A randomized trial of a family-based smoking prevention intervention in managed care

A review of research on cigarette smoking in Preventive Medicine in recognition of the journal's 50th anniversary

This report reviews the literature on cigarette smoking published in Preventive Medicine over the past 50 years. The goal is twofold. First, to acknowledge the 50th anniversary of Preventive Medicine and its role in disseminating research on cigarette smoking by providing an abridged summary of smoking research published in the journal from inception through June 23, 2022. Second, to review experimental reports to identify contributions to innovations in tobacco control and regulatory efforts to reduce cigarette smoking. We searched PubMed using the search terms cigarette/cigarettes, tobacco products, smoking, smoking cessation, Preventive Medicine. Titles and abstracts were reviewed in duplicate, excluding reports not addressing cigarette smoking. Included reports were categorized by study type (original study, commentary, review). Experimental articles were assessed for impact using iCite, a National Institutes of Health web application that provides bibliometric information for articles in defined topic areas. The review identified 1181 articles on cigarette smoking: 1018 original studies (86.2%), 107 literature reviews (9.1%), and 56 commentaries (4.7%); 166 of the 1018 original studies (16%) were experimental reports. In the iCite analysis these 166 experimental articles received 6366 total citations, a mean (standard error) citation rate/article of 38.35 (±3.21) and mean relative citation ratio of 1.85 (±0.17) which is at the 73rd percentile for NIH-funded field- and time-normalized reports. Overall, this review demonstrates an ongoing and impactful contribution of Preventive Medicine to efforts to reduce cigarette smoking, the most preventable cause of premature death.

The Effectiveness of Smoking Cessation Interventions Tailored to Smoking Parents of Children Aged 0–18 Years: A Meta-Analysis

INTRODUCTION

A meta-analysis was conducted to examine the effectiveness of smoking cessation interventions tailored to parents of children aged 0-18 years.

METHODS

A systematic search was carried out in PsycInfo, Embase, and PubMed in March 2020. A manual search of the reference lists of the included studies and systematic reviews related to the topic was also performed. Two authors independently screened the studies based on the following inclusion criteria: (1) effect studies with control groups that examine smoking cessation interventions tailored to parents of children (0-18 years), and (2) full-text original articles written in English and published between January 1990 and February 2020. In total, 18 studies were included in the analyses. The TiDieR checklist and the Cochrane Risk of Bias Tool 2.0 were used to extract data and to assess the risk of bias. Consensus among authors was reached at each stage.

RESULTS

Random-effects meta-analyses were performed. With a total number of 8,560 parents, the pooled relative risk was 1.62 (95% CI 1.38-1.90; p < 0.00001), showing a modest effect of the interventions on smoking cessation. Overall, 13.1% of the parents in the intervention conditions reported abstinence versus 8.4% of the parents in the control conditions.

DISCUSSION/CONCLUSION

Smoking cessation interventions tailored to parents are modestly effective. To increase the effectiveness and the impact of these interventions in terms of controlling tobacco use and public health, it is crucial for further research to explore how these interventions can be improved.

Primary Care-Relevant Interventions for Tobacco and Nicotine Use Prevention and Cessation in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Interventions to discourage the use of tobacco products (including electronic nicotine delivery systems or e-cigarettes) among children and adolescents may help decrease tobacco-related illness and injury.

OBJECTIVE

To update the 2013 review on primary care-relevant interventions for tobacco use prevention and cessation in children and adolescents to inform the US Preventive Services Task Force.

DATA SOURCES

The Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, MEDLINE, PsyINFO, and EMBASE (September 1, 2012, to June 25, 2019), with surveillance through February 7, 2020.

STUDY SELECTION

Primary care-relevant studies; randomized clinical trials and nonrandomized controlled intervention studies of children and adolescents up to age 18 years for cessation and age 25 years for prevention. Trials comparing behavioral or pharmacological interventions with no or a minimal tobacco use intervention control group (eg, usual care, attention control, wait list) were included.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality. Studies were pooled using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Tobacco use initiation; tobacco use cessation; health outcomes; harms.

RESULTS

Twenty-four randomized clinical trials (N = 44 521) met inclusion criteria. Behavioral interventions were associated with decreased likelihood of cigarette smoking initiation compared with control interventions at 7 to 36 months' follow-up (13 trials, n = 21 700; 7.4% vs 9.2%; relative risk [RR], 0.82 [95% CI, 0.73-0.92]). There was no statistically significant difference between behavioral interventions and controls in smoking cessation when trials were restricted to smokers (9 trials, n = 2516; 80.7% vs 84.1% continued smoking; RR, 0.97 [95% CI, 0.93-1.01]). There were no significant benefits of medication on likelihood of smoking cessation in 2 trials of bupropion at 26 weeks (n = 523; 17% [300 mg] and 6% [150 mg] vs 10% [placebo]; 24% [150 mg] vs 28% [placebo]) and 1 trial of nicotine replacement therapy at 12 months (n = 257; 8.1% vs 8.2%). One trial each (n = 2586 and n = 1645) found no beneficial intervention effect on health outcomes or on adult smoking. No trials of prevention in young adults were identified. Few trials addressed prevention or cessation of tobacco products other than cigarettes; no trials evaluated effects of interventions on e-cigarette use. There were few trials of pharmacotherapy, and they had small sample sizes.

CONCLUSIONS AND RELEVANCE

Behavioral interventions may reduce the likelihood of smoking initiation in nonsmoking children and adolescents. Research is needed to identify effective behavioral interventions for adolescents who smoke cigarettes or who use other tobacco products and to understand the effectiveness of pharmacotherapy.

Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Tobacco use is the leading cause of preventable death in the US. An estimated annual 480 000 deaths are attributable to tobacco use in adults, including from secondhand smoke. It is estimated that every day about 1600 youth aged 12 to 17 years smoke their first cigarette and that about 5.6 million adolescents alive today will die prematurely from a smoking-related illness. Although conventional cigarette use has gradually declined among children in the US since the late 1990s, tobacco use via electronic cigarettes (e-cigarettes) is quickly rising and is now more common among youth than cigarette smoking. e-Cigarette products usually contain nicotine, which is addictive, raising concerns about e-cigarette use and nicotine addiction in children. Exposure to nicotine during adolescence can harm the developing brain, which may affect brain function and cognition, attention, and mood; thus, minimizing nicotine exposure from any tobacco product in youth is important.

OBJECTIVE

To update its 2013 recommendation, the USPSTF commissioned a review of the evidence on the benefits and harms of primary care interventions for tobacco use prevention and cessation in children and adolescents. The current systematic review newly included e-cigarettes as a tobacco product.

POPULATION

This recommendation applies to school-aged children and adolescents younger than 18 years.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that primary care-feasible behavioral interventions, including education or brief counseling, to prevent tobacco use in school-aged children and adolescents have a moderate net benefit. The USPSTF concludes that there is insufficient evidence to determine the balance of benefits and harms of primary care interventions for tobacco cessation among school-aged children and adolescents who already smoke, because of a lack of adequately powered studies on behavioral counseling interventions and a lack of studies on medications.

RECOMMENDATION

The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care-feasible interventions for the cessation of tobacco use among school-aged children and adolescents. (I statement).

A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial

: media-1vid110.1542/5984243450001PEDS-VA_2018-2738Video Abstract OBJECTIVES: To improve the mental health (MH) referral process for children referred from primary care to community mental health clinics (CMHCs) by using a community-partnered approach.

METHODS

Our partners were a multisite federally qualified health center and 2 CMHCs in Los Angeles County. We randomly assigned 6 federally qualified health center clinics to the intervention or as a control and implemented a newly developed telehealth-enhanced referral process (video orientation to the CMHC and a live videoconference CMHC screening visit) for all MH referrals from the intervention clinics. Our primary outcome was CMHC access defined by completion of the initial access point for referral (CMHC screening visit). We used multivariate logistic and linear regression to examine intervention impact on our primary outcome. To accommodate the cluster design, we used mixed-effect regression models.

RESULTS

A total of 342 children ages 5 to 12 were enrolled; 86.5% were Latino, 61.7% were boys, and the mean age at enrollment was 8.6 years. Children using the telehealth-enabled referral process had 3 times the odds of completing the initial CMHC screening visit compared with children who were referred by using usual care procedures (80.49% vs 64.04%; adjusted odds ratio 3.02 [95% confidence interval 1.47 to 6.22]). Among children who completed the CMHC screening visit, intervention participants took 6.6 days longer to achieve it but also reported greater satisfaction with the referral system compared with controls. Once this initial access point in referral was completed, >80% of eligible intervention and control participants (174 of 213) went on to an MH visit.

CONCLUSIONS

A novel telehealth-enhanced referral process developed by using a community-partnered approach improved initial access to CMHCs for children referred from primary care.

Evidence-based prevention programs targeting youth mental and behavioral health in primary care: A systematic review

The objectives of this systematic review were to: 1) identify evidence-based youth (i.e., infancy, pre-school age, school age, and adolescence) mental and behavioral health disorder preventive interventions conducted in or offered by primary care settings, and 2) describe these interventions' characteristics, efficacy, and clinical involvement. Randomized controlled trials that targeted the prevention of mental or behavioral health outcomes for youth and had a connection to primary care were included. The PRISMA guidelines were utilized for two phases: 1) searching PubMed, EMBASE, PsycInfo, CINAHL, and Cochrane databases in January 2017; and 2) searching United States Preventive Services Task Force (USPSTF) Systematic Reviews in November 2017. The two phases revealed 504 and 58 potential articles, respectively. After removal of duplicates, screening of abstracts, and full-text reviews, 19 interventions (infancy: n = 2, pre-school age: n = 3, school age: n = 6, adolescence: n = 8) were included: 1) 10 interventions described in 17 articles from the databases, and 2) 9 interventions described in 11 articles from the USPSTF reviews. The included interventions capitalized on primary care settings as a natural entry point to engage youth and families into interventions without requiring a large amount of clinic involvement. Commonalities of efficacious interventions and recommendations for future research are discussed. The authors encourage primary care providers, mental and behavioral health providers, and/or public health researchers to continue developing and testing preventive interventions, or adapting existing interventions, to be implemented in primary care.

Smoking prevention in children and adolescents: A systematic review of individualized interventions

OBJECTIVE

This study systematically reviewed the literature to determine what type of cognitive-behavioral based interventions administered outside of formal school settings effectively prevent smoking initiation among children and adolescents.

METHODS

Applying the PRISMA guidelines we searched MEDLINE, PsycINFO, CINHAL, Pub Med, SCOPUS, and Sport Discus. Article review, data extraction, and assessment of risk of bias were conducted by two independent reviewers.

RESULTS

We included 16 studies administered in various settings: seven in health care; four informally during and outside of school hours; three in the home; and two in extra-curricular settings. Positive preventive effects in smoking behavior ranging from 3-months to 4-years were observed in eight studies. Social environmental influences (e.g., parental smoking, friends) are salient contributing factors.

CONCLUSIONS

Effective approaches involved interventions conducted in health care settings as well as those employing interpersonal communication and support strategies (e.g., via peer leaders, parent support, physicians).

