The effectiveness of a school-based substance abuse prevention program: 18-month follow-up of the EU-Dap cluster randomized controlled trial

Acceptability, feasibility and fidelity of the culturally adapted version of Unplugged ("Yo Se Lo Que Quiero"), a substance use preventive program among adolescents in Chile: a pilot randomized controlled study

INTRODUCTION

The consumption of alcohol, tobacco, and cannabis is a public health problem that impacts the cognitive, social, and emotional development of adolescents. Prevention strategies such as the "Unplugged" program are effective in delaying the progression of daily smoking and episodes of drunkenness among adolescents. "Yo Se Lo Que Quiero" (YSLQQ) corresponds to the adaptation of this program to the Chilean context. This study assesses the acceptability and feasibility of implementing this program to the local reality.

MATERIAL AND METHODS

This was a cluster-randomized controlled pilot study conducted on six public schools. All consented students attending 6th, 7th, and 8th grades (n = 1,180) participated in the study. The schools were randomly assigned to one of two conditions in a 1:1 ratio: (1) the "YSLQQ" intervention group (n = 526), and (2) the Control group (n = 654). The program consisted of a 12-hour class-based curriculum based on a comprehensive social-influence approach delivered by a trained facilitator. The acceptability and feasibility were assessed in the intervention group at the end of the intervention using questionnaires answered by students and facilitators. The quality and fidelity of the program were evaluated during the implementation using self-ported surveys answered by the facilitators and the assessment of video-recorded sessions rated by external observers. Finally, a pre-test and a post-test survey assessing past and current substance use and risk and protective factors were conducted before and immediately after the program's implementation.

RESULTS

A high proportion of students (49.6%) liked the sessions. 79.2% reported that the YSLQQ helped them learn about the dangers of substances, while 65.8% reported having more skills to avoid substance use in the future. Regarding students' satisfaction with YSLQQ, 62.9% reported being happy or very happy with the program. Facilitators reported implementing the intervention according to the manual in 73.9% of sessions. Regarding substance use, students who participated in the intervention groups reported a significant reduction in drunkenness in the last year and last 30-day prevalence and also a significant reduction in a lifetime and 30-day prevalence of cannabis use when compared with those students in the control group.

CONCLUSIONS

Our results suggest that YSLQQ has adequate acceptability and feasibility to be implemented in the Chilean context, and there were promising results in reducing drunkenness and cannabis use. Future research should confirm these results in a larger RCT study.

TRIAL REGISTRATION

The trial was registered in ClinicalTrials.gov, NCT04566627; registration date: 01/03/2019.

Evaluation of Effectiveness of the Unplugged Program on Gambling Behaviours among Adolescents: Study Protocol of the Experimental Controlled Study "GAPUnplugged"

Gambling risk behaviour is an emerging problem among adolescents. "Unplugged" is an effective Social Influence curriculum for preventing substance use among students. This study aims to develop and test a new component focused on gambling added to the Unplugged program. Schools of Piedmont region and Rome city were invited to participate in the study. A self-completed anonymous questionnaire including questions on socio-demographic characteristics, addictive behaviours, beliefs, attitudes and risk perceptions about gambling, normative perceptions, parental practices, school climate, refusal skills, impulsiveness, self-esteem, antisocial behaviours and sensation seeking was prepared for baseline and follow-up surveys. The protocol of the study was submitted and approved by the Novara Ethical Committee and registered in ClinicalTrials.gov (NCT05630157, Protocol ID: 080.742, 11/17/2022). Twenty-nine schools accepted to participate in the study. Sixty-three classes (1325 students) satisfied the eligibility criteria for intervention and were allocated to the intervention arm, and the other 61 (1269 students) were allocated to the control arm. Because of drop-out, absentees, refusals, and invalid questionnaires, data on 1874 students (998 in the intervention and 876 in the control arm), were available for the analysis at baseline. Data management of follow-up questionnaires is in progress. Results of the present study will be useful to clarify the effectiveness of prevention interventions in reducing gambling behaviours among adolescents. Moreover, this will be the first experience of evaluating a new component focused on a different risk behaviour, added to a curriculum previously shown as effective on other risk behaviours.

Review of the effects of social and emotional learning on mental health and academic outcomes: The role of teacher training and supportive interactions

Child and youth mental health in France has become an important public health priority. Social and emotional learning has been shown to contribute to mental health in children and adolescents. Therefore, an increasing number of interventions are being proposed in schools. However, teachers are not yet trained to develop these competencies through evidence-based interventions during their initial training. One way of increasing motivation and investment in teacher training in social and emotional learning is to increase awareness of the effects on academic outcomes. The aim of this scoping review based on systematic reviews and meta-analyses is to present the effectiveness of school-based social and emotional learning programs on mental health and academic success, while specifying the contributing processes such as motivation, teacher training, and student support. The discussion section suggests several avenues to promote the development of psychosocial competencies in school settings, notably based on teacher training.

Neuroscience-informed classification of prevention interventions in substance use disorders: An RDoC-based approach

Neuroscience has contributed to uncover the mechanisms underpinning substance use disorders (SUD). The next frontier is to leverage these mechanisms as active targets to create more effective interventions for SUD treatment and prevention. Recent large-scale cohort studies from early childhood are generating multiple levels of neuroscience-based information with the potential to inform the development and refinement of future preventive strategies. However, there are still no available well-recognized frameworks to guide the integration of these multi-level datasets into prevention interventions. The Research Domain Criteria (RDoC) provides a neuroscience-based multi-system framework that is well suited to facilitate translation of neurobiological mechanisms into behavioral domains amenable to preventative interventions. We propose a novel RDoC-based framework for prevention science and adapted the framework for the existing preventive interventions. From a systematic review of randomized controlled trials using a person-centered drug/alcohol preventive approach for adolescents, we identified 22 unique preventive interventions. By teasing apart these 22 interventions into the RDoC domains, we proposed distinct neurocognitive trajectories which have been recognized as precursors or risk factors for SUDs, to be targeted, engaged and modified for effective addiction prevention.

Heavy episodic drinking in adolescence and alcohol-related problems in adulthood: A developmental approach to alcohol use across the life course

Heavy episodic drinking (HED) is a major public health concern, and youth who engage in HED are at increased risk for alcohol-related problems that continue into adulthood. Importantly, there is heterogeneity in the onset and course of adolescent HED, as youth exhibit different trajectories of initiation and progression into heavy drinking. Much of what is known about the etiology of adolescent HED and alcohol-related problems that persist into adulthood comes from studies of predominantly White, middle-class youth. Because alcohol use and related problems vary by race/ethnicity and socioeconomic status, it is unclear whether previous findings are relevant for understanding developmental antecedents and distal consequences of adolescent HED for minoritized individuals. In the current study, we utilize a developmental psychopathology perspective to fill this gap in the literature. Using a racially and economically diverse cohort followed from adolescence well into adulthood, we apply group-based trajectory modeling (GBTM) to identify patterns of involvement in HED from age 14 to 17 years. We then investigate developmental antecedents of GBTM class membership, and alcohol-related distal outcomes in adulthood (∼ age 31 years) associated with GBTM class membership. Results highlight the importance of adolescent alcohol use in predicting future alcohol use in adulthood.

Delivering substance use prevention interventions for adolescents in educational settings: A scoping review

Currently, a proportion of adolescents use alcohol, tobacco, and illicit drugs, which inevitably harms their health and academic progress. Adolescence is a peak period for substance use initiation and a critical time for preventing substance use problems. Various entities, such as families, schools, and communities, have implemented a variety of interventions to alleviate adolescent substance use problems, and schools play a unique role. To explore the types, characteristics, and effectiveness of substance use interventions in educational settings for adole-scents, we conducted a scoping review and identified 32 studies after screening. We divided the 32 studies according to intervention type, including curriculum interventions focusing on cognitive-behavioral skill enhancement, exercise interventions, peer interventions and family-school cooperation, and electronic interventions. Except for the mixed results on electronic interventions, the results showed that the other interventions were beneficial to different extents in alleviating adolescent substance use problems. In addition, we analyzed and summarized the advantages and challenges of intervening in adolescent substance use in educational settings. Schools can use equipment and human resources to provide adolescents with various types of intervention measures, but they also face challenges such as stigmatization, ineffective coordination among multiple resources, and poor implementation effects. In the future, school-based intervention measures can fully utilize big data and artificial intelligence technology and collaborate with families and communities to intervene appro-priately while paying attention to the comorbidity risks of substance use disorders and psychological health issues.

