The promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews

Effectiveness of Smoking Prevention Programs on the Knowledge, Attitudes, and Anti-Smoking Exposure Self-Efficacy among Non-Smoking Rural Seventh-Grade Students in Taiwan

The disproportionate smoking prevalence among adolescents in rural Taiwan may be attributed to insufficient anti-smoking education. Increasing access to such education may help reduce initiation and promote smoking cessation in adolescents, particularly in rural areas. However, effects of these programs require verification. This study determined the effectiveness of a school-based prevention program in enhancing knowledge, attitudes, and anti-smoking exposure self-efficacy among seventh-grade non-smoking students. A quasi-experimental design with convenience sampling was employed, where participants included seventh graders from two junior high schools who completed a questionnaire 1−2 weeks before and after the intervention. Furthermore, the intervention group received four smoking and secondhand smoke (SHS) prevention classes, whereas the control group engaged in scheduled school activities. Knowledge on smoking (B = 4.38, p < 0.001) and SHS (B = 2.35, p < 0.001) were significantly greater in the intervention group. Moreover, the groups differed significantly in avoiding SHS exposure (B = 3.03, p = 0.031). Intervention modifications may be necessary to enhance the program’s effect on smoking exposure-related attitudes and self-efficacy. Additionally, cultural and other aspects (or “urban-rural gap”) might influence these results. Future randomized controlled trials should compare urban to rural adolescents, use longitudinal designs, and assess smoking initiation or cessation.

Rationale, design, and methods for the development of a youth adapted Brief Tobacco Intervention plus automated text messaging for high school students

BACKGROUND

Tobacco use is increasing among youth in the U.S. The current study seeks to develop and pilot test a universal group-based Youth Brief Tobacco Intervention (Y-BTI) plus mobile phone automated text messaging (ATM) for 9th grade students to both prevent initiation among non-users and promote cessation among current users.

METHODS

This study will use a sequential, multi-method research design beginning with mixed methods formative work with 9th grade students to adapt the existing young adult Brief Tobacco Intervention (BTI) for youth and develop automated text messages. The formative work with students will identify salient themes and strategies for the interventions and optimal delivery schedules for the ATM intervention. The second phase of the study evaluates the Y-BTI and ATM through a pilot cluster randomized controlled trial that compares four treatment combinations: (1) Y-BTI + ATM, (2) Y-BTI alone, (3) ATM alone, or (4) standard of care. The Y-BTI is a single session, group-based intervention delivered in schools. The ATM intervention will provide comparable content to the Y-BTI but be delivered via text messaging 3-5 times per week for four weeks.

CONCLUSION

In order to curb the rise of tobacco use among youth, interventions that are easily implemented and disseminated need to be developed. We aim to build upon previous research by showing that a universal group-based Y-BTI and ATM are effective in reducing tobacco use among a 9th graders by preventing initiation among tobacco naïve youth and promoting cessation among current users.

Evaluation of a school-based, experiential-learning smoking prevention program in promoting attitude change in adolescents

INTRODUCTION

School-based tobacco control programs exhibit great variety. Our study aimed to evaluate the effectiveness of an experiential learning smoking prevention program in facilitating knowledge acquisition, forging healthy attitudes, and decreasing intention to smoke.

METHODS

A school-based intervention-control study was implemented during the 2016–2017 academic year among middle-school students in Athens, Greece. The experiential learning intervention was delivered using an interdisciplinary approach, bridging excerpts from ancient classical Greek myths, Aesop fables and ancient classical literature (Aristotle, Herodotus, Plutarch, Xenophon, Homer’s Epics), with their decoded archetypal symbols applied in a smoking and tobacco control paradigm. An anonymous self-administered questionnaire was used at baseline and at follow-up at 3 months to evaluate program effectiveness.

RESULTS

A total of 351 students participated in our study; 181 (51.6%) in the intervention group and 170 (48.4%) in the control group. The mean age of student participants was 13 years (SD=0.96). Students in the intervention group were more likely to improve their knowledge of the adverse effects of smoking, develop attitudes against smoking and report a negative intention to smoke in the first year following the intervention, compared to the control group.

CONCLUSIONS

This study provides evidence that school-based experiential learning smoking prevention programs improve smoking-related knowledge, enhance anti-smoking attitudes and reinforce negative intentions toward tobacco products.

The Cigarette Smoking Initiation and Continuation in Adolescents Undergoing a Long-Term Behavioral Intervention

INTRODUCTION

Targeting adolescents' smoking reduces its burden on health systems. We investigated the effects of the first multidisciplinary community-based lifestyle intervention in the Eastern Mediterranean region, on smoking initiation, continuation, and risk of current smoking in Iranian adolescents.

METHODS

The current analyses were conducted on 945 nonsmoker adolescents (12-18 years) who participated in Phase II of Tehran Lipid and Glucose Study (TLGS) and were examined four times in 12 years. The lifestyle intervention including school-based and public programs was implemented, focusing on all components of healthy lifestyle. Using a two-step cluster analysis, families were classified as high and low risk, based on parental risk factors of adolescents' smoking. Participants who failed to complete all the follow-ups (n = 99) and those with missing smoking data were excluded. Subsequently, 872 adolescents (538 control, 334 intervention) were included in the Cox model on smoking initiation, and 674 adolescents (414 control, 260 intervention) were included in the logistic regression on smoking status.

