Evaluation of a tobacco prevention programme among teenagers in Sweden

Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review

PURPOSE

While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps.

METHODS

We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded.

RESULTS

A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco.

CONCLUSIONS

This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.

Socioeconomic Differences in Cigarette Smoking and Alternative Tobacco Product Use Among Adolescents in a School-Based Smoking Preventive Intervention: Findings From the Second Year of the X:IT II Study

Background

Health interventions may differently impact adolescents from diverse backgrounds. This study examined whether a smoking preventive intervention was equally effective in preventing cigarette smoking and use of alternative tobacco products (ATPs, i.e., snus, e-cigarettes, and waterpipe) among students from different socioeconomic backgrounds, i.e., occupational social classes (OSC).

Methods

Data was from the school-based intervention X:IT II targeting 13- to 15-year-olds Danes. The intervention focused on three main components: smoke-free school time, smoke-free curriculum, and parental involvement. In total, 46 schools were included at baseline (N = 2,307, response rate = 86.3%). Using a difference-in-differences approach, changes in current smoking and ever use of ATPs were estimated among students in high versus low OSC at second follow-up. Analyses were based on available cases (N = 826) and multiple imputations of missing data at the second follow-up (N = 1,965).

Results

At baseline (age 13), 1.0% of students from high OSC and 4.8% from low OSC currently smoked cigarettes, while this was the case among 24.5 and 25.6%, respectively, at the second follow-up (age 15). Estimates indicated that social inequalities in current smoking diminished over time (p < 0.001). Regarding ATPs, 10.0% of high OSC students and 13.9% of low OSC students had ever used ATPs at baseline, while at second follow-up, 46.8 and 60.8%, respectively, had ever used ATPs. Estimates indicated that social inequalities in ever use of ATPs widened over time (p < 0.001).

Conclusions

The X:IT II intervention seemed to diminish socioeconomic disparities in smoking over the study period. Meanwhile, social inequalities in ever use of ATPs increased. Therefore, besides focusing on narrowing the social disparities in cigarette smoking, future efforts may, to a larger extent, focus on adolescents' use of ATPs.

Evaluation of the Swedish school-based program "tobacco-free DUO" in a cluster randomized controlled trial (TOPAS study). Results at 2-year follow-up

Friends' and parents' tobacco use are strong predictors of tobacco uptake among adolescents, however the effectiveness of interventions based on public commitments and agreements to remain tobacco-free are not established. Here, we evaluated the effectiveness of the school-based Swedish program Tobacco-Free Duo (T-Duo) in preventing adolescents from initiating tobacco use (TOPAS study). T-Duo is a multi-component intervention witha formal agreement between a student and an adult partner to remain tobacco-free during the entire 3-year study period as core component. The standardized educational component of the same program was used as comparator (control). Primary outcome was the probability to "remain a non-user" of i) cigarettes and secondary outcomes ii) other types of tobacco at second (21-month) follow-up. Analysis was conducted according to Intention To Treat. In total 1776 adolescents (51% female) aged 12-13 in grade 7 from 34 participating high schools in Sweden were included at baseline in 2018, of which 1489 were retained after 21 months. The Risk Ratio (RR) of not having tried cigarettes 21-months after initiation of the intervention was 1.03(CI 0.98-1.08), Bayes Factor(BF) = 0.93, Absolute Risk Difference(ARD) = 3.1%. Similar associations were found for never smoked a whole cigarette and never use of other tobacco/nicotine products. There was a minimal reduction of tobacco use initiation among Swedish adolescents assigned to a multi-component intervention (T-Duo) compared to those assigned to standardized classroom education after 2 schoolyears. However, for most outcomes' findings were inconclusive and not reliably different from zero. Trial registration: ISRCTN5285808 (doi:https://doi.org/10.1186/ISRCTN52858080); Study protocol: DERR1-https://doi.org/10.2196/21100. Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered. Protocol: Galanti, M.R., Pulkki-Brännström, A.-M., Nilsson, M., 2020. Tobacco-free duo adult-child contract for prevention of tobacco use among adolescents and parents: protocol for a mixed-design evaluation. JMIR Res. Protoc. 9, e21100. doi:10.2196/21100.