The Indirect Effect of #Tamojunto2.0 Program on Bullying Through Reduction of Alcohol Use Initiation

PURPOSE

The Brazilian version of the prevention program Unplugged, #Tamojunto, has had a positive effect on bullying prevention. However, the curriculum has recently been revised, owing to its negative effects on alcohol outcomes. This study evaluated the effect of the new version, #Tamojunto2.0, on bullying. For adolescents exposed to the school-based program #Tamojunto2.0, we investigated (1) whether the prevalence of bullying victimization and perpetration was reduced, (2) whether this reduction was moderated by gender, and (3) whether the program's effect on bullying was mediated by adolescents' alcohol use.

METHODS

A cluster randomized controlled trial was conducted using 5,208 eighth-grade students from 73 Brazilian public schools. Baseline data were collected before program implementation, and follow-up data were collected nine months later. We used a multilevel mixed-effects model to examine the effect of #Tamojunto2.0 on bullying, and a moderation model to test the moderating effect of gender on program outcomes. A mediation analysis was performed to determine lifetime alcohol use as a mediator of the intervention effect on bullying.

RESULTS

We found that the positive effect of #Tamojunto2.0 on bullying victimization (β = -0.019, 95% confidence interval = -0.035; -0.002) and perpetration (β = -0.027, 95% confidence interval = -0.051; -0.004) was mediated by a decrease in alcohol use, but not moderated by gender.

DISCUSSION

#Tamojunto2.0 program can be indirectly effective in the prevention of bullying by decreasing adolescents' alcohol use. Moreover, alcohol and drug use prevention programs might also affect bullying outcomes through mediation, and we suggest that future studies consider this.

Externalizing and internalizing problems as predictors of alcohol-related harm and binge drinking in early adolescence: The role of gender

BACKGROUND

Externalizing problems are commonly associated with alcohol outcomes in adolescence. Nevertheless, findings regarding internalizing problems are mixed, and fewer longitudinal studies have considered the both problems concomitantly and the role of gender. We examined the role of externalizing and internalizing problems in predicting adolescent alcohol-related harm and binge drinking, taking into account the gender differences. We also evaluated if externalizing problems could moderate the association between internalizing problems and alcohol outcomes.

METHOD

We used longitudinal data from 2368 8th grade students across 37 public schools in three Brazilian cities. Linear and logistic regressions were performed to analyze the association between alcohol outcomes and the independent variables (externalization and internalization scores, and sociodemographic variables) according to gender. We also tested the same model with an interaction term between externalizing*internalizing.

RESULTS

Our results suggest that externalizing problems predict adolescents' binge drinking in both genders; it also may predict adolescents' alcohol-related harms, but only in boys. Internalizing problems seem to be a gender-specific risk factor for binge drinking among girls. All findings are independent of comorbid problems and sociodemographic variables.

LIMITATION

The findings should be considered taking into account the short follow-up period from risk factors to the outcomes.

CONCLUSION

Our results highlight the contribution of internalizing and externalizing problems to the development of alcohol-related harm and binge drinking in early adolescence and the need for interventions to prevent early behavioral problems that consider the role played by gender.

Changes in alcohol beliefs mediate the effects of a school-based prevention program on alcohol use among Brazilian adolescents

OBJECTIVE

To investigate the mechanisms of the #Tamojunto2.0 program that mediated the prevention of lifetime alcohol and drug use, including drug knowledge, behavioral beliefs, attitudes, decision-making skills, and refusal skills.

METHODS

A cluster-randomized controlled trial was conducted in 73 public middle schools in three Brazilian cities. The sample included 5208 students (49.4 % girls; M_age = 13.2 years). The intervention group attended twelve #Tamojunto2.0 lessons conducted by their previously trained teachers. The control group did not receive any intervention. Data were collected pre-intervention and at the 9-months follow-up. We performed multiple mediation models (for the whole sample, users, and non-users) with a post-estimation adjustment to standard errors to account for nesting. We analyzed all available mediators simultaneously according to each drug: alcohol, binge drinking, tobacco, marijuana, and inhalant lifetime use. To handle missing data, we used the "full-information maximum-likelihood" paradigm.

RESULTS

Outcomes in the whole sample and among non-users showed that #Tamojunto2.0 indirectly prevented lifetime alcohol use and binge drinking by increasing negative and non-positive alcohol beliefs. Only the direct effect on decreasing lifetime alcohol consumption was statistically significant. However, an indirect increase in binge drinking was observed through knowledge about alcohol, but the direct effect was not statistically significant. No effects were reported for marijuana, tobacco, or inhalants. Among users, no statistically significant effects were found for alcohol or drug use.

CONCLUSIONS

The results suggest that the #Tamojunto2.0 program was only effective in delaying alcohol consumption via increasing negative and non-positive alcohol beliefs. It seems that mediating mechanisms vary depending on contextual characteristics, differences in socializing among adolescents, features of the educational systems, psychosocial conditions, or, fidelity issues of program implementation.

Factors associated with attending "open bar" parties amongst early adolescents

BACKGROUND

"Open bar" parties are events where a flat fee is paid for unlimited alcohol consumption. At these events, alcohol intoxication is frequent amongst attendees. This study explored the prevalence of "open bar" attendance amongst Brazilian youth and the factors associated with this practice.

METHODS

Data was collected at the baseline of randomized controlled trial amongst 5,213 8th grade students in three Brazilian cities. Weighted logistic regression was performed.

RESULTS

Mean age was of 13.23 years (SE 0.01) and 17.1% of the students have reported attending "open bar" events in the past year. Attendees were wealthier, had higher odds to engage in binge drinking, to use marijuana, to be exposed to alcohol advertising, and to report more alcohol problems and clinical psychiatric symptoms when compared with non-attendees.

CONCLUSIONS

The ban on selling alcohol to minors has not been properly enforced. Legislation to restrict alcohol promotions and advertising in Brazil needs to be implemented and effectively monitored.

Implementation fidelity of a Brazilian drug use prevention program and its effect among adolescents: a mixed-methods study

BACKGROUND

Based on the US DARE-kiR, a version of the Keepin' it REAL program, the Drug and Violence Resistance Educational Program (PROERD) is the most widely implemented Brazilian prevention program. It originates from the translation of the DARE-kiR, a version of the Keepin' it REAL program. Previous results suggest its inefficiency in preventing drug use among Brazilian adolescents. Since kiR fidelity can impact program outcomes, this mixed-methods study evaluates the PROERD implementation fidelity and its effects on preventing drug use among adolescents.

METHODS

Data from two cluster randomized controlled trials (cRCTs) with 4,030 students from 30 public schools in São Paulo (1,727 fifth graders and 2,303 seventh graders), assessed at two-time points, were analyzed quantitatively. After implementing each lesson during the cRCT, 19 PROERD instructors answered fidelity forms. The effect of PROERD fidelity on alcohol, cigarettes, marijuana, inhalant, and cocaine use (the last two only among seventh graders) in the six months prior to follow-up assessment was analyzed by logistic regressions for fifth grade and mixed effect models for seventh graders. For qualitative analysis, semi-structured interviews were conducted with PROERD instructors and investigated by thematic analysis.

RESULTS

Quantitative analysis showed that PROERD implementation fidelity had no impact on drug use among fifth and seventh graders. Conversely, the qualitative analysis revealed important aspects that may influence implementation fidelity and consequently program effectiveness, such as adaptations made by instructors, school infrastructure, among others, besides program application.

CONCLUSION

PROERD requires cultural adaptation to improve its implementation in Brazilian public schools.