RESULTS

Mean age of adolescents was 15.08 ± 1.94 years at baseline. The hazard of the smoking initiation was significantly lower in the intervention (hazard ratio = 0.71, 95% confidence interval: 0.51-0.99; p = .044) compared with control group. At the end of the fourth follow-up, intervention reduced the odds of current cigarette smoking by 29%. Within the intervention group, the high-risk cluster was at a 35% lower risk of initiating smoking and had 37% lower odds of becoming a current smoker. However, the intervention could not make a difference in preventing those who initiated smoking from maintaining it during the follow-ups.

CONCLUSIONS

Our results demonstrate that lifestyle modification programs targeting at-risk populations could reduce risk of smoking initiation and current smoking in adolescents in long term.

IMPLICATIONS

Experiencing cigarette smoking at the critical period of adolescence could result in adulthood habitual smoking. Therefore, identifying adolescents who are more at risk of smoking initiation and implementing targeted interventions are of great importance in public health. Our findings highlight the long-term effectiveness of a multidisciplinary community-based behavioral intervention on forming smoking behaviors in adolescents. The current intervention was successful in reducing smoking uptake in adolescents living in high-risk families.

Effectiveness of a School-Based Tobacco Prevention Program for Middle School Students in Saudi Arabia: A Quasi-Experimental Controlled Trial

Objective:

To evaluate the effect of a school-based tobacco program in preventing initiation of tobacco use among adolescents in Saudi Arabia.

Methods:

We used a quasi-experimental controlled design. Four intervention and four control schools were selected from the regional education registry. A baseline questionnaire was administered to all grade 7 students before implementing the tobacco prevention program, Dentists Fighting Nicotine Dependence (DFND). The intervention group (n =379) received the DFND program whereas the control group (n = 255) received the regular tobacco program administered by the Department of Education. The program was delivered by trained health educators over 5 weeks. Pre- and post-test surveys (immediate and 2-year post-intervention) were collected. Study outcomes were current tobacco use, tobacco knowledge, attitude towards not using tobacco, and perceived behavioral control (PBC) of tobacco use. Covariates included sex, parent education, academic performance, absenteeism, student allowance, and religiosity. Data were analyzed using a two-level hierarchical mixed models.

Results:

In the immediate post-test, 597 participants (intervention, n = 366; control, n = 231) were surveyed. There was no difference in tobacco use between intervention and control schools, however, the intervention group had significantly higher mean scores for knowledge (β = 1.27, SE = 0.27, P < .01) and attitude toward not using tobacco (β = 5.17, SE = 2.48, P < .05) after adjusting for covariates. At 2-year post-intervention, 463 participants (intervention, n = 289; control, n = 173) were surveyed. There were no differences in tobacco use, knowledge, attitude or PBC between intervention and control groups.

Conclusions:

Our program did not impact tobacco use. In the short-term, the program significantly improved knowledge and attitude towards not using tobacco. These effects decayed 2 years post-intervention without additional programming. Increasing the effectiveness of DFND may be achieved by expanding curriculum content and practice time throughout the school years and by targeting high-risk adolescents within the program.

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research

INTRODUCTION

The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated.

METHOD

A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018.

RESULTS

The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes.

CONCLUSION

This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry.

IMPLICATIONS

This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

School-Based Tobacco Control and Smoking in Adolescents: Evidence from Multilevel Analyses

Since 2015, universal comprehensive school-based tobacco control programs have been provided in all primary and secondary schools in Korea. This study explored the association of school-level tobacco control with adolescent smoking, and the interactions to investigate whether gender moderates the impact of school tobacco control programs and school-level norms. Both school- and individual-level data were drawn from the 2015 School-Based Tobacco Prevention Program Survey. Multilevel logistic regression analyses were performed using data from 4631 students (ages 10-18 years) who were nested in 62 secondary schools in Seoul, Korea. Students who participated in more prevention programs were less likely to smoke (OR = 0.47, 95% CI 0.30-0.74). The effect of the programs was significantly moderated by gender. For boys, exposure to a greater number of programs decreased the risk of smoking (OR = 0.32, 95% CI 0.18-0.57) but not for girls. At the school level, the school norm regarding tobacco control regulations was negatively associated with smoking (OR = 0.28, 95% CI 0.11-0.76), and its effect was significant for girls only (OR = 0.35, 95% CI 0.17-0.76). This study highlights how the school environment is associated with adolescent smoking behavior, and the effects of programs and norms are different by gender. The findings suggest the need to develop strategies to enhance school-based tobacco control programs and the school norm considering gender differences.

Attitudes toward tobacco among low-income Hispanic adolescents: Implications for prevention

Background: Although US cigarette smoking rates have steadily declined, the changing nature of nicotine consumption and the popularity of non-combustible nicotine products urges us to revise tobacco prevention strategies. Research on smoking perspectives among Hispanic youth is limited yet crucial for prevention efforts with Hispanics being the largest minority in the U.S.Objective: This study sought to understand the experience and perceptions of low-income Hispanic youth regarding tobacco use.Methods: Forty-nine adolescents (ages 9 to 19) from El Paso, Texas, participated in five extended focus group discussions about tobacco/nicotine use.Results: Adolescents were predominantly exposed to tobacco through relatives, although school and party contexts became more relevant as youth aged. Youth had negative perceptions of tobacco and smokers, but believed their peers often viewed tobacco positively. Youth also saw tobacco use as a functional stress-management strategy, especially within their extended family. Health and family were strong motivators not to smoke.Conclusions: Youth maintain several tensions in their views on tobacco. Tobacco use is considered unpleasant and harmful, yet youth perceive their peers to view it as cool. Peer to peer discussion of tobacco experiences and perceptions may help correct these incongruent viewpoints. Adding to this tension is the perception that tobacco is used to manage stress. Given the importance of the home environment for Hispanic youth, tobacco prevention efforts may benefit from engaging family to identify the ways in which tobacco use causes stress.