PRACTICE IMPLICATIONS

Primary health care settings may be optimal for implementing cigarette smoking prevention interventions for children and adolescents. Providing tailored education and facilitating interpersonal discussions between health care providers and families about the risks of smoking/strategies to avoid uptake, as well as capitalizing on technology-based modalities may reduce rates among children and adolescents.

For Whom Do Parenting Interventions to Prevent Adolescent Substance Use Work?

Adolescent substance use continues to be a significant public health problem. Parent training interventions are effective preventive strategies to reduce youth substance use. However, little is known about differences in effectiveness for youth across demographic characteristics. This review assessed the effectiveness of parent training programs at reducing adolescent substance use by participant gender, age, and race/ethnicity. Pubmed/MEDLINE, ERIC, CINAHL, and PsycINFO were searched from database origin to October 31, 2016. We included randomized controlled trials that evaluated parent training interventions; reported youth initiation or use of tobacco, alcohol, or other illicit substances; and included adolescents aged 10 to 19. Two independent reviewers extracted data. Disagreements were resolved by consensus or a third researcher. Data were synthesized using harvest plots stratified by participant demographics. A total of 1806 publications were identified and reviewed; 38 unique studies were included. Risk of bias of included studies was high. No studies targeted male teens or youth in late adolescence. Few studies targeted Asian-American, Black/African-American, or Hispanic/Latino adolescents. Overall, interventions including male and female youth and youth in early adolescence (age 10 to 14 or in 5th to 8th grade) were more beneficial than interventions including female-only or both young and older adolescents. Programs tailored to specific racial/ethnic groups, as well as programs designed for youth from multiple races/ethnic groups, were effective. Current evidence supports the benefits of offering parenting guidance to all families with adolescent children, regardless of the gender, age, or race/ethnicity of the adolescent.

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

PURPOSE

To help clinicians and care systems determine the priority for tobacco counseling in busy clinic schedules, we assessed the lifetime health and economic value of annually counseling youth to discourage smoking initiation and of annually counseling adults to encourage cessation.

METHODS

We conducted a microsimulation analysis to estimate the health impact and cost effectiveness of both types of tobacco counseling in a US birth cohort of 4,000,000. The model used for the analysis was constructed from nationally representative data sets and structured literature reviews.

RESULTS

Compared with no tobacco counseling, the model predicts that annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by 2.0 percentage points, whereas annual counseling for adults will reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years (QALYs) by 756,601 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. Only one-third of the potential health and economic benefits of counseling are being realized at current counseling rates.

CONCLUSIONS

Brief tobacco counseling provides substantial health benefits while producing cost savings. Both youth and adult intervention are high-priority uses of limited clinician time.

Preteen Attitudes about Smoking and Parental Factors Associated with Favorable Attitudes

Purpose.

To describe youth smoking-related attitudes and evaluate the effects of parental factors on child adoption of positive attitudes about smoking.

Design.

This study used baseline and 20-month data from a family-based smoking-prevention study (82.9% completed both surveys).

Setting.

Telephone recruitment from two health maintenance organizations.

Subjects.

Children aged 10 to 12 years and one parent of each child (n = 418 families) were randomly assigned to a frequent assessment cohort (12.5% of participants).

Intervention.

Families received a mailed smoking-prevention packet (parent handbook, videotape about youth smoking, comic book, pen, and stickers), outreach telephone counselor calls to the parent, a newsletter, and medical record prompts for providers to deliver smoking-prevention messages to parents and children.

Measures.

Demographics, tobacco status, attitudes about smoking (Teenage Attitudes and Practices Survey), family discussions about tobacco, family cohesiveness (family support and togetherness), parent involvement, parent monitoring, and parenting confidence.

Results.

One-third of the children endorsed beliefs that they could smoke without becoming addicted, and 8% to 10% endorsed beliefs on the benefits of smoking. Children's positive attitudes about smoking were associated with lower family cohesiveness (p = .01). Parental use of tobacco was the only significant predictor of children's positive attitudes about tobacco at 20 months (p = .03).

Conclusions.

Children as young as 10 years underestimate addictive properties of smoking, which may place them at risk for future smoking. Parental use of tobacco and family cohesiveness are important factors in the formulation of preteen attitudes about smoking.

Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review

CONTEXT

Parenting interventions may prevent adolescent substance use; however, questions remain regarding the effectiveness of interventions across substances and delivery qualities contributing to successful intervention outcomes.

OBJECTIVE

To describe the effectiveness of parent-focused interventions in reducing or preventing adolescent tobacco, alcohol, and illicit substance use and to identify optimal intervention targeted participants, dosage, settings, and delivery methods.

DATA SOURCES

PubMed, PsycINFO, ERIC, and CINAHL.

STUDY SELECTION

Randomized controlled trials reporting adolescent substance use outcomes, focusing on imparting parenting knowledge, skills, practices, or behaviors.

DATA EXTRACTION

Trained researchers extracted data from each article using a standardized, prepiloted form. Because of study heterogeneity, a qualitative technique known as harvest plots was used to summarize findings.

RESULTS

A total of 42 studies represented by 66 articles met inclusion criteria. Results indicate that parenting interventions are effective at preventing and decreasing adolescent tobacco, alcohol, and illicit substance use over the short and long term. The majority of effective interventions required ≤12 contact hours and were implemented through in-person sessions including parents and youth. Evidence for computer-based delivery was strong only for alcohol use prevention. Few interventions were delivered outside of school or home settings.

LIMITATIONS

Overall risk of bias is high.