Body dissatisfaction, drug use, and associated factors among adolescents in three Brazilian cities

OBJECTIVE

analyze the association between drug use and body dissatisfaction among adolescents in three Brazilian cities.

METHOD

cross-sectional study, using a nested randomized controlled trial to evaluate the drug use prevention program #TamoJunto2.0 of the Ministry of Health in Brazilian schools. The sample consisted of 5,213 students from 73 schools in three Brazilian cities. The outcome body satisfaction was analyzed using the Stunkard scale and the explanatory variables were drug use and sociodemographic data.

RESULTS

the adolescents were between 12 and 14 years old; about 69.9% of them reported body dissatisfaction, and 35.67% used alcohol in the previous year. Dissatisfaction due to overweight was higher among girls (41.5%) and dissatisfaction due to underweight was higher among boys (33.1%). Adolescents who used marijuana were 39% (OR=1.39) more likely to feel dissatisfied due to underweight and being a girl increased the chances of feeling dissatisfied due to overweight by 24% (OR=1.24).

CONCLUSION

the levels of body dissatisfaction deserve attention in hebiatric nursing care and reinforce the importance of educational strategies addressing body image and drug use, relating them to the various subjective attributes that can affect the health of adolescents, whether in the community or at school.

(1) High prevalence of body dissatisfaction related to overweight. (2) Girls presented 24% more chances of feeling body dissatisfaction due to overweight. (3) Marijuana use in adolescence can increase by 39% body dissatisfaction due to underweight. (4) Last year, about 35.7% of adolescents had already consumed alcohol. (5) Health promotion and stimulation of positive perceptions of self-image.

Familial associations in adolescent substance use disorder: a population-based cohort study

BACKGROUND AND AIMS

Family history of substance use disorder (SUD) affects a child's risk of the disorder through both genetic and shared environmental factors. We aimed to estimate the association between parental or older sibling SUD history with the risk of adolescent SUD diagnosis.

DESIGN, SETTING AND PARTICIPANTS

We conducted a population-based cohort study using administrative health-care databases in the Province of Manitoba, Canada, which has a universal and publicly funded health-care system. We included all children born from 1984 to 2000 who have linkages to both parents and were followed until age 18 years. We used generalized estimating equation models to produce unadjusted and adjusted relative risk (RR) estimates of adolescent SUD risk. The study cohort included 134 389 children and 31 307 full sibling pairs; 51.3% were male and 35.4% first-born.

MEASUREMENTS

The exposure was SUD diagnosis in a mother or father in either hospitalization or outpatient physician visit records before the children's age of 13 years. The secondary exposure was an adolescent SUD diagnosis in an older full sibling. The outcome was SUD diagnosis during adolescence (13 and 18 years of age) identified in either hospitalization or physician visit records. Children demographics and characteristics associated with SUD diagnosis were included in the models.

FINDINGS

Of the 134 389 children, 9.5% had a mother with a history of SUD, 11.3% had a father and 1.3% had an older sibling with a history of SUD diagnosis; 2566 (1.9%) had an adolescent SUD diagnosis. An increased risk of adolescent SUD was observed with SUD history in mothers [adjusted RR (aRR) = 2.50; 95% confidence interval (CI) = 2.26, 2.79], fathers (aRR = 2.15; 95% CI = 1.95, 2.37), both parents (aRR = 3.74; 95% CI = 3.24, 4.31) and older sibling (aRR = 3.85; 95% CI = 2.53, 5.87).

CONCLUSIONS

A family history of substance use disorder in parents or older siblings appears to be associated with increased SUD risk in adolescents.

Applying a Pattern-Centered Approach to Assess the Effect of a School-Based Drug Use Prevention Program in Brazil: A Cluster Randomized Controlled Trial

This study evaluated the effectiveness of a drug and violence resistance educational program (Programa Educacional de Resistência às Drogas e à Violência-PROERD) on latent substance use profiles over a 9-month follow-up period. Two PROERD curricula were evaluated through a cluster randomized controlled trials with two parts that included a total of 4030 fifth-and seventh-grade students in 30 public schools in São Paulo. The intervention groups received 10 PROERD classes delivered by trained police officers, while the control group received no intervention. The primary outcome measures were drug use (any alcohol use, binge drinking, tobacco, marijuana, and inhalants) in the past 6 months, which was assessed using a pretest and a posttest 9 months later. Latent transition analysis was employed to investigate the effect of the intervention on the probabilities associated with the transition across drug use profiles. Latent drug use profiles are underlying subgroups of individuals similar to each other regarding their pattern of polysubstance use. Two different latent drug use profiles were revealed among the fifth graders (abstainers/low users and alcohol users/binge drinkers) and three drug use profiles among the seventh graders (abstainers/low users, alcohol users/binge drinkers, and polydrug users). For both, there was no evidence of the effect of PROERD on drug transition probabilities. In conclusion, the intervention was not successful in changing transitions across adolescent drug use profiles. Thus, the failure of the intervention to affect students' substance use profiles suggests that it should be reconsidered before it is implemented further in Brazilian schools.

“Intervention Program Based on Self”: A Proposal for Improving the Addiction Prevention Program “Unplugged” through Self-Concept

The “Intervention Program based on Self” (IPSELF) project was created to address the gap between the acquisition of life skills during prevention programs and their application with a session for developing one’s self-concept included in the European program “Unplugged”. The present study evaluated its effectiveness. A total of 157 middle school students (94 girls, 63 boys, M_AGE= 12.89, SD = 0.45) from three schools in France participated in this study. The participants attended one of two programs (Unplugged/IPSELF). The effectiveness of the IPSELF add-on session was measured with the Self-Concept Clarity Scale, and the differences between the two programs was measured with the prototype willingness model. Adolescents in IPSELF rated the typical nonsmoker and cannabis nonsmoker more favorably, and the typical drinker less favorably. They felt more different from the typical smoker and drinker after participation in IPSELF. More alcohol experimenters were observed in Unplugged. The knowledge gained in IPSELF appeared to help adolescents more than that gained in Unplugged to change their smoking behavior. Furthermore, IPSELF had a more beneficial effect for girls, who felt that they had gained more control over their alcohol and cannabis use than boys, whereas Unplugged had a more positive effect on boys, who gained better control over their consumption. Moreover, the girls felt that they had gained more knowledge about the substances discussed in IPSELF than in Unplugged. We therefore recommend the use of IPSELF especially with female audiences.

The Social Competence Promotion Program among Young Adolescents (SCPP-YA) in Chile ("Mi Mejor Plan") for substance use prevention among early adolescents: study protocol for a randomized controlled trial

BACKGROUND

Substance use is highly prevalent among children and adolescents in Chile, and it is known how it impacts their health and social adjustment. The call for effective prevention of substance use among children adolescents has resulted in numerous school-based programs, and particularly, the Social Competence Promotion Program among Young Adolescents (SCPP-YA) has been proved to be successful for promoting social and problem-solving skills in addition to preventing substance abuse in the US population. The purpose of this study is to test the effectiveness of the Social Competence Promotion Program among Young Adolescents (SCPP-YA) in Chile ("Mi Mejor Plan").

METHODS

This is a cluster randomized controlled trial, parallel-group type, where "Mi Mejor Plan" is compared to standard school preventive curricula in control schools. A total of 10 schools and 600 adolescents are expected to be recruited and randomized with 1:1 allocation. During formative work, the SCPP-YA program was culturally adapted to Chile. The effectiveness of this program will be assessed using the European Drug Addiction Prevention Trial Questionnaire (EU-Dap), measuring substance use prevalence and risk and protective factors in baseline, post-intervention, and 4 months after the end of the intervention.

DISCUSSION

The proposed study will be the first to test the effectiveness of the Social Competence Promotion Program among Young Adolescents (SCPP-YA) in Chile in a cluster randomized control trial and also the first study evaluating this program in Spanish-speaking Latin America. SCPP-YA has been implemented successfully in the USA. Thus, if the effects of the program are positive, wide implementation in Chile and Latin American countries is possible soon.

TRIAL REGISTRATION

Clinical Trials NCT04236947 . Registered on January 22, 2020.