A Brief Intervention on E-Cigarette, Regular Cigarette, and Marijuana Use Results in Generalization Effects: Lateral Attitude Change among College Students

OBJECTIVE

We hypothesized (1) perceived harm beliefs and intention to use e-cigarette attitudes will become more negative post-exposure to the intervention (2) this change will generalize to more negative beliefs and intention toward regular cigarettes and marijuana.

METHODS

MANOVAs of students' perceptions of harm beliefs and intention toward the use of e-cigarettes and regular cigarettes, and marijuana were performed to ascertain change in harm beliefs before (t₁) to after the intervention (t₂) for 188 nonwhite Hispanic and White college students who viewed educational material (informational text + video), the intervention, during an online experimental survey.

RESULTS

The first MANOVA yielded main effect with significant differences for substances, Wilks' Lambda (Λ) = 0.254, F = 234.920 (2, 160), p < 0.001, η_p² =0.746 and by time (Λ = 0.740, F = 56.684 (1, 161), p < 0.001, η_p² = 0.260). E-cigarettes, regular cigarettes, and marijuana were perceived more harmful for one's health and for the health of others at t₂. The MANOVA on peer influence and intention to use (Λ = 0.277, F = 222.890 (2, 171), p < 0.001), η_p² = 0.723) and by time (Λ = 0.922, F = 14.514 (1, 172), p < 0.001), η_p² = 0.078) was significant. Respondents were less likely to use any of the substances if their best friend offered at t_2. Intent for future use was also reduced at t₂.

CONCLUSION

A brief intervention potentiated favorable change in harm beliefs and intention to focal object (e-cigarettes) and lateral objects (regular cigarettes and marijuana).

How do educational disparities in smoking develop during early life? A Swedish longitudinal study

Smoking contributes to health inequalities, but how social inequalities in smoking develop in early life remains unclear. This study examines how measures of education attained over the early life course (representing socioeconomic position of origin, socioeconomic position of destination, and in-between) contribute to smoking behavior in a Swedish longitudinal sample. We used data obtained from the Swedish Level-of-Living Surveys in addition to national register data. Young adults (aged 20-28, n = 749) self-reported their educational attainment and smoking behavior (initiation and cessation) in 2010. Ten years earlier, their parents self-reported their own education and smoking behavior. We used linked register data on school performance in adolescence (in grade 9). Logistic regression models showed that lower parental education, lower adolescent school performance, and low young adult educational attainment were respectively associated with young adult smoking initiation. The association between parental education and young adult smoking initiation was explained by adolescent school performance and not parental smoking. Young adult smoking cessation was associated with high parental education and high adolescent school performance (marks in the top quartile), but only school performance remained significant in the final model, which included all measures of education and parental smoking. Results suggest that school performance in adolescence (which connects adolescents' socioeconomic position of origin with their destination) may play an important role in how educational disparities in smoking form over the life course.

Protocol for the evaluation of cost-effectiveness and health equity impact of a school-based tobacco prevention programme in a cluster randomised controlled trial (the TOPAS study)

INTRODUCTION

Despite a long-term downward trend in smoking prevalence, tobacco remains the number one risk factor for death and disability in Sweden. Globally, tobacco use generates a substantial economic burden for health systems and is also a major driver of socioeconomic inequalities in health. This article describes the planned cost-effectiveness and health equity impact evaluation of a multicomponent school-based programme to prevent the onset of tobacco use in adolescents.

METHODS AND ANALYSIS

Cost-effectiveness of the multicomponent Tobacco-Free Duo programme will be evaluated against the educational component of the same programme only. An incremental cost-effectiveness ratio (ICER) will be calculated in terms of the cost per case prevented using the trial primary outcome and within-trial payer costs. If the ICER is negative, an incremental net benefit ratio will be calculated. Robustness of the results will be assessed through one-way sensitivity analyses. The slope index of inequality will be computed to assess the potential impact of the Tobacco-free Duo programme on education-related inequalities in the onset of smoking and in adult smoking cessation, comparing the two trial arms.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Regional Ethics Review Board, Umeå (registration number 2017/255-31). The Public Health Agency of Sweden commissioned the study. The findings will be disseminated internationally within academia and to national and local policy-makers.

