Family Matters

The reduction of adolescent smoking and alcohol use has been identified by the U.S. Department of Health and Human Services as a national public health goal. In 2000, 63% of high school seniors reported they had smoked cigarettes, and 80% reported they had used alcohol. Prevention efforts have focused on tobacco and alcohol because of the serious negative consequences associated with these substances, because they are used more than other drugs, and because research suggests tobacco and alcohol are the first substances used and may lead to illicit drug use. Programs aimed at the family as a unit are particularly promising because families have strong and persistent influences on their children and because adolescent substance use is related to family characteristics. Most family programs designed to prevent adolescent tobacco and alcohol use have been evaluated with families in treatment or therapy, but few studies have rigorously evaluated such programs with the general population.

Family Matters is a family-oriented program designed to prevent adolescents 12-14 years of age from using tobacco and alcohol. The intervention is designed to influence population-level prevalence and can be implemented with large numbers of geographically dispersed families. The program encourages communication among family members and focuses on general family characteristics (e.g., supervision and communication skills) and substance-specific characteristics (e.g., family rules for tobacco and alcohol use and media/peer influences).

The program involves successive mailings of four booklets to families, each beginning with identification of the topics for the booklet and then proceeding in order with a question-and-answer section about the main substantive content of the booklet, a description of the suggested activities, a summary of the main considerations of the booklet, and a preview of the next part of the program. Booklet 1, "Why Families Matter", motivates the family to participate and become engaged by demonstrating the negative consequences to the family from adolescent substance use. Booklet 2 , "Helping Families Matter to Teens", focuses on general family characteristics known or believed to influence adolescents that are not specific to alcohol and tobacco use, such as supervision, support, communication skills, attachment, time spent together, educational achievement, conflict reduction, and how well adolescence is understood. Booklet 3, "Alcohol and Tobacco Rules are Family Matters", is concerned with tobacco and alcohol-specific variables that originate in the family and predict adolescent drug use. Booklet 4 is "Non-Family Influences That Matter", which considers variables that originate outside the family that can influence adolescent use.

Family members are asked to read the booklets and complete the activities intended to reinforce their content. Two weeks later, health educators contact the parent by telephone to confirm that the booklet was received, to arrange for sending another copy if not received, to determine if the booklet has been read and activities completed, to encourage family participation, to answer questions, and to assess the parent's satisfaction and other reactions to the booklet. A new booklet is mailed when the health educator determines that the prior booklet has been completed.

The average completion time for parents participating in Family Matters is 4.5 hours to read the booklets and do the activities, with an additional hour to talk with the health educator by telephone. The program can be completed in several months. It is expected that health educators would make an average of 34 calls to each of the families and speak to a parent an average of 8 times to complete the units. Health educator training requires 8 hours of formal training. Project director training is 1 hour of classroom instruction that occurs immediately after health educator training. The project director and health educator roles can be combined.

The intended audience for Family Matters is adolescents aged 12-14 years and their families.

Family Matters can be implemented by health promotion practitioners in health departments, school health educators and parent-teacher groups, volunteers in community-based programs, national nonprofit organizations, and other types of organizations.

Required materials include the four booklets and the Health Educator Guidebook. The use of a health educator is another essential component of the program, as personal contact by telephone encourages participation and allows for clarification of the program, if necessary. The cost of implementing Family Matters in a 2001 national evaluation was about $140 per eligible family.

Family Matters was evaluated using a randomized experimental design. A national probability sample of families with children aged 12-14 years living throughout the contiguous United States was selected based on random-digit dialing. Adolescent-parent pairs were matched by date and time of baseline completion, and then the pairs were allocated randomly either to receive the Family Matters intervention or to serve as controls, who did not receive booklets or health educator calls.

Data were obtained through telephone surveys at baseline and at 3 and 12 months after completion of the intervention. Adolescents were asked "How much have you ever smoked cigarettes in your life?" Response categories were "none at all, not even a puff", "1 or 2 puffs but not a whole cigarette", "1 to 5 whole cigarettes", "6 to 20 whole cigarettes", and "more than 20 whole cigarettes." Categories were collapsed to never used (first response category) and had used (all other categories). Adolescents also were asked "How much alcohol have you ever had in your life?" Response categories were "none at all, not even a sip", "1 or 2 sips but not a whole drink", "3 or more sips but never a whole drink at one time", "1 to 5 whole drinks", "6 to 20 whole drinks", and "more than 20 whole drinks." Categories were collapsed to never used (first response category) and had used (all other categories). To assess the overall prevalence of smoking and drinking, both baseline users and nonusers were included in the analyses. Only the adolescents classified at baseline as nonusers were included in analyses assessing onset of cigarette smoking.

Of the 1,135 adolescent-parent pairs who completed the 3-month follow-up, the 12-month follow-up, or both, 78.0% were non-Hispanic White, the average age was 13.9 years (SD=0.9), and 50.7% were female.

Effects on Smoking

• Smoking onset was reduced among adolescents who reported being nonusers at the start of the program. At 12-month follow-up, 16.4% fewer program participants (31% versus 25.9%) had initiated smoking compared with an adolescent control group (p=.037). Results were significantly stronger among non-Hispanic White adolescents than among adolescents of other ethnicity. 

Figure 1: Nonusers Who Began Cigarette Use

• Self-reported smoking also was reduced among both users and nonusers, after adjusting for demographic variables and use rates at the start of the program (p=.014). 

Figure 2: Lifetime Cigarette Use Among All Participants

 
Effects on Alcohol Use

• Self-reported alcohol use was reduced among both users and nonusers, after adjusting for use rates at the start of the program and demographic variables (p=.022). 

Figure 3: Lifetime Alcohol Use Among All Participants