Building evidence for peer-led interventions: assessing the cost of the Adolescent Asthma Action program in Australia

Asthma is the most common chronic illness among adolescents in Australia. Aboriginal and Torres Strait Islander adolescents, in particular, face substantial inequalities in asthma-related outcomes. Triple A (Adolescent Asthma Action) is a peer-led education intervention, which aims to improve asthma self-management and reduce the uptake of smoking among adolescents. The aim of this study was to determine the cost of implementing the Triple A program in Australia. Standard economic costing methods were used. It involved identifying the resources that were utilised (such as personnel and program materials), measuring them and then valuing them. We later performed sensitivity analysis so as to identify the cost drivers and a stress test to test how the intervention can perform when some inputs are lacking. Results indicate that the estimated cost of implementing the Triple A program in five schools was $41060, assuming that the opportunity cost of all the participants and venues was accounted for. This translated to $8212 per school or $50 per target student. From sensitivity analysis and a stress test, it was identified that the cost of the intervention (in practice) was $14 per student. This appears to be a modest cost, given the burden of asthma. In conclusion, the Triple A program is an affordable intervention to implement in high schools. The potential asthma cost savings due to the program are significant. If the Triple A program is implemented nation-wide, the benefits would be substantial.

A Role for Epigenetics in Broadening the Scope of Pediatric Care in the Prevention of Adolescent Smoking

Adolescence presents a critical opportunity to support the development of healthy patterns of behavior and prevent future health problems. Unfortunately, there is not yet a well-developed prevention model that allows pediatricians to initiate and monitor prevention efforts for the substantial minority of individuals who engage in risky behavior during adolescence. We suggest that recently developed epigenetic technologies may provide a bridge to a new prevention paradigm in which pediatricians screen for indicated smoking prevention services. Specifically, since currently available tobacco use screening measures are insensitive to low levels of use, newly developed methylation based approaches may enhance the sensitivity of the initial screening for nascent smoking behavior as well monitoring of outcomes. We conclude that the incorporation of Next Gen screening technologies into standard pediatric evaluations may allow for more effective referral to prevention programming for tobacco use. In addition to the potential direct impact on long-term enhancement of health outcomes secondary to smoking prevention, well-established links between smoking and other risk behaviors suggest that expanded referral for nascent smoking may also create opportunities to address other risky adolescent behaviors, and so decrease several interrelated drivers of long-term health care costs.

Smoking Prevention for Students: Findings From a Three-Year Program of Integrated Harm Minimization School Drug Education

BACKGROUND

This study investigated the impact of the Drug Education in Victorian Schools (DEVS) program on tobacco smoking. The program taught about licit and illicit drugs in an integrated manner over 2 years, with follow up in the third year. It focused on minimizing harm, rather than achieving abstinence, and employed participatory, critical-thinking and skill-based teaching methods.

METHODS

A cluster-randomized, controlled trial of the program was conducted with a student cohort during years 8 (13 years), 9 (14 years), and 10 (15 years). Twenty-one schools were randomly allocated to the DEVS program (14 schools, n = 1163), or their usual drug education program (7 schools, n = 589). One intervention school withdrew in year two.

RESULTS

There was a greater increase in the intervention students' knowledge about drugs, including tobacco, in all 3 years. Intervention students talked more with their parents about smoking at the end of the 3-year program. They recalled receiving more education on smoking in all 3 years. Their consumption of cigarettes had not increased to the same extent as controls at the end of the program. Their change in smoking harms, relative to controls, was positive in all 3 years. There was no difference between groups in the proportionate increase of smokers, or in attitudes towards smoking, at any time.

CONCLUSIONS

These findings indicate that a school program that teaches about all drugs in an integrated fashion, and focuses on minimizing harm, does not increase initiation into smoking, while providing strategies for reducing consumption and harm to those who choose to smoke.

Overview of systematic reviews on the health-related effects of government tobacco control policies

BACKGROUND

Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

METHODS

An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

RESULTS

Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

CONCLUSION

When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.

Langzeiteffekte des Präventionsprogramms Klasse2000 auf den Substanzkonsum

Zielsetzung: Untersuchung der langfristigen Auswirkungen des für die Grundschule konzipierten Präventionsprogramms Klasse2000 auf den Substanzkonsum. Methodik: Klasse2000 will mittels interaktiver Methoden die Lebenskompetenzen fördern und zu einem gesunden Lebensstil motivieren. Die Daten wurden in schriftlichen Nachbefragungen einer Kontrollgruppenstudie mit Messwiederholung 16 Monate (N = 501, mittl. Alter 11,4 Jahre, 43,7 % männlich) und 36 Monate (N = 408, mittl. Alter 12,9 Jahre, 43,1 % männlich) nach Ende der Intervention gewonnen. Die Zuteilung zu den Gruppen erfolgte in der Ursprungsstudie auf Ebene der Schulen unter Berücksichtigung der Präferenz der Schulen. Ergebnisse: In beiden Nachbefragungen waren Lebenszeitprävalenz und Inzidenz des Rauchens in der Interventionsgruppe statistisch bedeutsam geringer als in der Kontrollgruppe. Beim Alkoholkonsum konnte nur in der ersten Nachbefragung eine signifikant geringere Lebenszeitprävalenz in der Interventionsgruppe gefunden werden. In der zweiten Nachbefragung war in der Untergruppe derjenigen Jugendlichen, die bereits Alkohol konsumiert hatten, in der Interventionsgruppe die Intensität des Alkoholkonsums geringer als in der Kontrollgruppe. Schlussfolgerungen: 16 bzw. 36 Monate nach Abschluss der Intervention finden sich Hinweise auf präventive Effekte des Programms Klasse2000 auf das Rauchverhalten. Für den Alkoholkonsum ist die Befundlage weniger überzeugend.