Neuroscience Outside the Box: From the Laboratory to Discussing Drug Abuse at Schools

One of the effects of the current COVID-19 pandemic is that low-income countries were pushed further into extreme poverty, exacerbating social inequalities and increasing susceptibility to drug use/abuse in people of all ages. The risks of drug abuse may not be fully understood by all members of society, partly because of the taboo nature of the subject, and partly because of the considerable gap between scientific production/understanding and communication of such knowledge to the public at large. Drug use is a major challenge to social development and a leading cause of school dropout rates worldwide. Some public policies adopted in several countries in recent decades failed to prevent drug use, especially because they focused on imposing combative or coercive measures, investing little or nothing in education and prevention. Here we highlight the role of neuroscience education as a valid approach in drug use education and prevention. We propose building a bridge between schools and scientists by promoting information, student engagement and honest dialogue, and show evidence that public policy regulators should be persuaded to support such science-based education programs in their efforts to effect important positive changes in society.

Spread of gambling abstinence through peers and comments in online self-help chat forums to quit gambling

Habit formation occurs in relation to peer habits and comments. This general principle was applied to gambling abstinence in the context of online self-help forums to quit gambling. Participants in this study, conducted between September 2008 and March 2020, were 161 abstinent and 928 non-abstinent gamblers who participated in online self-help chat forums to quit gambling. They received 269,317 comments during their first 3 years of forum participation. Gamblers had an increased likelihood of 3-year continuous gambling abstinence if they had many peers in the forums. However, they had a decreased likelihood of gambling abstinence if they received rejective comments from the forums. Based on these results, online social network-based interventions may be a new treatment option for gamblers.

DUDE - a universal prevention program for non-suicidal self-injurious behavior in adolescence based on effective emotion regulation: study protocol of a cluster-randomized controlled trial

BACKGROUND

Non-suicidal self-injury (NSSI) has become a substantial public health problem. NSSI is a high-risk marker for the development and persistence of mental health problems, shows high rates of morbidity and mortality, and causes substantial health care costs. Thus, there is an urgent need for action to develop universal prevention programs for NSSI before adolescents begin to show this dangerous behavior. Currently, however, universal prevention programs are lacking.

METHODS

The main objective of the present study is to evaluate a newly developed universal prevention program ("DUDE - Du und deine Emotionen / You and your emotions"), based on a skills-based approach in schools, in 3200 young adolescents (age 11-14 years). The effectiveness of DUDE will be investigated in a cluster-randomized controlled trial (RCT) in schools (N = 16). All groups will receive a minimal intervention called "Stress-free through the school day" as a mental health literacy program to prevent burnout in school. The treatment group (N = 1600; 8 schools) will additionally undergo the universal prevention program DUDE and will be divided into treatment group 1 (DUDE conducted by trained clinical psychologists; N = 800; 4 schools) and treatment group 2 (DUDE conducted by trained teachers; N = 800; 4 schools). The active control group (N = 1600; 8 schools) will only receive the mental health literacy prevention. Besides baseline assessment (T0), measurements will occur at the end of the treatment (T1) and at 6- (T2) and 12-month (T3) follow-up evaluations. The main outcome is the occurrence of NSSI within the last 6 months assessed by a short version of the Deliberate Self-Harm Inventory (DSHI-9) at the 1-year follow-up (primary endpoint; T3). Secondary outcomes are emotion regulation, suicidality, health-related quality of life, self-esteem, and comorbid psychopathology and willingness to change.

DISCUSSION

DUDE is tailored to diminish the incidence of NSSI and to prevent its possible long-term consequences (e.g., suicidality) in adolescents. It is easy to access in the school environment. Furthermore, DUDE is a comprehensive approach to improve mental health via improved emotion regulation.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00018945. Registered on 01 April 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00018945.

The Unplugged program in Chile (“Yo Sé Lo Que Quiero”) for substance use prevention among early adolescents: study protocol for a randomized controlled trial

Background

Substance use is among the main contributors to disease among children and adolescents in the Americas region. The call for effective prevention of substance use among adolescents has resulted in numerous school-based programs, and particularly the Unplugged program has been proved to be successful in reducing the prevalence of different substances in seven European countries. The purpose of this study is to test the effectiveness of the Unplugged program in Chile (“Yo Sé Lo Que Quiero”).

Methods

This is a cluster randomized controlled trial, parallel-group type, where “Yo Sé Lo Que Quiero” is compared to standard school preventive curricula in control schools. A total of 70 schools and 8400 adolescents are expected to be randomized with 1:1 allocation. During formative work, the Unplugged program was culturally adapted to Chile, and the instrument to assess the primary and secondary outcomes was validated. The effectiveness of this program will be assessed using the European Drug Addiction Prevention Trial Questionnaire (EU-Dap), measuring substance use prevalence and risk and protective factors in baseline, post-intervention, and four months after the end of the intervention.

Discussion

The proposed study will be the first to test the effectiveness of a school-based substance use prevention program in Chile in a cluster randomized control trial and the first study evaluating the Unplugged program in Spanish-speaking Latin America. A model for disseminating the Unplugged program inside Europe already exists and has been implemented successfully in several countries. Thus, if the effects of the program are positive, wide implementation in Chile and Latin American countries is possible soon.

Trial registration

ClinicalTrials.govNCT04236999. Registered on January 17, 2020.

Effects of the "Unplugged" school-based substance use prevention program in Nigeria: A cluster randomized controlled trial

BACKGROUND

School-based programs are the most convenient interventions to tackle substance use among youth. "Unplugged" is a Social Influence universal school curriculum developed and tested in the "EU-Dap" project. In 2015, Nigeria implemented a large-scale project to promote healthy lifestyles in schools, families and communities. Within the project, the effectiveness of "Unplugged" was evaluated through a cluster randomized controlled trial.

METHODS

The program was adapted to the Nigerian context, assembling suggestions from monitoring forms and interviews, and performing fidelity checks on content and method. Thirty-two secondary schools were extracted from a list provided by the Federal Ministry of Education, and randomly allocated to intervention and control arms. A self-completed anonymous questionnaire was used for baseline and follow-up surveys. The analysis sample finally included 2685 pupils (mean age 14.2 years). Multilevel models were run to estimate program effects on prevalence of self-reported cigarettes, alcohol, and marijuana use. Mediation analysis was performed to identify possible mediators of program effect on alcohol use.

RESULTS

Unplugged significantly reduced the prevalence of recent alcohol use in intervention vs control pupils. The effect on prevalence of cigarette and marijuana use was not statistically significant. The program prevented progress and encouraged regress across stages of intensity of alcohol use. Negative beliefs, risk perceptions, and class climate mediated the effect of Unplugged on alcohol use.

CONCLUSIONS

Unplugged was effective in preventing alcohol use improving beliefs, class climate and risk perceptions among Nigerian students. The implementation of the program at a larger scale in the country should be supported.

Effects of a School-Based Intervention for Preventing Substance Use among Adolescents at Risk of Academic Failure: A Pilot Study of the Reasoning and Rehabilitation V2 Program

Tobacco, alcohol and cannabis use are important health problems that contribute greatly to causes of death in worldwide. Early onset of substance use increases rapidly during adolescence and it has been associated with a wide range of adverse events. Because substance use is associated with dramatic consequences, delaying the initiation of substance use among adolescents remains a major public priority. This study examined the effectiveness of a school-based intervention program based on the application of the Reasoning and Rehabilitation V2 (R&R2) program for preventing substance use among adolescents at risk of academic failure. A sample of 142 participants (aged 13-17 years old) who were studying alternative education provision in Spain were randomly allocated to two conditions (68 experimental group, 74 control group). A pre-test survey assessing past and current substance use was conducted prior the implementation of the program, while a post-test survey was conducted about 12 months after the pre-test. The results showed a significant effect of the R&R program in the reduction of cigarette smoking, episodes of drunkenness, alcohol consumption and cannabis use. However, for daily smoking and episodes of drunkenness such benefits showed a reduction over time. These findings offer additional evidence of the effectiveness of the Reasoning and Rehabilitation V2 program in Spanish adolescent students who are exposed to substance use and suggest areas of future research.