CONCLUSIONS

This review suggests that relatively low-intensity group parenting interventions are effective at reducing or preventing adolescent substance use and that protection may persist for multiple years. There is a need for additional evidence in clinical and other community settings using an expanded set of delivery methods.

Family-Based Interventions in Preventing Children and Adolescents from Using Tobacco: A Systematic Review and Meta-Analysis

BACKGROUND

Tobacco is the main preventable cause of death and disease worldwide. Adolescent smoking is increasing in many countries with poorer countries following the earlier experiences of affluent countries. Preventing adolescents from starting smoking is crucial to decreasing tobacco-related illness.

OBJECTIVE

To assess effectiveness of family-based interventions alone and combined with school-based interventions to prevent children and adolescents from initiating tobacco use.

DATA SOURCES

Fourteen bibliographic databases and the Internet, journals hand-searched, and experts consulted.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized controlled trials (RCTs) with children or adolescents and families, interventions to prevent starting tobacco use, and follow-up ≥6 months.

STUDY APPRAISAL/SYNTHESIS METHODS

Abstracts/titles independently assessed and data independently entered by 2 authors. Risk of bias was assessed with the Cochrane Risk-of-Bias tool.

RESULTS

Twenty-seven RCTs were included. Nine trials of never-smokers compared with a control provided data for meta-analysis. Family intervention trials had significantly fewer students who started smoking. Meta-analysis of 2 RCTs of combined family and school interventions compared with school only, showed additional significant benefit. The common feature of effective high-intensity interventions was encouraging authoritative parenting.

LIMITATIONS

Only 14 RCTs provided data for meta-analysis (approximately a third of participants). Of the 13 RCTs that did not provide data for meta-analysis 8 compared a family intervention with no intervention and 1 reported significant effects, and 5 compared a family combined with school intervention with a school intervention only and none reported additional significant effects.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There is moderate-quality evidence that family-based interventions prevent children and adolescents from starting to smoke.

A component-centered meta-analysis of family-based prevention programs for adolescent substance use

Although research has documented the positive effects of family-based prevention programs, the field lacks specific information regarding why these programs are effective. The current study summarized the effects of family-based programs on adolescent substance use using a component-based approach to meta-analysis in which we decomposed programs into a set of key topics or components that were specifically addressed by program curricula (e.g., parental monitoring/behavior management,problem solving, positive family relations, etc.). Components were coded according to the amount of time spent on program services that targeted youth, parents, and the whole family; we also coded effect sizes across studies for each substance-related outcome. Given the nested nature of the data, we used hierarchical linear modeling to link program components (Level 2) with effect sizes (Level 1). The overall effect size across programs was .31, which did not differ by type of substance. Youth-focused components designed to encourage more positive family relationships and a positive orientation toward the future emerged as key factors predicting larger than average effect sizes. Our results suggest that, within the universe of family-based prevention, where components such as parental monitoring/behavior management are almost universal, adding or expanding certain youth-focused components may be able to enhance program efficacy.

Interventions for prevention and treatment of tobacco smoking in school-aged children and adolescents: A systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of primary health care relevant interventions to prevent and treat tobacco smoking in school-aged children and adolescents.

METHODS

This systematic review considered studies included in a prior review. We adapted and updated the search to April 2015. Titles, abstracts and full-text articles were reviewed in duplicate; data extraction and quality assessments were performed by one reviewer and verified by another. Meta-analyses and pre-specified sub-group analyses were performed when possible. PROSPERO #CRD42015019051.

RESULTS

After screening 2118 records, we included nine randomized controlled trials. The mostly moderate quality evidence suggested targeted behavioral interventions can prevent smoking and assist with cessation. Meta-analysis showed intervention participants were 18% less likely to report having initiated smoking at the end of intervention relative to controls (Risk Ratio 0.82; 95% confidence interval 0.72, 0.94); the absolute effect is 1.92% for smoking initiation, Number Needed to Treat is 52 (95% confidence interval 33, 161). For cessation, meta-analysis showed intervention participants were 34% more likely to report having quit smoking at the end of intervention relative to controls (Risk Ratio 1.34; 95% confidence interval 1.05, 1.69); the absolute effect is 7.98% for cessation, Number Needed to Treat is 13 (95% confidence interval 6, 77). Treatment harms were not mentioned in the literature and no data were available to assess long-term effectiveness.

CONCLUSION

Primary care relevant behavioral interventions improve smoking outcomes for children and youth. The evidence on key components is limited by heterogeneity in methodology and intervention strategy. Future trials should target tailored prevention or treatment approaches, establish uniform definition and measurement of smoking, isolate optimal intervention components, and include long-term follow-up.

Perspectives in Implementing a Primary Care-Based Intervention to Reduce Alcohol Misuse

In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended screening followed by brief behavioral counseling to reduce alcohol misuse. Our study, Options Regarding Consumption of Alcohol (ORCA), was one of the studies included in an evidence review that comprised 23 RCTs. ORCA was designed to test whether a primary care-based intervention would reduce alcohol misuse among patients who screened positive for risky or hazardous drinking. Data collection occurred between 1995 and 1999; data analysis was conducted in 2000-2002. Study design and implementation built from a behavioral counseling research paradigm with four components: (1) population-based screening; (2) centralized delivery of intervention components; (3) involvement of primary care practitioners to motivate and reinforce behavior change; and (4) personalization of intervention components. In this paper, we assess the study features using the Pragmatic-Explanatory Continuum Indicator Summary Model domains. As a randomized trial, the study included some explanatory features (e.g., standardized follow-up surveys administered by study personnel); however, several aspects of the study were highly pragmatic. Practicable recruitment and training of providers, embedding population-based screening in pre-visit surveys, and keeping the delivery of the primary care intervention components consistent with the tempo and competing priorities of practice are three key features that contributed to the study's success and relevance to the USPSTF.