TRIAL REGISTRATION NUMBER

ISRCTN52858080; Pre-results.

Predictors of electronic cigarette use among Swedish teenagers: a population-based cohort study

OBJECTIVES

The aim was to identify predictors of electronic cigarette (e-cigarette) use among teenagers.

DESIGN AND SETTING

A prospective population-based cohort study of schoolchildren in northern Sweden.

PARTICIPANTS

In 2006, a cohort study about asthma and allergic diseases among schoolchildren started within the Obstructive Lung Disease in Northern Sweden studies. The study sample (n=2185) was recruited at age 7-8 years, and participated in questionnaire surveys at age 14-15 and 19 years. The questionnaire included questions about respiratory symptoms, living conditions, upper secondary education, physical activity, diet, health-related quality of life, parental smoking and parental occupation. Questions about tobacco use were included at age 14-15 and 19 years.

PRIMARY OUTCOME

E-cigarette use at age 19 years.

RESULTS

At age 19 years, 21.4% had ever tried e-cigarettes and 4.2% were current users. Among those who were daily tobacco smokers at age 14-15 years, 60.9% had tried e-cigarettes at age 19 years compared with 19.1% of never-smokers and 34.0% of occasional smokers (p<0.001). Among those who had tried e-cigarettes, 28.1% were never smokers both at age 14-15 and 19 years, and 14.4% were never smokers among the current e-cigarette users. In unadjusted analyses, e-cigarette use was associated with daily smoking, use of snus and having a smoking father at age 14-15 years, as well as with attending vocational education, physical inactivity and unhealthy diet. In adjusted analyses, current e-cigarette use was associated with daily tobacco smoking at age 14-15 years (OR 6.27; 95% CI 3.12 to 12.58), attending a vocational art programme (OR 2.22; 95% CI 1.04 to 4.77) and inversely associated with eating a healthy diet (OR 0.74; 95% CI 0.59 to 0.92).

CONCLUSIONS

E-cigarette use was associated with personal and parental tobacco use, as well as with physical inactivity, unhealthy diet and attending vocational upper secondary education. Importantly, almost one-third of those who had tried e-cigarettes at age 19 years had never been tobacco smokers.

Tobacco-Free Duo Adult-Child Contract for Prevention of Tobacco Use Among Adolescents and Parents: Protocol for a Mixed-Design Evaluation

BACKGROUND

Universal tobacco-prevention programs targeting youths usually involve significant adults, who are assumed to be important social influences. Commitment not to use tobacco, or to quit use, as a formal contract between an adolescent and a significant adult is a preventive model that has not been widely practiced or explored and has been formally evaluated even less. In this paper, we present the rationale and protocol for the evaluation of the Swedish Tobacco-free Duo program, a multicomponent school-based program the core of which rests on a formal agreement between an adolescent and an adult. The adolescent's commitment mainly concerns avoiding the onset of any tobacco use while the adult commits to support the adolescent in staying tobacco free, being a role model by not using tobacco themselves.

OBJECTIVE

To assess (1) whether Tobacco-free Duo is superior to an education-only program in preventing smoking onset among adolescents and promoting cessation among their parents, (2) whether exposure to core components (adult-child agreement) entails more positive effects than exposure to other components, (3) the impact of the program on whole school tobacco use, (4) potential negative side effects, and (5) school-level factors related to fidelity of the program's implementation.

METHODS

A mixed-design approach was developed. First, a cluster randomized controlled trial was designed with schools randomly assigned to either the comprehensive multicomponent program or its educational component only. Primary outcome at the adolescent level was identified as not having tried tobacco during the 3-year junior high school compulsory grades (12-15 years of age). An intention-to-treat cohort-wise approach and an as-treated approach complemented with a whole school repeated cross-sectional approach was devised as analytical methods of the trial data. Second, an observational study was added in order to compare smoking incidence in the schools participating in the experiment with that of a convenience sample of schools that were not part of the experimental study. Diverse secondary outcomes at both adolescent and adult levels were also included.

