Incentives for preventing smoking in children and adolescents

Child-Adult Contract for Prevention of Tobacco Use: "As-Treated" Analysis of a Cluster Randomized Controlled Trial (the TOPAS Study) at 3-Year Follow-Up

To estimate the effect of a 3-year commitment to remain tobacco free on tobacco uptake among high school students in Sweden. The commitment is developed in the form of a contract between a child and a significant adult, constituting the core component of Tobacco-free Duo (T-Duo), a Swedish school-based tobacco prevention program. Secondary analysis of data from a cluster randomized controlled trial. Participants were 586 students in high schools assigned to the intervention arm of T-Duo. At inception, participants attended grade 7 (i.e., age 12-13). Only students who were tobacco naïve at baseline for the respective outcome and participated in all follow-ups were included. The exposure was defined as signing a 3-year contract with a significant adult, categorized as "stable contract" (3 years contract with the same contract partner), "unstable" (signed a contract sometime during follow-up but this was not sustained over time and/or with the same partner), and "no contract" at all during the intervention period. The primary outcome was having never tried cigarette smoking at the end of grade 9. Exposure and outcomes were self-reported in yearly questionnaires. Of 586 students, 321 (55%) held a stable contract, 204 (35%) an unstable contract, and 61 (10%) did not sign a contract at all. At the end of grade 9 (age 15-16), the relative risk (RR) to remain cigarette free was 1.11 (95% CI 1.00-1.22) (Number Needed to Treat = 10) among students in any type of contract compared to students that did not write a contract at all. The RRs for remaining tobacco free (secondary outcomes) ranged from 1.07 (0.98-1.16) for regular snus use to 1.16 (1.00-1.35) for any type of tobacco use. A commitment to remain tobacco free through a child-adult contract seems to exert a preventive effect on the uptake of tobacco use among Swedish adolescents over 3 school years. The current findings apply to a selected sample of both schools and students. Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered.

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Prevention of tobacco use in an adolescent population through a multi-personal intervention model

INTRODUCTION

The study aimed to assess the impact of a new intervention proposal involving students, teachers, and parents on smoking prevalence in secondary school adolescents.

METHODS

A quasi-experimental study was conducted, in which the response to a preventive multi-personal intervention model (intervention) against tobacco consumption was compared with a standard anti-smoking activity carried out by the local government administration (control). The study was carried out during the 2017-2018 academic year. The study population included 306 students (intervention 151, control 155) with a mean age of 13.4 years. The model involved the parents, the students (aged 15-17 years), and the teachers. The primary outcome was the change in smoking status one year after the intervention.

RESULTS

The percentage of non-smokers increased from 84.1% to 88.7% in the intervention group and remained almost unchanged among controls (89.3% vs 89.9%). After one year, there was an increase in the prevalence of non-smokers of 4.6% and a decrease in the prevalence of smokers of 4.7% among students who received the multi-personal intervention, whereas changes among controls were almost negligible (there was in fact a slight increase in the prevalence of smokers of 0.9%). The students who received the intervention smoked less or quit smoking more than those in the control group (OR=0.135; 95% CI: 0.019-0.973, p=0.047).

CONCLUSIONS

The multi-personal model developed in the study with the participation of teachers and parents focused on students was feasible, and effectively reduced the prevalence of smoking among high school adolescents.

Non-pharmacological interventions for smoking cessation: analysis of systematic reviews and meta-analyses

BACKGROUND

Although non-pharmacological smoking cessation measures have been widely used among smokers, current research evidence on the effects of smoking cessation is inconsistent and of mixed quality. Moreover, there is a lack of comprehensive evidence synthesis. This study seeks to systematically identify, describe, and evaluate the available evidence for non-pharmacological interventions in smoking populations through evidence mapping (EM), and to search for best-practice smoking cessation programs.