Family-based programmes for preventing smoking by children and adolescents

BACKGROUND

There is evidence that family and friends influence children's decisions to smoke.

OBJECTIVES

To assess the effectiveness of interventions to help families stop children starting smoking.

SEARCH METHODS

We searched 14 electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO, CINAHL unpublished material, and key articles' reference lists. We performed free-text internet searches and targeted searches of appropriate websites, and hand-searched key journals not available electronically. We consulted authors and experts in the field. The most recent search was 3 April 2014. There were no date or language limitations.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions with children (aged 5-12) or adolescents (aged 13-18) and families to deter tobacco use. The primary outcome was the effect of the intervention on the smoking status of children who reported no use of tobacco at baseline. Included trials had to report outcomes measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We reviewed all potentially relevant citations and retrieved the full text to determine whether the study was an RCT and matched our inclusion criteria. Two authors independently extracted study data for each RCT and assessed them for risk of bias. We pooled risk ratios using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

Twenty-seven RCTs were included. The interventions were very heterogeneous in the components of the family intervention, the other risk behaviours targeted alongside tobacco, the age of children at baseline and the length of follow-up. Two interventions were tested by two RCTs, one was tested by three RCTs and the remaining 20 distinct interventions were tested only by one RCT. Twenty-three interventions were tested in the USA, two in Europe, one in Australia and one in India.The control conditions fell into two main groups: no intervention or usual care; or school-based interventions provided to all participants. These two groups of studies were considered separately.Most studies had a judgement of 'unclear' for at least one risk of bias criteria, so the quality of evidence was downgraded to moderate. Although there was heterogeneity between studies there was little evidence of statistical heterogeneity in the results. We were unable to extract data from all studies in a format that allowed inclusion in a meta-analysis.There was moderate quality evidence family-based interventions had a positive impact on preventing smoking when compared to a no intervention control. Nine studies (4810 participants) reporting smoking uptake amongst baseline non-smokers could be pooled, but eight studies with about 5000 participants could not be pooled because of insufficient data. The pooled estimate detected a significant reduction in smoking behaviour in the intervention arms (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.68 to 0.84). Most of these studies used intensive interventions. Estimates for the medium and low intensity subgroups were similar but confidence intervals were wide. Two studies in which some of the 4487 participants already had smoking experience at baseline did not detect evidence of effect (RR 1.04, 95% CI 0.93 to 1.17).Eight RCTs compared a combined family plus school intervention to a school intervention only. Of the three studies with data, two RCTS with outcomes for 2301 baseline never smokers detected evidence of an effect (RR 0.85, 95% CI 0.75 to 0.96) and one study with data for 1096 participants not restricted to never users at baseline also detected a benefit (RR 0.60, 95% CI 0.38 to 0.94). The other five studies with about 18,500 participants did not report data in a format allowing meta-analysis. One RCT also compared a family intervention to a school 'good behaviour' intervention and did not detect a difference between the two types of programme (RR 1.05, 95% CI 0.80 to 1.38, n = 388).No studies identified any adverse effects of intervention.

AUTHORS' CONCLUSIONS

There is moderate quality evidence to suggest that family-based interventions can have a positive effect on preventing children and adolescents from starting to smoke. There were more studies of high intensity programmes compared to a control group receiving no intervention, than there were for other compairsons. The evidence is therefore strongest for high intensity programmes used independently of school interventions. Programmes typically addressed family functioning, and were introduced when children were between 11 and 14 years old. Based on this moderate quality evidence a family intervention might reduce uptake or experimentation with smoking by between 16 and 32%. However, these findings should be interpreted cautiously because effect estimates could not include data from all studies. Our interpretation is that the common feature of the effective high intensity interventions was encouraging authoritative parenting (which is usually defined as showing strong interest in and care for the adolescent, often with rule setting). This is different from authoritarian parenting (do as I say) or neglectful or unsupervised parenting.

Berlin evaluates school tobacco prevention - BEST prevention: study design and methodology

BACKGROUND

The hazardous health effects of smoking are established, but there remains a need to evaluate existing smoking prevention strategies and to increase their effectiveness in adolescents. Strategies focusing on parental attitudes and rule setting have been identified as a potentially effective approach. The present manuscript describes objectives, study design and methodology of the BEST Prevention study.

METHODS/DESIGN

BEST Prevention is a three-armed cluster randomized-controlled trial among 7th grade (11-16 years) students in Berlin, Germany. Schools were enrolled between 2010 and 2011 and allocated using a centralized randomization list into 1) a student smoking prevention intervention (visit to an established interactive circuit), 2) the same intervention plus a parent intervention, and 3) a control group (visit to an established exercise and nutrition interactive circuit). Students were assessed at baseline, 12 and 24 months via self-report, as well as via carbon monoxide and cotinine in saliva at the 24 month follow-up. Statistical analyses uses multi-level regression models with cluster effects (school and class within school) based on the intention to treat population. Here we report descriptive baseline characteristics of recruited schools, and schools classes. Two schools from the control group dropped out after allocation. Hence, 47 secondary schools from all 12 districts of the city, including 161 school classes and 3023 students are participating in the study. Of those, 2801 students completed the baseline assessment.

DISCUSSION

The present manuscript provides details on the study design and methodology of a large school-based smoking prevention trial in a metropolitan area in Germany. Findings from this study will yield important insight into the long-term effectiveness of specific smoking prevention strategies, also in disadvantaged population groups.