Validation of the European Drug Addiction Prevention Trial Questionnaire (EU-Dap) for substance use screening and to assess risk and protective factors among early adolescents in Chile

BACKGROUND

Substance use is highly prevalent among Chilean adolescents, and the damage it causes at the neurobiological, psychological, and social levels is known. However, there are no validated screening instruments that also assess risk and protective factors for this population in Chile, which is essential for evaluating future prevention interventions.

OBJECTIVE

To determine the psychometric properties of the European Drug Addiction Prevention Trial Questionnaire (EU-Dap) questionnaire.

METHODS

A cross-sectional study was carried out in 13 schools in the city of Santiago de Chile. The sample included 2261 adolescents ranging from 10 to 14 years old. Linguistic and cultural adaptation was assessed using focus groups with adolescents, the construct validity was evaluated using confirmatory factor analysis, and measures of its reliability were also determined. Furthermore, the associations regarding risk and protective factors with substance use were explored.

RESULTS

Substance use questions were well understood and seemed to adequately capture the consumption of different drugs. Regarding the subscales of risk and protective factors, the analyses showed that most subscales had good psychometric properties, and few needed some degree of improvement (e.g., some items were removed). After the changes, most final subscales had good or adequate goodness of fit adjustments and good or acceptable internal consistency. Finally, the main associated factors with the substance use outcomes were: future substance use and school bonding for tobacco use; negative beliefs about alcohol, future substance use, school bonding and refusal skills for alcohol use; and negative beliefs about marihuana, positive attitudes towards drugs, risk perception, and substance abuse index for marihuana use. Normative beliefs increased the risk for all substances use.

CONCLUSIONS

The current findings suggest that the EU-Dap is a valid and reliable instrument, and it may help to evaluate the effectiveness of drug use prevention interventions.

Effectiveness of a school-based substance use prevention program taught by police officers in Brazil: Two cluster randomized controlled trials of the PROERD

BACKGROUND

The Drug and Violence Resistance Educational Program (PROERD) is widely disseminated and implemented as a public policy in Brazil. PROERD's current curricula are the translation of the North American program DARE-Keepin'it REAL, based on the theories of socio-emotional learning and resistance training. The present study aims to evaluate the effectiveness of PROERD in the prevention of drug use.

METHOD

Two PROERD curricula were analyzed through two cluster randomized controlled trials conducted with 4030 students (1727 5th graders and 2303 7th graders) in 30 public schools in São Paulo. The intervention group received ten PROERD classes delivered by trained police officers, and the control group received no intervention. Data collection was performed using self-administered questionnaires on smartphones at two points in time (baseline pre-intervention and nine months follow-up). The outcomes evaluated were initiation and recent drug use. Two different paradigms were used in a multilevel analysis: an analysis of complete cases (CC) and an intention to treat missing data through full information maximum likelihood and selection model.

RESULTS

We found no evidence of the effectiveness of PROERD as an intervention for the prevention of drug use. For the conditional transition analysis, we found that 7th graders in the PROERD group who were already binge drinking at baseline had a significantly higher chance of maintaining this consumption pattern when compared to the control group.

CONCLUSION

The lack of preventive effects found here suggests that a process evaluation may address concrete implementation and cultural adaptation issues.

Short-Term Secondary Effects of a School-Based Drug Prevention Program: Cluster-Randomized Controlled Trial of the Brazilian Version of DARE's Keepin' it REAL

This study aimed to evaluate the effectiveness of the drug and violence resistance educational program (PROERD) on short-term secondary outcomes, such as intentions to use drugs, attitudes toward drugs, school experience, and life skills (refusal, decision-making, and communication). Two cluster-randomized controlled trials were conducted in 30 public schools in the city of São Paulo (Brazil) with 4030 students (1727 fifth and 2303 seventh graders). The intervention group attended 10 PROERD classes conducted by trained police officers, whereas the control group received no intervention. PROERD is a Brazilian adaptation of the North American Drug Abuse Resistance Education (DARE) program Keepin' it REAL. Data were collected at two time points: pre-intervention and at 9-month follow-up. Two different paradigms were used in the multilevel analysis, complete case (CC), and intention-to-treat (ITT) analyses, using full information maximum likelihood (FIML). We found mixed results. Although the seventh-year curriculum seems to have positive effects on school experience (coef = 0.093; 95% CI: 0.001, -0.185), it also increases the intention to use cigarettes in the future (OR = 1.93, 95% CI: 1.109, 3.379) and the chances of accepting marijuana (OR = 1.62, 95% CI: 1.03, 2.53), and it appears to slightly reduce decision-making skills among fifth graders (coef = -0.078; 95% CI: -0.131, -0.025). Our results suggest that PROERD implementation and cultural adaptation should be reevaluated to understand why the program does not achieve the expected preventive goals and produces potential iatrogenic effects.

Validation of a Tool to Evaluate Drug Prevention Programs Among Students

Background: School-based prevention programs have been implemented worldwide with the intention of reducing or delaying the onset of alcohol and drug use among adolescents. However, their effects need to be evaluated, being essential to use validated and reliable questionnaires for this purpose. This study aimed to verify the semantic validity and reliability of an instrument developed to evaluate the results of a government drug prevention program for schoolchildren called #Tamojunto2.0. Methods: This is a mixed methods study with quantitative (test-retest, confirmatory factor analysis and non-response evaluation) and qualitative analyses (focus group and field cards). The self-administered questionnaires were used for a sample of 262 eighth-grade students (elementary school II) in 11 classes of four public schools in the city of São Paulo. Results: The level of agreement was substantial (Kappa 0.60-0.79) or almost perfect (Kappa > 0.8) for almost all questions about the use of marijuana, alcohol, cigarettes, cocaine, crack, and binge drinking. The model fit indices, for almost all secondary outcomes, indicated that the modls underlying each scale, constituted by observed and latent variables, had a good fit adjustument. The focus groups and field cards provided high-quality information that helped the researchers identify the main difficulties in applying and understanding the questions. Conclusion: The questionnaire showed high factorial validity, reliability and understanding by adolescents. After the necessary changes, identified in this study, the questionnaire will be suitable to evaluate the results of the #Tamojunto2.0 program in a randomized controlled trial.

A cluster randomized controlled trial evaluating the effectiveness of the school-based drug prevention program #Tamojunto2.0

AIMS

The study aimed to evaluate the effectiveness of the government school-based program #Tamojunto2.0, the third Brazilian version of the European drug prevention program, Unplugged, in preventing the use of alcohol and other drugs.

DESIGN

A parallel, two-arm cluster randomized controlled trial was conducted in 205 classes in 73 public schools (37 intervention and 36 control) with a baseline assessment and follow-up after 9 months.

SETTING

Schools in the cities of São Paulo, Fortaleza and Eusebio in Brazil.

PARTICIPANTS

A total of 5208 students in the 8th grade with a mean age of 13.2 years (standard deviation = 0.8 years) and an equal gender ratio.

INTERVENTION

In 2019, the intervention group attended 12 classes of the program #Tamojunto2.0, under the supervision of a team from the Ministry of Health. The control group did not receive any intervention to prevent alcohol and drug use.

MEASUREMENTS

The primary outcome measured was prevalence of binge drinking (five or more doses of alcohol in an occasion) within the past month. Secondary outcomes were prevalence of initiation and use of alcohol, tobacco, inhalants, marijuana and cocaine within the past month.

FINDINGS

A statistically significant difference was not found in the prevalence of binge drinking within the past month between intervention and control groups [odds ratio (OR) = 0.934; 95% confidence interval (CI) = 0.761-1.146]. However, students who were exposed to the program were less likely to initiate alcohol use than those in the control group (OR = 0.782; 95% CI = 0.636-0.961). The Bayes factor for reduction in binge drinking was 0.01, providing evidence in favor of the null hypothesis for this variable.

CONCLUSIONS

The drug prevention program #Tamojunto 2.0 reduced alcohol initiation, but appeared not to reduce past-month binge drinking among 8th grade students in Brazil.