Strategies for tobacco control in India: a systematic review

BACKGROUND

Tobacco control needs in India are large and complex. Evaluation of outcomes to date has been limited.

AIM

To review the extent of tobacco control measures, and the outcomes of associated trialled interventions, in India.

METHODS

Information was identified via database searches, journal hand-searches, reference and citation searching, and contact with experts. Studies of any population resident in India were included. Studies where outcomes were not yet available, not directly related to tobacco use, or not specific to India, were excluded. Pre-tested proformas were used for data extraction and quality assessment. Studies with reliability concerns were excluded from some aspects of analysis. The Framework Convention on Tobacco Control (FCTC) was use as a framework for synthesis. Heterogeneity limited meta-analysis options. Synthesis was therefore predominantly narrative.

RESULTS

Additional to the Global Tobacco Surveillance System data, 80 studies were identified, 45 without reliability concerns. Most related to education (FCTC Article 12) and tobacco-use cessation (Article 14). They indicated widespread understanding of tobacco-related harm, but less knowledge about specific consequences of use. Healthcare professionals reported low confidence in cessation assistance, in keeping with low levels of training. Training for schoolteachers also appeared suboptimal. Educational and cessation assistance interventions demonstrated positive impact on tobacco use. Studies relating to smoke-free policies (Article 8), tobacco advertisements and availability (Articles 13 and 16) indicated increasingly widespread smoke-free policies, but persistence of high levels of SHS exposure, tobacco promotions and availability-including to minors. Data relating to taxation/pricing and packaging (Articles 6 and 11) were limited. We did not identify any studies of product regulation, alternative employment strategies, or illicit trade (Articles 9, 10, 15 and 17).

CONCLUSIONS

Tobacco-use outcomes could be improved by school/community-based and adult education interventions, and cessation assistance, facilitated by training for health professionals and schoolteachers. Additional tobacco control measures should be assessed.

Strategies for tobacco control in India: a systematic review

BACKGROUND

Tobacco control needs in India are large and complex. Evaluation of outcomes to date has been limited.

AIM

To review the extent of tobacco control measures, and the outcomes of associated trialled interventions, in India.

METHODS

Information was identified via database searches, journal hand-searches, reference and citation searching, and contact with experts. Studies of any population resident in India were included. Studies where outcomes were not yet available, not directly related to tobacco use, or not specific to India, were excluded. Pre-tested proformas were used for data extraction and quality assessment. Studies with reliability concerns were excluded from some aspects of analysis. The Framework Convention on Tobacco Control (FCTC) was use as a framework for synthesis. Heterogeneity limited meta-analysis options. Synthesis was therefore predominantly narrative.

RESULTS

Additional to the Global Tobacco Surveillance System data, 80 studies were identified, 45 without reliability concerns. Most related to education (FCTC Article 12) and tobacco-use cessation (Article 14). They indicated widespread understanding of tobacco-related harm, but less knowledge about specific consequences of use. Healthcare professionals reported low confidence in cessation assistance, in keeping with low levels of training. Training for schoolteachers also appeared suboptimal. Educational and cessation assistance interventions demonstrated positive impact on tobacco use. Studies relating to smoke-free policies (Article 8), tobacco advertisements and availability (Articles 13 and 16) indicated increasingly widespread smoke-free policies, but persistence of high levels of SHS exposure, tobacco promotions and availability-including to minors. Data relating to taxation/pricing and packaging (Articles 6 and 11) were limited. We did not identify any studies of product regulation, alternative employment strategies, or illicit trade (Articles 9, 10, 15 and 17).

CONCLUSIONS

Tobacco-use outcomes could be improved by school/community-based and adult education interventions, and cessation assistance, facilitated by training for health professionals and schoolteachers. Additional tobacco control measures should be assessed.

Adolescent Substance Use Following Participation in a Universal Drug Prevention Program: Examining Relationships With Program Recall and Baseline Use Status

BACKGROUND

The study examined whether adolescents receiving a universal, school based, drug prevention program in Grade 7 varied, by student profile, in substance use behaviors post program implementation. Profiles were a function of recall of program receipt and substance use at baseline.

METHODS

A secondary analysis was conducted on data from the Adolescent Substance Abuse Prevention Study, a large, geographically diverse, longitudinal school-based cluster-randomized controlled trial of the Take Charge of Your Life drug prevention program. Profiles were created using self-reported substance use (preintervention) and program recall (postintervention) at Grade 7. First, characteristics of each of the 4 profiles of treatment students who varied by program recall and baseline substance use were explored. Then, multilevel logistic regression analyses were used to examine differences in the odds of substance use (alcohol, tobacco, and marijuana) among student profiles at the 6 additional study waves (Time 2 [Grade 7] through Time 7 [Grade 11]).