TRIAL REGISTRATION

NCT01306552 (January 2011).

Anti-smoking initiatives and current smoking among 19,643 adolescents in South Asia: findings from the Global Youth Tobacco Survey

BACKGROUND

Cigarette smoking habit usually begins in adolescence. The developing countries in South Asia like Pakistan, India, Bangladesh, and Nepal, where the largest segment of the population is comprised of adolescents, are more susceptible to smoking epidemic and its consequences. Therefore, it is important to identify the association between anti-smoking initiatives and current smoking status in order to design effective interventions to curtail the smoking epidemic in this region.

METHODS

This is a secondary analysis of national data from the Global Youth Tobacco Survey (GYTS) conducted in Pakistan (year 2003), India (year 2006), Bangladesh (year 2007), and Nepal (year 2007). GYTS is a school-based survey of students targeting adolescents of age 13-15 years. We examined the association of different ways of delivering anti-smoking messages with students' current smoking status.

RESULTS

A total of 19,643 schoolchildren were included in this study. The prevalence of current smoking was 5.4% with male predominance. No exposure to school teachings, family discussions regarding smoking hazards, and anti-smoking media messages was significantly associated with current smoking among male students. Participants who were deprived of family discussion regarding smoking hazards (girls: odds ratio (OR) 1.56, 95% confidence interval (CI) 0.84-2.89, p value 0.152; boys: OR 1.37, 95% CI 1.04-1.80, p value 0.025), those who had not seen media messages (girls: OR 2.89, 95% CI 1.58-5.28, p value <0.001; boys: OR 1.32, 95% CI 0.91-1.88, p value 0.134), and those who were not taught the harmful effects of smoking at school (girls: OR 2.00, 95% CI 0.95-4.21, p value 0.066; boys: OR 1.89, 95% CI 1.44-2.48, p value <0.001) had higher odds of being current smokers after multivariate adjustment.

CONCLUSION

School-going adolescents in South Asia (Pakistan, India, Nepal, and Bangladesh) who were not exposed to anti-tobacco media messages or were not taught about the harmful effects in school or at home had higher odds of being current smokers than their counterparts.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Evaluation of a U.S. evidence-based parenting intervention in rural Western Kenya: from parents matter! To families matter!

We evaluated Families Matter! Program (FMP), an intervention designed to improve parent-child communication about sexual risk reduction and parenting skills. Parents of 10- to 12-year-olds were recruited in western Kenya. We aimed to assess community acceptability and FMP's effect on parenting practices and effective parent-child communication. Data were collected from parents and their children at baseline and 1 year postintervention. The intervention's effect was measured on six parenting and parent-child communication composite scores reported separately for parents and children. Of 375 parents, 351 (94%) attended all five intervention sessions. Parents' attitudes regarding sexuality education changed positively. Five of the six composite parenting scores reported by parents, and six of six reported by children, increased significantly at 1 year postintervention. Through careful adaptation of this U.S. intervention, FMP was well accepted in rural Kenya and enhanced parenting skills and parent-child sexuality communication. Parents are in a unique position to deliver primary prevention to youth before their sexual debut as shown in this Kenyan program.

Pre-risk HIV-prevention paradigm shift: the feasibility and acceptability of the parents matter! Program in HIV risk communities

OBJECTIVES

Many youth begin human immunodeficiency virus (HIV) sexual risk behaviors in preadolescence, yet risk-reduction programs are typically implemented in middle or late adolescence, missing an important window for prevention. Parent-based programming may play an important role in reaching youth early with prevention messages. One such program is the Parents Matter! Program (PMP), a five-session theory- and evidence-based intervention for parents of children aged 9 to 12 years. A randomized controlled trial showed PMP to be efficacious in promoting effective parent-child communication about sexuality and sexual risk reduction. We assessed the feasibility and acceptability of PMP when implemented under typical programmatic circumstances in communities at high risk for HIV infection.

METHODS

We selected 15 sites (including health departments, local education agencies, community-based organizations, and faith-based organizations) throughout the U.S. and Puerto Rico to participate in delivering PMP. Sites were provided training, program materials, and ongoing technical assistance. We collected multilevel data to assess the feasibility of program implementation and delivery, program relevance, and satisfaction with PMP activities and materials.

RESULTS

PMP was successfully implemented and evaluated in 13 of 15 sites; 76% of parents attended at least four of five sessions. Organization-, facilitator-, and parent-level data indicated the feasibility and acceptability of PMP, and overall high satisfaction with PMP activities and materials.

CONCLUSION

The results of this project demonstrate that HIV pre-risk prevention programs for parents can be implemented and embraced by a variety of community organizations in HIV at-risk communities. The time to embrace parents as partners in public health HIV-prevention efforts has come.

Review of strategies to recruit smokers for smoking cessation: a population impact perspective

This paper reviews published articles describing several instruments used currently to "capture" the attention of smokers for quit-smoking interventions and emphasizes the distinction between the strategies used to reach eligible individuals and those used to recruit them for the proposed smoking cessation intervention. The search for articles was conducted using MEDLINE, PsychARTICLE, and LILACS. Key words for the search included recruitment, enrollment, reach, smoking cessation, quitline, and helpline mentioned in the abstracts and titles of the articles. Articles published in English, Portuguese, and Spanish through November 2006 that emphasized capture instruments related to different populations and specific interventions were included in this review. Twenty-nine studies met the inclusion criteria. Studies that used active and mixed strategies reached, on average, a smaller and less diverse possible number of eligible individuals and had greater participation proportions than those that used reactive strategies. Future studies are needed to evaluate the effectiveness of new associations between current interventions and reactive capture strategies, in view of the potential for increasing the population impact related to reactive capture.