["Klar bleiben" (keep a clear head)-a competition for school classes to reduce alcohol consumption]

In Germany, alcohol is the most popular drug among adolescents. So far, school-based alcohol prevention programs have focused on elementary school children and pupils in early adolescence. The school program "Klar bleiben" ("Keep a Clear Head") was especially designed for young people in late adolescence (10th graders) with the aim of establishing non-binge drinking as a social norm.Students in the participating classes commit themselves to abstain from binge drinking for six weeks (contract management). The class gives feedback after each week. After at least five positive feedbacks, the class is rated as successful and enters a prize draw. Elaborated teaching impulses and information resources for teachers and parents are further components of the prevention program.The evaluation of the class competition by 92 teachers can be regarded as consistently positive. The results of a cluster-randomized study showed a relative risk reduction of 10.4% in binge drinking in the last month for those adolescents who had already consumed alcohol before and belong to the intervention group. After the end of the intervention, this group of adolescents consumed an average of 0.19 fewer alcoholic beverages per drinking occasion compared to adolescents from the control group. The findings presented here are encouraging, keeping in mind that the intervention is relatively inexpensive.

Translating science into policy: mental health challenges during the COVID-19 pandemic

Several stressors associated with the coronavirus disease 2019 (COVID-19) are expected to affect the mental health of global populations: the effects of physical distancing, quarantine, and social isolation; the emotional suffering of health and other frontline workers; neuropsychiatric sequelae in those affected by the virus; the impact to families of lives lost to the disease; differential effects for those with severe mental disorders; and the consequences of social and economic deterioration.

In this context, we sought: to form a panel of Brazilian experts on child and adolescent health, neurodevelopment, health services, and adult and elderly mental health; and to compile evidence-based interventions to support suggested policy changes in Brazil to mitigate the expected increase in mental health disorders during the pandemic and its mental health consequences. The following actions are recommended: 1) invest in prevention programs for the safe return of students to schools; 2) adopt evidence-based psychosocial interventions to maintain an adequate environment for child and adolescent development; 3) target socially vulnerable populations and those experiencing discrimination; 4) train primary care teams to solve common mental health problems, provide needs-based assessments, and manage long-term, at-home care for older patients; 5) invest in technological advancements (e.g., telemedicine, e-Health, and web-based algorithms) to promote coordinated care; 6) increase access to and literacy in the use of computers and mobile phones, especially among older adults; 7) expand protocols for remote, brief psychotherapy interventions and psychoeducation to manage common mental health problems.

Piloting of the Just Say Know prevention program: a psychoeducational approach to translating the neuroscience of addiction to youth

BACKGROUND

Substance use during adolescence can have a number of negative consequences and interfere with normal brain development. Given limited time and resources, brief group- and school-based prevention programs are an efficient strategy for educating youth about the effects of substance use on health outcomes.

OBJECTIVES

To determine if a science-based, interactive substance prevention program could improve student knowledge and influence students' attitudes toward future substance use behaviors.

METHODS

The Just Say Know program was given to 1,594 middle and high school students. The facilitator engaged students in an interactive, hour-long session covering brain basics and effects of substance use. Students completed an eight-item pre- and post-knowledge-based test to measure learning outcomes along with feedback questions about youths' attitudes toward substance use and the program.

RESULTS

After the program, 94% of students reported that it provided helpful information; 92% reported it may influence their approach to substance use, with 76% specifying that they would delay or cut back on substance use. Knowledge-based test performance increased by 78%, with high schoolers displaying significantly higher scores than middle schoolers, but both showing similar improvements in scores. Students who reported higher levels of friends' substance use had smaller improvements from pre- to posttest.

CONCLUSION

Results suggest Just Say Know, a scientifically-based prevention program, is effective in increasing adolescents' program based-knowledge, has the potential to affect youths' attitudes toward substance use, and is well-received. These findings provide preliminary evidence that a cost-effective, neuroscience-informed group prevention program might reduce or delay adolescents' future substance use.

Non-communicable diseases among adolescents: current status, determinants, interventions and policies

BACKGROUND

Addressing non-communicable disease (NCDs) is a global priority in the Sustainable Development Goals, especially for adolescents. However, existing literature on NCD burden, risk factors and determinants, and effective interventions and policies for targeting these diseases in adolescents, is limited. This study develops an evidence-based conceptual framework, and highlights pathways between risk factors and interventions to NCD development during adolescence (ages 10-19 years) and continuing into adulthood. Additionally, the epidemiologic profile of key NCD risk factors and outcomes among adolescents and preventative NCD policies/laws/legislations are examined, and a multivariable analysis is conducted to explore the determinants of NCDs among adolescents and adults.

METHODS

We reviewed literature to develop an adolescent-specific conceptual framework for NCDs. Global data repositories were searched from Jan-July 2018 for data on NCD-related risk factors, outcomes, and policy data for 194 countries from 1990 to 2016. Disability-Adjusted Life Years were used to assess disease burden. A hierarchical modeling approach and ordinary least squares regression was used to explore the basic and underlying causes of NCD burden.

RESULTS

Mental health disorders are the most common NCDs found in adolescents. Adverse behaviours and lifestyle factors, specifically smoking, alcohol and drug use, poor diet and metabolic syndrome, are key risk factors for NCD development in adolescence. Across countries, laws and policies for preventing NCD-related risk factors exist, however those targeting contraceptive use, drug harm reduction, mental health and nutrition are generally limited. Many effective interventions for NCD prevention exist but must be implemented at scale through multisectoral action utilizing diverse delivery mechanisms. Multivariable analyses showed that structural/macro, community and household factors have significant associations with NCD burden among adolescents and adults.

CONCLUSIONS

Multi-sectoral efforts are needed to target NCD risk factors among adolescents to mitigate disease burden and adverse outcomes in adulthood. Findings could guide policy and programming to reduce NCD burden in the sustainable development era.

Predicting latent classes of drug-related problems among adolescents: secondary analysis of a cluster randomized controlled trial

Objective:

To detect latent patterns of drug-related problems and their predictors among adolescents.

Methods:

A three-wave randomized controlled trial was conducted among 6,391 7th and 8th graders (51.02% girls) at 72 public schools in six Brazilian cities to evaluate the #Tamojunto school-based drug prevention program. Patterns of drug use and behavior problems were identified through latent class analysis, and logistic regression analyses were used to detect predictors of high-risk and low-risk groups.

Results:

Two groups were found that best explained the patterns of drug use and problem behaviors: high drug use/high problems and low drug use/low problems, representing 36.7 and 63.3% of the sample, respectively. No program effect was a determinant of the risk of belonging to these groups. Any reported problem behavior in the year preceding baseline assessment increased the likelihood of belonging to the high-risk group at the 21-month follow-up by 16 times. Alcohol use at baseline and female gender increased the likelihood of belonging to the high-risk group by 70%.

Conclusion:

Previous behavior problems and alcohol use were the strongest predictors of higher risk, suggesting that effective earlier interventions and early screening for alcohol use and behavioral problems are needed at schools, particularly for girls.

Clinical trial registration:

Registro Brasileiro de Ensaios Clínicos (REBEC), RBR-4mnv5g

'High schools High on life': Development of an Intervention to Reduce Excessive Drinking in Danish High Schools

Background: Clear documentation of the understanding of the problem, process of development, and content of interventions is essential to enable other researchers to understand why interventions succeed or fail and to enable researcher to build on previous evidence and replicate and adapt findings in other contexts. In this paper we describe the rationale, intervention development, and final design of the 'High schools High on life' intervention; a high school-based, multi-component intervention to reduce excessive drinking among Danish high school students. Methods: The development of the intervention 'High schools High on life' was guided by the planning steps of the Intervention Mapping protocol (IM) in combination with the behavior change wheel and the behavior change techniques, theory, evidence, practice, and new empirical studies of contextual factors in the Danish high school setting. Results: The development process resulted in a multi-component intervention with the following intervention elements: a school environmental component targeting school alcohol policies and norms, a school educational component addressing students' social norms around alcohol, and a parental component encouraging parent-child communication around alcohol. Discussion: Not all steps of IM were followed rigidly. However, IM proved useful as a planning tool in combination with the behavior change wheel and the behavior change techniques, as it provided a systematic approach to the intervention development process. IM forced the research group to be explicit about decisions and choices throughout the planning process. The transparency of the developmental process and theoretical, empirical and practical/contextual foundation of the 'High schools High on life' intervention may enable future intervention studies to build on our findings and accumulate knowledge to reduce excessive drinking among young people. Trial registration: The trial was registered at clinicaltrials.gov (Trial registration number NCT03906500) prior to randomization.