RESULTS

Pearson's chi-square tests showed sample characteristics varied by student profile. Multilevel logistic regression results were consistent across all examined substance use behaviors at all time points. Namely, as compared with students who had no baseline substance use and had program recall (No Use, Recall), each of the remaining 3 profiles (No Use, No Recall; Use, Recall; Use, No Recall) were more likely to engage in substance use. Post hoc analyses showed that for the 2 subprofiles of baseline substance users, there were only 2 observed, and inconsistent, differences in the odds of subsequent substance use by recall status.

CONCLUSIONS

Findings suggest that for students who were not baseline substance users, program recall significantly decreased the likelihood of subsequent substance use. For students who were baseline substance users, program recall did not generally influence subsequent substance use. Implications for school-based drug prevention programs are discussed.

Cognitive mediators and disparities in the relation between teen depressiveness and smoking

BACKGROUND

Depressiveness and tobacco use in adolescents are linked, however, there is limited evidence about the cognitive mediators involved and how the role of mediators may differ by gender and racial/ethnic subgroups.

METHODS

We used a racially/ethnically diverse population-based cross-sectional sample of middle and high school students (n=24,350). Logistic regression models measured the associations of depressiveness with tobacco smoking status, and whether smoking-related knowledge and attitudes (KA) and smoking refusal self-efficacy (SE) attenuated the associations indicating preliminary evidence of mediation.

RESULTS

Depressiveness was associated with intention to smoke (OR=2.41; 95% CI=2.22, 2.61), experimental smoking (OR=1.93; 95% CI=1.72, 2.17) and established smoking (OR=1.85; 95% CI=1.57, 2.18). The percent attenuation of these associations due to the inclusion of smoking-related KA and smoking refusal SE was 58% for intention to smoke (p<0.001), 68% for experimental smoking (p<0.001) and 86% for established smoking (p<0.001). The association of depressiveness with established smoking did not remain statistically significant (OR=1.16; CI=0.97, 1.40) after including smoking-related KA and smoking refusal SE. Attenuation was more pronounced in males and white students.

CONCLUSIONS

The results suggest that smoking-related KA and smoking refusal SE attenuated the relation between depressiveness and smoking, indicating that they may serve as mediators of the link between depressiveness and smoking. Tobacco use prevention programs targeting teens with the aim of increasing anti-smoking KA and smoking refusal SE may benefit from addressing depressiveness, particularly by using gender and racially/ethnically tailored strategies. The cross-sectional nature of the data precludes causal inferences.

Social networks and smoking: exploring the effects of peer influence and smoker popularity through simulations

Adolescent smoking and friendship networks are related in many ways that can amplify smoking prevalence. Understanding and developing interventions within such a complex system requires new analytic approaches. We draw on recent advances in dynamic network modeling to develop a technique that explores the implications of various intervention strategies targeted toward micro-level processes. Our approach begins by estimating a stochastic actor-based model using data from one school in the National Longitudinal Study of Adolescent Health. The model provides estimates of several factors predicting friendship ties and smoking behavior. We then use estimated model parameters to simulate the coevolution of friendship and smoking behavior under potential intervention scenarios. Namely, we manipulate the strength of peer influence on smoking and the popularity of smokers relative to nonsmokers. We measure how these manipulations affect smoking prevalence, smoking initiation, and smoking cessation. Results indicate that both peer influence and smoking-based popularity affect smoking behavior and that their joint effects are nonlinear. This study demonstrates how a simulation-based approach can be used to explore alternative scenarios that may be achievable through intervention efforts and offers new hypotheses about the association between friendship and smoking.

Effectiveness of the 'Healthy School and Drugs' prevention programme on adolescents' substance use: a randomized clustered trial

AIM

To evaluate the effectiveness of the Healthy School and Drugs programme on alcohol, tobacco and marijuana use among Dutch early adolescents.

DESIGN

Randomized clustered trial with two intervention conditions (i.e. e-learning and integral).

SETTING

General population of 11-15-year-old adolescents in the Netherlands.

PARTICIPANTS

A total of 3784 students of 23 Dutch secondary schools.

MEASUREMENTS

Structured digital questionnaires were administered pre-intervention and at 32 months follow-up. The primary outcome measures were new incidences of alcohol (life-time and 1-month prevalence), tobacco (life-time and 1-month prevalence) and marijuana use (life-time prevalence).

FINDINGS

Main effect analyses showed no programme effects on incidences of alcohol consumption (life-time prevalence: e-learning condition: B = 0.102, P = 0.549; integral condition: B = -0.157, P = 0.351; 1-month prevalence: e-learning condition: B = 0.191, P = 0.288; integral condition: B = -0.140, P = 0.445), tobacco consumption (life-time prevalence: e-learning condition: B = 0.164, P = 0.444; integral condition: B = 0.160, P = 0.119; 1-month prevalence: e-learning condition: B = 0.088, P = 0.746; integral condition: B = 0.261, P = 0.093), or marijuana consumption (life-time prevalence: e-learning condition: B = 0.070, P = 0.732; integral condition: B = 0.186, P = 0.214).

CONCLUSION

The non-significant impact of the Healthy School and Drugs programme (a Dutch school-based prevention programme for early adolescents) on incidences of alcohol, tobacco and marijuana use indicates that the programme is either ineffective or implemented inadequately.