METHODS

A comprehensive search for relevant studies published from the establishment of the library to January 8, 2023, was conducted in PubMed, Web of Science, Embase, the Cochrane Library, CNKI, CBM, Wan Fang, and VIP. Two authors independently assessed eligibility and extracted data. The PRISMA statement and AMSTAR 2 tool were used to evaluate the report quality and methodology quality of systematic reviews/meta-analyses (SRs/MAs), respectively. Bubble plots were utilized to display information, such as the study population, intervention type, evidence quality, and original study sample size.

RESULTS

A total of 145 SRs/MAs regarding non-pharmacological interventions for smoking cessation were investigated, with 20 types of interventions identified. The most commonly used interventions were cognitive behaviour education (n = 32, 22.07%), professional counselling (n = 20, 13.79%), and non-nicotine electronic cigarettes (e-cigarettes) (n = 13, 8.97%). Among them, counselling and behavioural support can improve smoking cessation rates, but the effect varies depending on the characteristics of the support provided. These findings are consistent with previous SRs/MAs. The general population (n = 108, 74.48%) was the main cohort included in the SRs/MAs. The total score of PRISMA for the quality of the reports ranged from 8 to 27, and 13 studies (8.97%) were rated as high confidence, and nine studies (6.21%) as moderate confidence, in the AMSTAR 2 confidence rating.

CONCLUSIONS

The abstinence effect of cognitive behaviour education and money incentive intervention has advantages, and non-nicotine e-cigarettes appear to help some smokers transition to less harmful replacement tools. However, the methodological shortcomings of SRs/MAs should be considered. Therefore, to better guide future practice in the field of non-pharmacological smoking cessation, it is essential to improve the methodological quality of SRs and carry out high-quality randomized controlled trials (RCTs).

Evaluating the Immediate Impact of Graphic Messages for Vaping Prevention among Black and Latino Adolescents: A Randomized Controlled Trial

The purpose of this pilot study was to assess the immediate impact of vaping prevention graphic messages on the susceptibility to future vaping among Black and Latino adolescents (ages 12 to 17). Graphic messages (available in English and Spanish) were developed using participatory research procedures with Black and Latino adolescents. Recruitment was conducted by a team of diverse, bilingual (English and Spanish), trained recruiters. Participants (n = 362) were randomized in a 1:1:1:1 schema to receive one of four graphic messages (health rewards, financial rewards, autonomy, and social norms). Overall, all graphic messages but one showed a slight decrease in the number of participants susceptible to future vaping, though none of these differences was statistically significant. The graphic message on health rewards decreased the number of participants susceptible to future vaping the most (55.7% vs. 50%, at pre- vs. post-viewing, p = 0.125), followed by the graphic messages on social norms and autonomy (55.1% vs. 52.8%, p = 0.687; 55.4% vs. 52.2%, p = 0.435; respectively). The graphic message on financial rewards increased the number of participants susceptible to future vaping slightly (52.7% vs. 53.8%, p = 1.00). Future research is needed to evaluate susceptibility to future vaping before and after exposure to different and/or repeated vaping prevention graphic messages.

Factors That Influence the Effectiveness of Primary Prevention of Substance Use: A Review of Reviews

Context: The fact that substance use may result in dependence and severe harm to the user and the community has led to serious and extensive endeavors to design and implement preventive interventions. Prevention programs, however, have been shown to have different effects, and that should not be taken for granted. Systematic reviews and meta-analyses in the field have tried to reveal the effects of different types of substance use prevention programs and to identify the influencing factors. Objectives: The purpose of the current review was to more accurately identify factors associated with the effectiveness of interventions or reversal of desired effects. Evidence Acquisition: We systematically reviewed systematic review and meta-analyses studies within the period of 2009 - 2019 that reported the effectiveness of substance use prevention programs. After the systematic screening of 1586 articles, 43 articles were finally reviewed. Results: In preparation for extracting our data, we designed a structural model for analyzing the results of research on the effectiveness of substance use prevention programs. In general, universal types of prevention programs were reported as more effective than the two other types of selective and indicated programs. Regarding the context of programs, the school setting was more effective than others. In the case of interventions performed in the family setting, selective programs were more effective. Interventions provided by specialists were more effective than those provided by laypeople and / or peers. Interventions provided by more than one person and from more than one discipline showed higher effectiveness. Conclusions: Based on our structural design, we feel that further studies are needed to extend our knowledge regarding the effectiveness of substance use prevention programs.