Primary Substance Use Prevention Programs for Children and Youth: A Systematic Review

CONTEXT

An updated synthesis of research on substance abuse prevention programs can promote enhanced uptake of programs with proven effectiveness, particularly when paired with information relevant to practitioners and policy makers.

OBJECTIVE

To assess the strength of the scientific evidence for psychoactive substance abuse prevention programs for school-aged children and youth.

DATA SOURCES

A systematic review was conducted of studies published up until March 31, 2020.

STUDY SELECTION

Articles on substance abuse prevention programs for school-aged children and youth were independently screened and included if they met eligibility criteria: (1) the program was designed for a general population of children and youth (ie, not designed for particular target groups), (2) the program was delivered to a general population, (3) the program only targeted children and youth, and (4) the study included a control group.

DATA EXTRACTION

Two reviewers independently evaluated study quality and extracted outcome data.

RESULTS

Ninety studies met eligibility criteria, representing 16 programs. Programs evaluated with the largest combined sample sizes were Drug Abuse Resistance Education, Project Adolescent Learning Experiences Resistance Training, Life Skills Training (LST), the Adolescent Alcohol Prevention Trial, and Project Choice.

LIMITATIONS

Given the heterogeneity of outcomes measured in the included studies, it was not possible to conduct a statistical meta-analysis of program effectiveness.

CONCLUSIONS

The most research has been conducted on the LST program. However, as with other programs included in this review, studies of LST effectiveness varied in quality. With this review, we provide an updated summary of evidence for primary prevention program effectiveness.

Sample size calculation in three-level cluster randomized trials using generalized estimating equation models

Three-level cluster randomized trials (CRTs) are increasingly used in implementation science, where 2fold-nested-correlated data arise. For example, interventions are randomly assigned to practices, and providers within the same practice who provide care to participants are trained with the assigned intervention. Teerenstra et al proposed a nested exchangeable correlation structure that accounts for two levels of clustering within the generalized estimating equations (GEE) approach. In this article, we utilize GEE models to test the treatment effect in a two-group comparison for continuous, binary, or count data in three-level CRTs. Given the nested exchangeable correlation structure, we derive the asymptotic variances of the estimator of the treatment effect for different types of outcomes. When the number of clusters is small, researchers have proposed bias-corrected sandwich estimators to improve performance in two-level CRTs. We extend the variances of two bias-corrected sandwich estimators to three-level CRTs. The equal provider and practice sizes were assumed to calculate number of practices for simplicity. However, they are not guaranteed in practice. Relative efficiency (RE) is defined as the ratio of variance of the estimator of the treatment effect for equal to unequal provider and practice sizes. The expressions of REs are obtained from both asymptotic variance estimation and bias-corrected sandwich estimators. Their performances are evaluated for different scenarios of provider and practice size distributions through simulation studies. Finally, a percentage increase in the number of practices is proposed due to efficiency loss from unequal provider and/or practice sizes.

Evaluating the effects of parenting styles dimensions on adolescent drug use: secondary analysis of #Tamojunto randomized controlled trial

The present study examined parenting style dimensions (demandingness and responsiveness) as predictors of adolescent drug use and also evaluated whether parenting styles dimensions moderate the effects of the implemented prevention program. 6.391 students in the 7th and 8th grades at 72 Brazilian public schools participated in a three-wave randomized controlled trial to evaluate a school drug-use prevention program. We used structural equation modeling to test if baseline parenting style dimensions (demandingness and responsiveness) would predict the use of drugs (alcohol, binge drinking, cannabis, inhalants, and tobacco) after 21 months. Additionally, we evaluated an interaction version of the above-described model to test if the effect of the prevention program would be moderated by either or both parenting style dimensions. Higher levels of parent demandingness predicted lower chances of adolescent drug use (e.g., Cigarette use OR 0.76, 95% CI 0.64-0.89); responsiveness on the five outcomes showed p value superior to 0.01. The effect of the #Tamojunto intervention is unlikely to be conditioned to either parenting style dimensions on the assessed outcomes.Clinical trial registration Brazilian Register of Clinical Trials (REBEC): #RBR-4mnv5g ( https://www.ensaiosclinicos.gov.br/rg/?q=tamojunto ).

Changes in tobacco-related morbidity and mortality in French women: worrying trends

BACKGROUND

The high prevalence of smoking among French women since the 1970s has been reflected over the past decade by a strong impact on the health of women. This paper describes age and gender differences in France of the impact of smoking on morbidity and mortality trends since the 2000s.

METHODS

Smoking prevalence trends were based on estimates from national surveys from 1974 to 2017. Lung cancer incidence were estimated from 2002-12 cancer registry data. Morbidity data for chronic obstructive pulmonary disease (COPD) exacerbation and myocardial infarction were assessed through hospital admissions data, 2002-15. For each disease, number of deaths between 2000 and 2014 came from the national database on medical causes of death. The tobacco-attributable mortality (all causes) was obtained using a population-attributable fraction methodology.

RESULTS

The incidence of lung cancer and COPD increased by 72% and 100%, respectively, among women between 2002 and 2015. For myocardial infarction before the age of 65, the incidence increased by 50% between 2002 and 2015 in women vs. 16% in men and the highest increase was observed in women of 45-64-year-olds. Mortality from lung cancer and COPD increased by 71% and 3%, respectively, among women. The estimated number of women who died as a result of smoking has more than doubled between 2000 and 2014 (7% vs. 3% of all deaths).

CONCLUSIONS

The increase in the prevalence of smoking among women has a major impact on the morbidity and mortality of tobacco-related diseases in women and will continue to increase for a number of years.

Binge drinking and frequent or heavy drinking among adolescents: prevalence and associated factors

OBJECTIVE

To analyze the sociodemographic, school, and family factors associated with the patterns of binge drinking and frequent or heavy drinking among adolescents.

METHODS

This was a cross-sectional study, nested in a randomized controlled trial, of 6285 seventh and eighth grade adolescent students from Brazilian public schools. The associations between binge drinking (consumption of five or more doses of alcohol on a single occasion) in the last 12 months and frequent or heavy drinking (alcohol consumption on six or more days) in the last month and the several factors were analyzed through weighted logistic regression.

RESULTS

16.5% of the students reported binge drinking in the year before the interview and 2.2% reported frequent/heavy drinking in the previous month. The factors associated with binge drinking were cigarette smoking (OR=6.7, 95% CI=3.96; 11.23), use of marijuana (OR=2.2, 95% CI=1.17; 4.31), use of inhalant drugs (OR=3.0, 95% CI=1.98; 4.43), exposure to a drunk relative (OR=2.1, 95% C=1.67; 2.53), practice of bullying (OR=1.8, 95% CI=1.47; 2.17), verbal aggression (OR=1.7, 95%CI=1.40; 2.14), and intermediate/low school grades (OR=1.7, 95% CI=1.35; 2.20). The factors associated with frequent/heavy drinking were cigarette smoking (OR=2.5, 95% CI=1.16; 5.22), use of marijuana (OR=3.2, 95% CI=1.32; 7.72), and physical aggression (OR=2.2, 95% CI=1.36; 3.50).

CONCLUSIONS

The analyzed outcomes showed an association between the risk consumption of alcohol in early adolescence and low academic performance, involvement with other drugs, aggressiveness, and witnessing episodes of a family member's drunkenness. Considering the impact on public health of the damages caused by alcohol consumption during adolescence, these factors that showed such association should be considered in the development of preventive interventions.