Design of a school-based randomized trial to reduce smoking among 13 to 15-year olds, the X:IT study

BACKGROUND

Adolescent smoking is still highly prevalent in Denmark. One in four 13-year olds indicates that they have tried to smoke, and one in four 15-year olds answer that they smoke regularly. Smoking is more prevalent in socioeconomically disadvantaged populations in Denmark as well as in most Western countries. Previous school-based programs to prevent smoking have shown contrasting results internationally. In Denmark, previous programs have shown limited or no effect. This indicates a need for developing a well-designed, comprehensive, and multi-component intervention aimed at Danish schools with careful implementation and thorough evaluation.This paper describes X:IT, a study including 1) the development of a 3-year school-based multi-component intervention and 2) the randomized trial investigating the effect of the intervention. The study aims at reducing the prevalence of smoking among 13 to 15-year olds by 25%.

METHODS/DESIGN

The X:IT study is based on the Theory of Triadic Influences. The theory organizes factors influencing adolescent smoking into three streams: cultural environment, social situation, and personal factors. We added a fourth stream, the community aspects. The X:IT program comprises three main components: 1) smoke-free school premises, 2) parental involvement including smoke-free dialogues and smoke-free contracts between students and parents, and 3) a curricular component. The study encompasses process- and effect-evaluations as well as health economic analyses. Ninety-four schools in 17 municipalities were randomly allocated to the intervention (51 schools) or control (43 schools) group. At baseline in September 2010, 4,468 year 7 students were eligible of which 4,167 answered the baseline questionnaire (response rate = 93.3%).

DISCUSSION

The X:IT study is a large, randomized controlled trial evaluating the effect of an intervention, based on components proven to be efficient in other Nordic settings. The X:IT study directs students, their parents, and smoking prevention policies at the schools. These elements have proven to be effective tools in preventing smoking among adolescents. Program implementation is thoroughly evaluated to be able to add to the current knowledge of the importance of implementation. X:IT creates the basis for thorough effect and process evaluation, focusing on various social groups.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77415416.

Effectiveness of a school-based multi-component smoking prevention intervention: the LdP cluster randomized controlled trial

OBJECTIVE

We assessed the effectiveness of the Luoghi di Prevenzione-Prevention Grounds school-based smoking prevention programme.

METHODS

We undertook a cluster randomized controlled trial of 989 students aged 14-15 years in 13 secondary schools located in Reggio Emilia, Italy. The intervention consisted of the "Smoking Prevention Tour" (SPT) out-of-school workshop, one in-depth lesson on one Smoking Prevention Tour topic, a life-skills peer-led intervention, and enforcement surveillance of school antismoking policy. Self-reported past 30-day smoking of ≥ 20 or 1-19 days of cigarette smoking (daily or frequent smoking, respectively) was recorded in 2 surveys administered immediately before and 18 months after the beginning of the programme. Analysis was by intention to treat. The effect of the intervention was evaluated using random effects logistic regression and propensity score-matching analyses.

RESULTS

Past 30-day smoking and daily cigarette use at eighteen months follow-up were 31% and 46% lower, respectively, for intervention students compared to control students. Taking into account non-smokers at baseline only, daily smoking at eighteen months follow-up was 59% lower in intervention students than in controls. Past 30-day smoking in school areas was 62% lower in intervention students compared to controls.

CONCLUSIONS

The Luoghi di Prevenzione-Prevention Grounds programme was effective in reducing daily smokers and in reducing smoking in school areas.

Efficacy of a Web-based computer-tailored smoking prevention intervention for Dutch adolescents: randomized controlled trial

Background

Preventing smoking initiation among adolescents is crucial to reducing tobacco-caused death and disease. This study focuses on the effectiveness of a Web-based computer-tailored smoking prevention intervention aimed at adolescents.

Objective

The intent of the study was to describe the intervention characteristics and to show the effectiveness and results of a randomized controlled trial. We hypothesized that the intervention would prevent smoking initiation among Dutch secondary school students aged 10-20 years and would have the largest smoking prevention effect among the age cohort of 14-16 years, as smoking uptake in that period is highest.

Methods

The intervention consisted of a questionnaire and fully automated computer-tailored feedback on intention to start smoking and motivational determinants. A total of 89 secondary schools were recruited via postal mail and randomized into either the computer-tailored intervention condition or the control condition. Participants had to complete a Web-based questionnaire at baseline and at 6-month follow-up. Data on smoking initiation were collected from 897 students from these schools. To identify intervention effects, multilevel logistic regression analyses were conducted using multiple imputation.

Results

Smoking initiation among students aged 10-20 years was borderline significantly lower in the experimental condition as compared to the control condition 6 months after baseline (OR 0.25, 95% CI 0.05-1.21, P=.09). Additional analyses of the data for the 14-16 year age group showed a significant effect, with 11.5% (24/209) of the students in the control condition reporting initiation compared to 5.7% (10/176) in the experimental condition (OR 0.22, 95% CI 0.05-1.02, P=.05). No moderation effects were found regarding gender and educational level.

Conclusions

The findings of this study suggest that computer-tailored smoking prevention programs are a promising way of preventing smoking initiation among adolescents for at least 6 months, in particular among the age cohort of 14-16 years. Further research is needed to focus on long-term effects.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 77864351; http://www.controlled-trials.com/ISRCTN77864351 (Archived by WebCite at http://www.webcitation.org/6BSLKSTm5).

Effects of a school-based prevention programme on smoking in early adolescence: a 6-month follow-up of the 'Eigenstandig werden' cluster randomised trial

OBJECTIVES

To test the effects of a school-based prevention programme on students' smoking-related behaviour, attitudes and knowledge 6 months after implementation over 2 school-years has ended.

DESIGN

Two-arm prospective cluster randomised controlled trial with a follow-up survey 6 months after end of programme implementation, that is, 26 months after baseline.