Development of an Evidence and Gap Map (EGM) of interventions to increase smoking cessation: A study protocol

Smoking remains one of the leading risk factors contributing to the global burden of disease. Sub-optimal implementation of evidence-based tobacco control and smoking cessation practice is a major challenge despite a substantial evidence base for interventions to increase smoking cessation globally. We aim to develop an Evidence and Gap Map (EGM) to collate the existing evidence and identify the gap in research on interventions to increase smoking cessation worldwide. A conceptual framework was developed followed by the formulation of a search strategy with key search terms and search period (1970 - date of search). The search will be conducted in relevant bibliographic databases (e.g. MEDLINE, Embase, SCOPUS), systematic reviews databases (e.g. Cochrane Library, Joanna Briggs systematic reviews, EPPI-Reviewer) and impact evaluation databases (e.g. 3ie Impact Evaluation repository and Cochrane tobacco addiction group specialized register) with support from a research librarian. Subsequently, two coders will screen and retrieve systematic reviews and individual impact evaluation studies. The adapted SURE (Supporting the Use of Research Evidence) checklist will be used to evaluate the quality of the included systematic reviews. A narrative synthesis from the systematic review findings and line listing of the impact evaluations will form the basis of this EGM. The EGM report will be presented in an interactive visual format. The proposed EGM will organise the pieces of evidence generated in systematic reviews and impact evaluations on smoking cessation interventions and identify the current research gaps, if any. The findings will inform evidence-based practice and future research.

The effect of school smoke-free policies on smoking stigmatization: A European comparison study among adolescents

The increasing denormalization of smoking by tobacco control policies and a normative smoke-free climate may shift power towards adolescent non-smokers. It is unclear, however, how common stigmatization of smokers is among adolescents or how stigmatization relates to the denormalization of smoking in their school and social environment. This paper aims to measure (1) whether stigmatization among European adolescents varies according to smoking status and socioeconomic position (SES), and (2) whether stigmatization is greater in school environments in which smoking is denormalized (i.e. those with low smoking rates and strong school tobacco policies). Data on 12,991 adolescents were collected in 55 schools in seven European countries (SILNE R-survey, 2016/17). We applied Stuber’s adapted scale of perceived stereotyping and discrimination towards smokers to smoking status and five variables indicating a power shift towards non-smokers: the school’s tobacco control policy (STP) score, the percentage of adolescents in the school who smoke, parents’ level of education, students’ academic performance, and the percentage of their friends who smoke. Multilevel regressions were applied to the global score for perceived stigmatization. Discrimination against smokers and stereotyping of smokers were frequently reported. Smokers reported less ‘perceived stigmatization of smoking’ than non-smokers (Beta = -0.146, p < 0.001). High-SES students reported stereotyping and discrimination more frequently than lower-SES students. The perception of stigmatization was lower among students whose academic performance was poor (Beta = -0.070, p < 0.001) and among those who had friends who smoked (Beta = -0.141, p < 0.001). Stigmatization was lower in schools with greater exposure to smoking and was not associated with the school’s STP score. Perceived stigmatization of smoking is common among European adolescents. Smokers themselves, however, perceive stigmatization less often than non-smokers. Strong school tobacco policies do not increase stigmatization, but a social environment that is permissive of smoking decreases perceived stigmatization.

Smoking prevention among youth

For majority of smokers, onset of smoking occurs during adolescence, period of intensive growth and development, and this early smoking initiation is associated with many adverse health effects. Smoking prevention measures include not only prevention of onset, but also prevention of transition from experimentation to chronic tobacco use and dependence and smoking cessation. Effective preventive measures should be based on relevant theory and scientific evidence on behavior determinants. In this review article, we present evidence from researches on effectiveness of school programs, community-based programs, media campaigns and stress the importance of considering new challenges in tobacco control and other promising strategies, as well as the need for early detection of nicotine dependence signs among adolescents. In practice, many preventive measures are not based on theory and some interventions can be contra productive. Regardless of type of intervention and setting in which is implemented, it is of importance to take into account context for its implementation.