School-based interventions for preventing substance use in indigenous children ages 7-13: a scoping review protocol

INTRODUCTION

Throughout the world, indigenous peoples share traumatic colonial experiences that have caused gross inequalities for them and continue to impact every aspect of their lives. The effect of intergenerational trauma and other health disparities have been remarkable for Indigenous children and adolescents, who are at a greater risk of adverse mental health and addiction outcomes compared with non-indigenous people of the same age. Most indigenous children are exposed to addictive substances at an early age, which often leads to early initiation of substance use and is associated with subsequent physical and mental health issues, poor social and relational functioning, and occupational and legal problems. The aim of this paper is to report the protocol for the scoping review of school-based interventions for substance use prevention in Indigenous children ages 7-13 living in Canada, the USA, Australia and New Zealand. This scoping review seeks to answer the following questions: (1) What is known about indigenous school-based interventions for preventing substance use and (2) What are the characteristics and outcomes of school-based interventions for preventing substance use?

METHODS AND ANALYSIS

This scoping review will use steps described by Arksey and O'Malley and Levac: (1) identifying the research question(s); (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; (5) collating, summarising and reporting the results and (6) consulting with experts. Our findings will be reported according to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

ETHICS AND DISSEMINATION

Ethics review approval is not required for this project. Findings from this study will be presented to lay public, at scientific conferences and published in a peer-reviewed journal.

Decision-making skills as a mediator of the #Tamojunto school-based prevention program: Indirect effects for drug use and school violence of a cluster-randomized trial

BACKGROUND

The aim of the present study was to evaluate a formal mediation analysis effect of the #Tamojunto program on adolescents' drug use and violent behavior in schools through decision-making skills using a potential outcomes approach.

METHODS

An in-cluster randomized controlled trial was conducted in 2014-2015 with 6691 7th- and 8th-grade students in 72 public schools in 6 Brazilian cities to evaluate the effects of the European drug prevention program Unplugged, called #Tamojunto in Brazil. Baseline data were collected prior to program implementation, and follow-up data were collected 9 and 21 months later. Mediation analysis using a potential outcomes approach, in which counterfactuals are modeled if positivity is met, was used to evaluate the indirect effects of the program #Tamojunto on the third-wave of drug use (alcohol, tobacco, marijuana, inhalants, and binge drinking) and school violence (bullying or physical, verbal and sexual aggression) assessment through decision-making skills.

RESULTS

When controlling for all covariates, the Total Natural Indirect Effect (TNIE) was significant only for past-year drug use (TNIE = 0.003, 95%CI = 0.001; 0.007). In the adjusted models, 37.5% of the effect of the intervention on drug use was mediated by decision-making skills.

CONCLUSIONS

The #Tamojunto program increased drug use through decreasing decision-making skills. The findings demonstrate that this program changes decision-making skills but in the opposite direction proposed by the theoretical model of the program, suggesting that modifications are needed to produce the intended effect of the program.

Application of Social Cognitive Theory to Prevent Waterpipe Use in Male High-school Students in Kerman, Iran

BACKGROUND

The growing supply and prevalence of waterpipe (WP) smoking among Iranian adolescents have become a concern for both families and policymakers. The aim of this study was to determine the factors underlying WP use and also to design an intervention program based on social cognitive theory (SCT) aimed to reduce the demand for WP smoking among male adolescents.

METHODS

This quasi-experimental study involved 189 high-school students in Kerman, Iran, who were split into two groups, an intervention group and a control group. A validated questionnaire based on SCT constructs was used to collect data. The intervention was performed over four sessions with a focus on preventing WP smoking.

RESULTS

Before intervention, the lifetime and current-use prevalence of WP smoking across both groups was 48.5% and 20.2%, respectively. In the intervention group, the most change was related to knowledge score from 10.70 ± 4.38 to 16.52 ± 3.89 (P < 0.0001) and outcome values score from 12.40 ± 3.81 to 13.53 ± 4.23 (P = 0.007); however, in the control group, no significant changes were seen in posttest scores. The scores for self-efficacy (P = 0.21), outcome expectations (P = 0.09), and environment constructs (P = 0.06) did not show any statistically significant changes after the intervention in both groups. Overall, there was no significant difference in the rate of WP smoking after the intervention.

CONCLUSIONS

Based on the results of this study, although some construct scores showed significant differences after the intervention, there was no significant change in the prevalence of WP smoking. More effective educational interventions based on this theory but with a greater focus on self-efficacy and environmental influences may be warranted.

Effects of a prevention program on multiple health-compromising behaviours in adolescence: A cluster randomized controlled trial

We aimed to assess the effectiveness of 'Paesaggi di Prevenzione', a school-based prevention program delivered by trained teachers and designed to tackle smoking, alcohol misuse, dietary risks, and physical inactivity in adolescence. We evaluated the program between 2010 and 2013 with a two-arm, parallel-group, multicentre cluster randomized controlled trial in which schools were the units of randomization. We collected data on health-compromising behaviours using self-reported measurements of behaviour frequency administered before and after program implementation. We used multivariable mixed-effects logistic regression models to estimate program effects on health-compromising behaviours. The analysis sample included 3410 middle school students and 1651 high school students. Among middle school students, mean age at baseline was 12 years (standard deviation [SD] 0.5 years), 51% were boys, and 41% had high socioeconomic status [SES] (defined as having at least one parent/guardian with university level education). In high school students, mean age at baseline was 14 years (SD 0.7 years), 56% were boys, and 31% had high SES. The program did not have effects on smoking, alcohol misuse, and physical activity. The program had iatrogenic effects in regard to some eating behaviours, resulting in (i) lower odds of fruit consumption among middle-school students (odds ratio [OR] 0.82; 95% confidence interval [CI] 0.68-0.99) and (ii) lower odds of having breakfast every day in high-school students at the post-intervention measurement (OR 0.76; 95%CI 0.58-0.99) but not at one-year follow-up (OR 0.94; 95%CI 0.69-1.28). Due to the possibility of unintended effects, we advise against disseminating 'Paesaggi di Prevenzione' in its present form. TRIAL REGISTRATION: ISRCTN00953701.

Effectiveness evaluation of the school-based drug prevention program #Tamojunto2.0: protocol of a cluster randomized controlled trial

Background

The European school-based drug addiction prevention program Unplugged was adapted to the Brazilian context by the Ministry of Health and renamed #Tamojunto. Its first implementations, in the form of a public policy in Brazil, showed contradictory and different effects from those observed in Europe. Adaptations were made to #Tamojunto in 2018 to reintroduce the essential content of the original program.

Methods

A parallel, two-arm, randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of the new version of the school-based government program #Tamojunto2.0 for the prevention of drug use among 8th grade middle school students from 70 public schools in three Brazilian cities, totaling approximately 6.300 participating students distributed in 210 classes. For intervention, the experimental group will receive the 12 lessons of the #Tamojunto2.0 program under the supervision of a Brazilian Ministry of Health team. The control group will not receive any intervention. Information will be collected from the students at three time points: preintervention and 9 and 18 months postintervention. Multilevel analyses will be performed using the Gllamm Stata program to assess simultaneous differences in prevalence, in time and among groups for the outcomes of interest. Structural equation modeling will be used to evaluate the effectiveness of the intervention in changing the behavioral patterns of the adolescents through latent transition analysis. The effect of the mediators involved in the program effectiveness outcomes will also be analyzed. The program doses applied in all classes of the intervention group will be collected using a form completed by the teacher at the end of each lesson, indicating the activities taught and not taught in each lesson.

Discussion

This study will show whether the #Tamojunto2.0 program can be expanded as a public policy for all schools with the aim of preventing drug use among Brazilian students.

Trial registration

Brazilian Clinical Trials Registry (RBR-8cnkwq) under the name “Avaliação do Efeito do Programa de Prevenção Escolar ao Uso de Drogas #Tamojunto2.0, Versão 2018”, on August 30th, 2018 (http://www.ensaiosclinicos.gov.br/rg/RBR-8cnkwq/).