Family composition and children's exposure to adult smokers in their homes

OBJECTIVE

Smoking behavior is strongly influenced by the social environment. More information is needed about how the composition of households with children is associated with adult smoking behavior so that more effective interventions to reduce children's secondhand smoke exposure can be devised and implemented.

METHODS

Using data from the Medical Expenditure Panel Survey 2000-2004, we conducted cross-sectional analyses to assess how adult smoking behavior is associated with household characteristics, including the number of adults and smokers present, the relationship of the child to the head of household, and relationships between adult members of the household.

RESULTS

More than one third (34.4%) of children lived with > or =1 adult smoker. Almost half (49.4%) of poor children lived with a smoker, and they were more likely to live with multiple smokers compared with those who lived at >400% of the federal poverty level (21.2% vs 7.8%). Approximately 5 million children lived in households headed by an adult other than their parent, and they were significantly more likely to live with smokers: 53.4% of children who lived in their grandparents' homes and 46.2% of children in homes of other adults lived with at least 1 adult smoker, compared with 33.3% who lived in their parents' home. A total of 59.4% of all children who lived with a smoker had a smoking mother, and 56.7% of those children lived with > or =2 smokers, whereas only 17.0% of children whose mother did not smoke had smoking adults in the home.

CONCLUSIONS

These findings demonstrate the significant influence of household composition on children's likelihood to live in homes with adult smokers.

Predictors of smoking cessation and relapse after hospitalization for acute coronary syndrome

BACKGROUND

A hospital admission for a serious cardiac event offers a unique opportunity for smoking cessation. Understanding the factors that predict and enhance cessation among smoking cardiac inpatients is important for hospital physicians and clinical staff.

STUDY OBJECTIVE

To determine factors that predict smoking cessation, relapse, or continued smoking among posthospitalized cardiac patients who were smoking at the time of admission.

SAMPLE

Patients hospitalized with acute coronary syndrome (ACS) were recruited from 5 hospitals in Michigan to participate in a study assessing hospital quality improvement plus at-home health behavior change counseling.

MEASUREMENTS

Patient interview data were collected shortly after discharge and 3 and 8 months later to describe patient demographics, clinical characteristics, tobacco use, and other behaviors. Multinomial logit regression was used to predict smoking cessation, relapse, and continued smoking.

RESULTS

Of patients smoking at hospitalization who completed both follow-up interviews, 56.8% (n = 111) were not smoking at 8 months. A significant predictor of successful cessation was higher household income (odds ratio [OR] = 4.72; P = 0.003), while having other smokers in the household decreased the odds of cessation (OR = 0.20; P = 0.001). History of depression increased the odds of relapse (OR = 6.38; P = 0.002) and being a lighter smoker decreased the odds (OR = 0.16; P = 0.026).

CONCLUSIONS

Although approximately one-half of the smokers in this study reported successful cessation, interventions are still needed to assist all smokers to successfully quit smoking after an ACS hospitalization. Our data suggest targeting follow-up programs to include other family members and using specialized methods for heavy smokers.

Adolescent neurological development and its implications for adolescent substance use prevention

Recent technological advancements have facilitated the study of adolescent neurological development and its implications for adolescent decision-making and behavior. This article reviews findings from the adolescent neurodevelopment and substance use prevention literatures. It also discusses how findings from these two distinct areas of adolescent development can complement each other and be used to build more developmentally appropriate interventions for preventing adolescent substance use. Specifically, a combination of child-centered and family-based strategies is advocated based on extant neurological and prevention literature. EDITORS' STRATEGIC IMPLICATIONS: Researchers are encouraged to take up the authors' challenge and study the links between adolescent neurological development/decision making ability and the long term efficacy of comprehensive interventions for preventing adolescent substance use.

Family-based programmes for preventing smoking by children and adolescents

BACKGROUND

There is evidence that children's decisions to smoke are influenced by family and friends.

OBJECTIVES

To assess the effectiveness of interventions to help family members to strengthen non-smoking attitudes and promote non-smoking by children and other family members.

SEARCH STRATEGY

We searched 14 electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and CINAHL. We also searched unpublished material, and the reference lists of key articles. We performed both free-text Internet searches and targeted searches of appropriate websites, and we hand-searched key journals not available electronically. We also consulted authors and experts in the field. The most recent search was performed in July 2006.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of interventions with children (aged 5-12) or adolescents (aged 13-18) and family members to deter the use of tobacco. The primary outcome was the effect of the intervention on the smoking status of children who reported no use of tobacco at baseline. Included trials had to report outcomes measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We reviewed all potentially relevant citations and retrieved the full text to determine whether the study was an RCT and matched our inclusion criteria. Two authors independently extracted study data and assessed them for methodological quality. The studies were too limited in number and quality to undertake a formal meta-analysis, and we present a narrative synthesis.

MAIN RESULTS

We identified 19 RCTs of family interventions to prevent smoking. We identified five RCTs in Category 1 (minimal risk of bias on all counts); nine in Category 2 (a risk of bias in one or more areas); and five in Category 3 (risks of bias in design and execution such that reliable conclusions cannot be drawn from the study). Considering the fourteen Category 1 and 2 studies together: (1) four of the nine that tested a family intervention against a control group had significant positive effects, but one showed significant negative effects; (2) one of the five RCTs that tested a family intervention against a school intervention had significant positive effects; (3) none of the six that compared the incremental effects of a family plus a school programme to a school programme alone had significant positive effects; (4) the one RCT that tested a family tobacco intervention against a family non-tobacco safety intervention showed no effects; and (5) the one trial that used general risk reduction interventions found the group which received the parent and teen interventions had less smoking than the one that received only the teen intervention (there was no tobacco intervention but tobacco outcomes were measured). For the included trials the amount of implementer training and the fidelity of implementation are related to positive outcomes, but the number of sessions is not.