SETTING

45 public secondary schools from four federal states in Germany (Bremen, Hesse, North Rhine-Westphalia, Schleswig-Holstein).

PARTICIPANTS

A total of 3444 students from 172 classes with a mean age of 10.37 years (SD=0.59) and 47.9% girls at baseline. Analysis sample with follow-up up data merged to baseline data comprises 2513 datasets (73%).

INTERVENTION

'Eigenständig werden 5+6', a school-based prevention programme for grades 5 and 6 to enhance substance-specific and general life skills, consisting of 14 units (à 90 min) and two workshops (4-6 h) being taught over a time period of 2 school-years by trained teachers.

OUTCOME MEASURES

Lifetime and current smoking, incidence of smoking in baseline never smokers, smoking-related knowledge, attitudes, perceived norms of smoking and self-efficacy to refuse cigarette offers were assessed in students.

RESULTS

6 months after the end of programme implementation, students of intervention classes showed significantly lower rates for lifetime smoking (adjusted OR=0.63; 95% CI 0.41 to 0.96; p=0.026) and incidence of smoking (adjusted OR=0.66; 95% CI 0.43 to 1.00; p=0.047), a higher increase of smoking-related knowledge (adjusted β=9.38; 95% CI 6.73 to 12.04; p<0.001) and a greater change in attitudes towards a more critical perception of risks and disadvantages of smoking (adjusted β=0.10; 95% CI 0.03 to 0.16; p=0.002). No group differences were found for current smoking, perceived norms of smoking and self-efficacy to refuse cigarette offers.

CONCLUSIONS

Participation in the school-based prevention programme 'Eigenständig werden 5+6' may have small effects on smoking behaviour and attitudes and a moderate effect on smoking-related knowledge.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99442407.

Multilevel analysis of the impact of school-level tobacco policies on adolescent smoking: the case of Michigan

BACKGROUND

In efforts to curb and prevent youth smoking, school tobacco policies have become an important and effective strategy. This study explores the degrees and types of tobacco-free school policy (TFSP) enforcement that are associated with adolescent smoking.

METHODS

A multilevel analysis was performed using 983 students who are nested in 14 schools. The individual-level data are drawn from the 2009 Michigan Youth Risk Behavior Survey. The school-level data are drawn from the 2008 School Health Profiles survey.

RESULTS

Two factors are associated with lower adolescent smoking: greater punishment for TFSP violation and more tobacco control communication efforts. By contrast, the factors associated with higher adolescent smoking are designation of a tobacco-free school zone and school-level smoking.

CONCLUSIONS

This study theoretically and methodologically guides researchers to test TFSP effectiveness in other states. Three strategic implications emerge: (1) schools should provide a consistent antismoking message in smoke-free environments; (2) schools should integrate TFSP into a comprehensive tobacco control initiative, including community-wide tobacco control programs and messages; and (3) the way a specific TFSP is promoted and communicated could determine how effective it is.

Evaluation of a Swedish version of the Strengthening Families Programme

BACKGROUND

Adolescents' alcohol consumption is a public health concern in Sweden as well as in many other countries. Underage drinking is associated with increased risks of alcohol-related injuries, risky sexual behaviours and dependence later in life. Different strategies have been used in the effort to prevent this behaviour, and to postpone the onset of alcohol. The Strengthening Families Programme 10-14 (SFP 10-14) from the USA has been highlighted as one of the more effective prevention programmes. The aim of the present article was to evaluate the effectiveness of a culturally adapted Swedish version of the SFP 10-14.

METHODS

This was a cluster randomized controlled trial including 587 sixth-grade students (age 12) and their parents in 19 elementary schools in Stockholm. Schools were randomly assigned to either control (9 schools, 216 students) or to the family skills training intervention (10 schools, 371 students). The SFP Swedish version consisted of two parts with seven and five sessions, respectively, held separately for youths and parents except two joint family sessions. Measures of students' self-reported episodes of drunkenness, smoking, illicit drug use and other norm-breaking behaviours were collected at baseline (March 2003) and at three subsequent yearly surveys. Data were analysed using multilevel models with an intention-to-treat approach.

RESULTS

No preventive effects were found for smoking, alcohol and illicit drug use and other norm-breaking behaviours, nor did moderators affect the outcome.

CONCLUSION

The Swedish version of the SFP 10-14 was not effective in preventing youths' substance use in a Swedish context.

Cardiovascular disease risk factors: a childhood perspective

Atherosclerotic cardiovascular disease (CVD) is one of the leading causes of death and disability worldwide including in developing countries like India. Indians are known to be predisposed to CVD, which occur almost a decade earlier in them. Though these diseases manifest in the middle age and beyond, it is now clear that the roots of CVD lie in childhood and adolescence. Many of the conventional risk factors of CVD such as high blood pressure, dyslipidemia, tobacco use, unhealthy diet and obesity have their beginnings in childhood and then track overtime. It is thus important to screen and identify these risk factors early and treat them to prevent onset of CVD. Similarly community based strategies to prevent onset of these risk factors is imperative to tackle this burgeoning public health crisis especially in countries like ours with limited resources.

Limited potential of school textbooks to prevent tobacco use among students grade 1-9 across multiple developing countries: a content analysis study

OBJECTIVE

To evaluate the content of school textbooks as a tool to prevent tobacco use in developing countries.

DESIGN

Content analysis was used to evaluate if the textbooks incorporated the following five core components recommended by the WHO: (1) consequences of tobacco use; (2) social norms; (3) reasons to use tobacco; (4) social influences and (5) resistance and life skills.