RESULTS

The study was approved by the Umeå Regional Ethics Review Board (registration number 2017/255-31) in 2017. Recruitment of schools started in fall 2017 and continued until June 2018. In total, 43 schools were recruited to the experimental study, and 16 schools were recruited to the observational study. Data collection started in the fall 2018, is ongoing, and is planned to be finished in spring 2021.

CONCLUSIONS

Methodological, ethical, and practical implications of the evaluation protocol were discussed, especially the advantage of combining several sources of data, to triangulate the study questions. The results of these studies will help revise the agenda of this program as well as those of similar programs.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 52858080; https://doi.org/10.1186/ISRCTN52858080.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21100.

Absolute rather than relative income is a better socioeconomic predictor of chronic obstructive pulmonary disease in Swedish adults

BACKGROUND

While psychosocial theory claims that socioeconomic status (SES), acting through social comparisons, has an important influence on susceptibility to disease, materialistic theory says that socioeconomic position (SEP) and related access to material resources matter more. However, the relative role of SEP versus SES in chronic obstructive pulmonary disease (COPD) risk has still not been examined.

METHOD

We investigated the association between SES/SEP and COPD risk among 667 094 older adults, aged 55 to 60, residing in Sweden between 2006 and 2011. Absolute income in five groups by population quintiles depicted SEP and relative income expressed as quintile groups within each absolute income group represented SES. We performed sex-stratified logistic regression models to estimate odds ratios and the area under the receiver operator curve (AUC) to compare the discriminatory accuracy of SES and SEP in relation to COPD.

RESULTS

Even though both absolute (SEP) and relative income (SES) were associated with COPD risk, only absolute income (SEP) presented a clear gradient, so the poorest had a three-fold higher COPD risk than the richest individuals. While the AUC for a model including only age was 0.54 and 0.55 when including relative income (SES), it increased to 0.65 when accounting for absolute income (SEP). SEP rather than SES demonstrated a consistent association with COPD.

CONCLUSIONS

Our study supports the materialistic theory. Access to material resources seems more relevant to COPD risk than the consequences of low relative income.

Examination of the community-specific prevalence of and factors associated with substance use and misuse among Rural and Urban adolescents: a cross-sectional analysis in Bosnia and Herzegovina

OBJECTIVE

The community of residence (ie, urban vs rural) is one of the known factors of influence on substance use and misuse (SUM). The aim of this study was to explore the community-specific prevalence of SUM and the associations that exist between scholastic, familial, sports and sociodemographic factors with SUM in adolescents from Bosnia and Herzegovina.

METHODS

In this cross-sectional study, which was completed between November and December 2014, the participants were 957 adolescents (aged 17 to 18 years) from Bosnia and Herzegovina (485; 50.6% females). The independent variables were sociodemographic, academic, sport and familial factors. The dependent variables consisted of questions on cigarette smoking and alcohol consumption. We have calculated differences between groups of participants (gender, community), while the logistic regressions were applied to define associations between the independent and dependent variables.

RESULTS

In the urban community, cigarette smoking is more prevalent in girls (OR=2.05; 95% CI 1.27 to 3.35), while harmful drinking is more prevalent in boys (OR=2.07; 95% CI 1.59 to 2.73). When data are weighted by gender and community, harmful drinking is more prevalent in urban boys (OR=1.97; 95% CI 1.31 to 2.95), cigarette smoking is more frequent in rural boys (OR=1.61; 95% CI 1.04 to 2.39), and urban girls misuse substances to a greater extent than rural girls (OR=1.70; 95% CI 1.16 to 2.51,OR=2.85; 95% CI 1.88 to 4.31,OR=2.78; 95% CI 1.67 to 4.61 for cigarette smoking, harmful drinking and simultaneous smoking-drinking, respectively). Academic failure is strongly associated with a higher likelihood of SUM. The associations between parental factors and SUM are more evident in urban youth. Sports factors are specifically correlated with SUM for urban girls.

CONCLUSIONS

Living in an urban environment should be considered as a higher risk factor for SUM in girls. Parental variables are more strongly associated with SUM among urban youth, most probably because of the higher parental involvement in children' personal lives in urban communities (ie, college plans, for example). Specific indicators should be monitored in the prevention of SUM.