AUTHORS' CONCLUSIONS

Some well-executed RCTs show family interventions may prevent adolescent smoking, but RCTs which were less well executed had mostly neutral or negative results. There is thus a need for well-designed and executed RCTs in this area.

Nursing intervention and smoking cessation: meta-analysis update

OBJECTIVE

The study objective was to determine through meta-analysis the effects of nursing-delivered smoking-cessation interventions.

RESULTS

Thirty-four studies met inclusion criteria in this updated meta-analysis. Twenty-six studies compared a nursing intervention with a control or usual care group of adults and found interventions of high and low intensity to modestly increase the odds of quitting (1.36, 95% confidence interval 1.22-1.51). The study results demonstrated heterogeneity; using a random effects model did not make a difference. There was evidence that interventions were most effective for hospital inpatients with cardiovascular disease than for patients with other conditions (odds ratio 2.14, confidence interval 1.39-3.31). Interventions in nonhospitalized adults were beneficial as well; no effect was found for additive intervention components. Counseling during health-screening programs or as part of multifactorial secondary preventions programs was found to be the least effective. The challenge will be to incorporate smoking-cessation interventions into evidence-based nursing practice.

Smoking Initiation Prevention Among Youths: Implications for Community Health Nursing Practice

Cigarette smoking among youths has long been documented as a national problem affecting health and economic status in the United States. A number of studies have documented that cigarette-smoking initiation occurs primarily between late childhood and young adolescence. This evidence has brought about the need for awareness among community health nurses to find and deliver effective antismoking programs to reduce the prevalence of youth smoking initiation. Generally, community health nurses are in an excellent position to help the nation achieve its goals in terms of reducing the incidence of youth smoking initiation. However, current knowledge about community health nursing practice and smoking initiation interventions is limited. This article raises awareness about smoking initiation prevention in youth and the need to implement effective smoking prevention programs in practice settings and encourages community health nurses to increase their involvement in antismoking initiation research and interventions.

Teen reach: outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care

OBJECTIVE

To test the long-term efficacy of brief counseling plus a computer-based tobacco intervention for teens being seen for routine medical care.

METHODS

Both smoking and nonsmoking teens, 14 to 17 years of age, who were being seen for routine visits were eligible for this 2-arm controlled trial. Staff members approached teens in waiting rooms of 7 large pediatric and family practice departments within a group-practice health maintenance organization. Of 3747 teens invited at > or =1 visits, 2526 (67%) consented and were randomized to tobacco intervention or brief dietary advice. The tobacco intervention was individually tailored on the basis of smoking status and stage of change. It included a 30-second clinician advice message, a 10-minute interactive computer program, a 5-minute motivational interview, and up to two 10-minute telephone or in-person booster sessions. The control intervention was a 5-minute motivational intervention to promote increased consumption of fruits and vegetables. Follow-up smoking status was assessed after 1 and 2 years.

RESULTS

Abstinence rates after 2 years were significantly higher for the tobacco intervention arm, relative to the control group, in the combined sample of baseline smokers and nonsmokers (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 1.03-1.47). Treatment effects were particularly strong among baseline self-described smokers (OR: 2.42; 95% CI: 1.40-4.16) but were not significant for baseline nonsmokers (OR: 1.25; 95% CI: 0.97-1.61) or for those who had "experimented" in the past month at baseline (OR: 0.95; 95% CI: 0.45-1.98).

CONCLUSIONS

Brief, computer-assisted, tobacco intervention during routine medical care increased the smoking cessation rate among self-described smokers but was less effective in preventing smoking onset.

Physician Tobacco Advice to Preteens in a Smoking-Prevention Randomized Trial: Steering Clear

OBJECTIVE

To examine preadolescent and parental recall of tobacco prevention messages by health care providers.

METHODS

As part of a smoking prevention trial, providers were cued to reinforce the study and advise intervention participants (N=4,026) not to use tobacco. All parents were surveyed at baseline; children were surveyed at 20 months; and a subsample (504 households) was surveyed at 6 and 12 months to assess discussion of tobacco use prevention and other health behavior topics by providers as well as susceptibility and experimentation with tobacco among children.

RESULTS

During the 20-month follow-up, less than 25% of children recalled a provider discussing tobacco use prevention. Recall of exposure to tobacco prevention messages at school (68%), from parents (53%), and from mass media (71%) was higher.

CONCLUSIONS

Physician tobacco counseling is occurring at lower rates in pre-adolescents than it is in adults. A chart reminder to providers was insufficient to create a meaningful effect.

Depressed mood and smoking experimentation among preteens

The authors examined children's depressed mood, parental depressed mood, and parental smoking in relation to children's smoking susceptibility and experimentation over 20 months in a cohort of 418 preteens (ages 10-12 at baseline) and their parents. Depressed mood in preteens was strongly related to experimentation but not to susceptibility. In cross-sectional analyses parental depressed mood was related to children's experimentation, but in longitudinal analyses parental depressed mood at baseline did not differentiate children who experimented from those who did not. Although parental smoking was strongly related to experimentation, it was not related to susceptibility either cross-sectionally or longitudinally. Depressed mood among preteens and parents appeared to be more strongly related to children's smoking behaviors than to their intentions to smoke.