE 16 Introduction 16 Problems Related to Tobacco Use 17 Tobacco Use in the U.S 18 Military Tobacco Use and Related Problems 19 Navy Tobacco Use 24 Smoking Relapse 26 Smoking Policy and Effect on Smoking Cessation 36 Other Relapse Research 39 Smoking Prevention 39 Educational Intervention 45 Validation of Smoking Status Self-Report 47 Bogus Pipeline 48 Biochemical Tests 49 Concluding Statement 52 METHODS AND MATERIALS 55 Introduction 55 Subjects 55 Instruments 59 Self-Report Validation Techniques 62 Procedures 64 Data Preparation 75 Analysis Plan 76 IV RESULTS AND DISCUSSION 79 Introduction 79 Population Description 79 Results 82 Discussion 95 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 107 , Summary 107 Conclusions 110 Recommendations 113 APPENDIX A INTAKE SURVEY 116 APPENDIX B GRADUATION SURVEY 123 APPENDIX C THREE MONTH FOLLOW-UP SURVEY 126 APPENDIX D HUMAN FACTORS COMMITTEE APPROVAL 131 APPENDIX E CONSENT STATEMENT 132 APPENDIX F EDUCATION CURRICULUM 133 APPENDIX G SHAM TREATMENT CURRICULUM 146 APPENDIX H QUIT SMOKING WALLET CARD 148 APPENDIX I CERTIFICATE OF PARTICIPATION 150 LIST OF REFERENCES 151 BIOGRAPHICAL SKETCH 162 LIST OF TABLES page Table 1 . Population comparisons 23 Table 2 Study group comparison 58 . Table 3 Test-retest reliability 61 . Table 4 Treatment group assignments 65 . Table 5 Repeated measures design 77 . Table 6 Chi-square frequency table 77 . Table 7. Percent survey completion at each measurement period 80 Table 8. Percentage of smokers in non-respondent group and original study population 81 Table 9. Percent of current smokers at each measurement period 82 Table 10. Percent of current smokers by gender and corresponding relapse rates 83 Table 11. Nicotine tolerance levels reported with corresponding relapse rates 84 Table 12 Percentage smoking initiation 86 . Table 13. Attitude scores at each measurement period and differences pre to post for all subjects 88 Table 14. Attitude scores at each measurement period and differences pre to post for smokers 89 Table 15. Knowledge scores at each measurement period and differences observed 91 Table 16. Percent of respondents indicating intention not to smoke in the future 92 Table 17 Cigarette consumption 93 . VI Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY RECRUITS By THOMAS LEE POKORSKI August, 1992 Chairman: Wei William Chen, PhD Major Department: Health and Human Performance This study examined impact of an education program on smoking knowledge, attitudes, and intentions of Navy recruits undergoing 8 weeks of training in a normal no-smoking environment. Also examined were smoking relapse and cigarette consumption subsequent to recruit graduation. Specifically the study was designed to (1) add to literature information on effective educational smoking prevention/cessation techniques; (2) measure effect of current no-smoking policy at Recruit Training Center, Orlando, FL; (3) examine differences in observed levels of smoking knowledge, attitudes, intentions, and relapse after intervention; (4) examine smoking initiation rate differences (for non-smokers prior to recruit training); and (5) examine variables affecting smoking relapse. vii This study included 496 recruits (357 men and 139 women), in seven companies. Companies were randomly assigned to 4 treatment conditions: (1) policy only comparison; (2) policy plus education; (3) policy plus education, with a booster; and policy plus sham treatment. Tobacco use (4) knowledge/behavior surveys were administered to all subjects at the beginning of recruit training, at graduation, and three months after graduation. Subjects in both education groups received a three-hour education intervention. The booster group received an additional hour-long booster program at the end of the training cycle. Cotinine analyses of randomly selected urine samples were performed concurrently with pre- and postsurveys. Data analysis was accomplished using repeated measures analysis of variance, frequency tables incorporating Pearson's chi-square statistic, and categorical modeling procedures (SAS PROC CATMOD). Results indicated significant educational effects for smoking knowledge and attitude scores, reduced violation of liberty no-smoking rules, and cigarette consumption for relapsers. No significant treatment group differences were noted for relapse rate, smoking initiation, or smoking intentions. In summary, the education program used, though not significantly affecting smoking relapse in the short term, may positively affect future cessation attempts. The best predictors of smoking relapse in Navy recruits were nicotine addiction and heavy prior cigarette consumption. Study viii results recommend that smoking prevention/cessation education be part of recruit training, but further research is needed to identify more effective ways of reaching the heavier, addicted smokers entering the Navy. IX CHAPTER 1 INTRODUCTION Cigarette smoking can be linked to 1 in 6 deaths in the United States each year. Surgeons' General for the past 10 years named cigarette smoking as the most important preventable cause of death in society (U.S. Department of Health and Human Services [USDHHS], 1989, 1990). Specifically, cigarette smoking has been linked to the three leading causes of death in the U.S. (heart disease, cancer, and cerebrovascular disease). Likewise, involuntary smoking causes many of the same diseases associated with active smokers (USDHHS, 1986). The annual cost to society in disease, death, and absenteeism related to smoking has been estimated in excess of $50 billion (Fielding, 1986). In response to this problem, health professionals have provided tobacco prevention and smoking cessation programs for many years. These efforts have shown encouraging results in the general population. Smoking prevalence has dropped from 40% in 1965 to 29% in 1987 (USDHHS, 1989). The Surgeon General reports that while over 50 million Americans continue to smoke, more than 90 million would be smoking in the absence of recent changes in the smoking and health environment (USDHHS, 1989). Smoking cessation produces major and immediate health benefits for smokers of all ages