A Smoking Prevention Program Delivered by Medical Students to Secondary Schools in Brazil Called "Education Against Tobacco": Randomized Controlled Trial

Background

Smoking is the largest preventable cause of mortality in Brazil. Education Against Tobacco (EAT) is a network of more than 3500 medical students and physicians across 14 countries who volunteer for school-based smoking prevention programs. EAT educates 50,000 adolescents per year in the classroom setting. A recent quasi-experimental study conducted in Germany showed that EAT had significant short-term smoking cessation effects among adolescents aged 11 to 15 years.

Objective

The aim is to measure the long-term effectiveness of the most recent version of the EAT curriculum in Brazil.

Methods

A randomized controlled trial was conducted among 2348 adolescents aged 12 to 21 years (grades 7-11) at public secondary schools in Brazil. The prospective experimental design included measurements at baseline and at 6 and 12 months postintervention. The study groups comprised randomized classes receiving the standardized EAT intervention (90 minutes of mentoring in a classroom setting) and control classes in the same schools (no intervention). Data were collected on smoking status, gender, social aspects, and predictors of smoking. The primary endpoint was the difference in the change in smoking prevalence between the intervention group and the control group at 12-month follow-up.

Results

From baseline to 12 months, the smoking prevalence increased from 11.0% to 20.9% in the control group and from 14.1% to 15.6% in the intervention group. This difference was statistically significant (P<.01). The effects were smaller for females (control 12.4% to 18.8% vs intervention 13.1% to 14.6%) than for males (control 9.1% to 23.6% vs intervention 15.3% to 16.8%). Increased quitting rates and prevented onset were responsible for the intervention effects. The differences in change in smoking prevalence from baseline to 12 months between the intervention and control groups were increased in students with low school performance.

Conclusions

To our knowledge, this is the first randomized trial on school-based tobacco prevention in Brazil that shows significant long-term favorable effects. The EAT program encourages quitting and prevents smoking onset, especially among males and students with low educational background.

Trial Registration

ClinicalTrials.gov NCT02725021; https://clinicaltrials.gov/ct2/show/NCT02725021

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.7134

A smoking prevention photoageing intervention for secondary schools in Brazil delivered by medical students: protocol for a randomised trial

INTRODUCTION

Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous; the dramatic health consequences are too far in the future to fathom. We recently designed and tested an intervention that takes advantage of the broad availability of mobile phones as well as adolescents' interest in their appearance. A free photoageing mobile app (Smokerface) was implemented by medical students in secondary schools via a novel method called mirroring. The pupils' altered three-dimensional selfies on tablets were 'mirrored' via a projector in front of their whole grade. This is the first randomised trial to measure the effectiveness of the mirroring approach on smoking behaviour in secondary schools.

METHODS AND ANALYSIS

The mirroring intervention, which lasts 45 min, is implemented by Brazilian medical students in at least 35 secondary school classes with 21 participants each (at least 35 classes with 21 participants for control) in February 2018 in the city of Itauna, Brazil. External block randomisation via computer is performed on the class level with a 1:1 allocation. In addition to sociodemographic data, smoking behaviour is measured via a paper-pencil questionnaire before, 3 and 6 months postintervention plus a random carbon monoxide breathing test at baseline and end line. The primary outcome is cigarette smoking in the past week at 6 months follow-up. Smoking behaviour (smoking onset, quitting) and effects on the different genders are studied as secondary outcomes. Analysis is by intention to treat.

ETHICS AND DISSEMINATION

Ethical approval is obtained from the ethics committee of the University of Itauna in Brazil. Results will be disseminated at conferences, in peer-reviewed journals, throughout the Education Against Tobacco network social media channels and on our websites.

TRIAL REGISTRATION NUMBER

NCT03178227.