SETTING

Nine developing countries: Bangladesh, Cambodia, Laos, Nepal, Sri Lanka, Benin, Ghana, Niger and Zambia. TEXTBOOKS ANALYSED: Of 474 textbooks for primary and junior secondary schools in nine developing countries, 41 were selected which contained descriptions about tobacco use prevention.

RESULTS

Of the 41 textbooks, the consequences of tobacco use component was covered in 30 textbooks (73.2%) and the social norms component was covered in 19 (46.3%). The other three components were described in less than 20% of the textbooks.

CONCLUSIONS

A rather limited number of school textbooks in developing countries contained descriptions of prevention of tobacco use, but they did not fully cover the core components for tobacco use prevention. The chance of tobacco prevention education should be seized by improving the content of school textbooks.

Comparing effects of tobacco use prevention modalities: need for complex system models

Many modalities of tobacco use prevention programming have been implemented including various policy regulations (tax increases, warning labels, limits on access, smoke-free policies, and restrictions on marketing), mass media programming, school-based classroom education, family involvement, and involvement of community agents (i.e., medical, social, political). The present manuscript provides a glance at these modalities to compare relative and combined impact of them on youth tobacco use. In a majority of trials, community-wide programming, which includes multiple modalities, has not been found to achieve impacts greater than single modality programming. Possibly, the most effective means of prevention involves a careful selection of program type combinations. Also, it is likely that a mechanism for coordinating maximally across program types (e.g., staging of programming) is needed to encourage a synergistic impact. Studying tobacco use prevention as a complex system is considered as a means to maximize effects from combinations of prevention types. Future studies will need to more systematically consider the role of combined programming.

Reconceptualizing efficacy in substance use prevention research: refusal response efficacy and drug resistance self-efficacy in adolescent substance use

The purpose of this study is to utilize the Extended Parallel Process Model (EPPM) to expand the construct of efficacy in the adolescent substance use context. Using survey data collected from 2,129 seventh-grade students in 39 rural schools, we examined the construct of drug refusal efficacy and demonstrated relationships among response efficacy (RE), self-efficacy (SE), and adolescent drug use. Consistent with the hypotheses, confirmatory factor analyses of a 12-item scale yielded a three-factor solution: refusal RE, alcohol-resistance self-efficacy (ASE), and marijuana-resistance self-efficacy (MSE). Refusal RE and ASE/MSE were negatively related to alcohol use and marijuana use, whereas MSE was positively associated with alcohol use. These data demonstrate that efficacy is a broader construct than typically considered in drug prevention. Prevention programs should reinforce both refusal RE and substance-specific resistance SE.

The cost-effectiveness of a school-based smoking prevention program in India

Intervention programs aimed at preventing tobacco use among youth have been shown to be effective in curbing tobacco use onset and progression. However, the effects of even very successful tobacco prevention programs may not always impress policy-makers and lay audiences. Economic analysis potentially strengthens the case. In this paper, we evaluate the cost-effectiveness of a youth tobacco use prevention program which has been translated and implemented in India, a developing country. Although programs like these are inexpensive to implement in the USA, they are even less expensive in India due to low labor costs. Our results show that the costs per quality-adjusted life-year added, due to averted smoking, was $2057, even without including averted medical costs. If we ignore student time, cost-effectiveness improves by roughly 10%. To put the cost-effectiveness of this smoking prevention program into context, it is over 24 times more cost-effective than dialysis in the USA, which costs $50,000 for a life-year.

How Influences on Teenage Smoking Reflect Gender and Society in Mali, West Africa

Objectives

To provide further understanding and discussion on the influences on smoking in young people in Mali.

Design

A generic qualitative methodological approach was used following Caelli's generic principles. Six focus group discussions were conducted with a total of 31 participants followed by two semi-structured interviews. A reflexive account was kept to record development in the researcher's theoretical position

Setting

The setting was recreational areas of Bamako, capital city of Mali, West Africa.

Participants

Participants aged 13–15 years were recruited opportunistically in a recreational area of Bamako.

Mainoutcome measures

To develop further understanding of the influences of teenage smoking in Mali, West Africa.

Results

Five main categories that explained influences on youth smoking emerged: knowledge and awareness of smoking; associations with smoking; influential people; key messages in Malian society; and access to tobacco. The results showed that influences were complex and interwoven, notable gender differences were revealed, and the role of elder members of the community proved decisive in participants' smoking experiences. Participants described vague knowledge of the impact on health of smoking and reported trying smoking from an early age. Often contact with smoking was through elders and being sent to buy and sometimes light cigarettes for them. Associations with smoking were influenced by gender with smoking more desirable for boys than girls.

Conclusions

Any approach to preventing smoking initiation in young people requires an understanding of the social influences and pressures on young people. A tobacco control strategy is required to look at all areas of influence on smoking behaviours. Different needs should also account for the differing characteristics and perceptions of specific population groups.

Meta-analysis on the effects of the smoke-free class competition on smoking prevention in adolescents

BACKGROUND

The 'Smoke-Free Class competition' (SFC) is a school-based smoking prevention programme including commitment not to smoke, contract management and prizes as rewards broadly implemented in Europe.

OBJECTIVES

To meta-analyse (randomised) controlled trials on the effects of SFC on current smoking at latest follow-up in adolescents.

METHODS

A systematic review of articles using MEDLINE and the Cochrane Library was conducted. The study selection included randomised controlled trials and controlled trials with follow-up assessment that investigated the efficacy of SFC on current smoking in students participating in SFC compared to non-participating students. Independent extraction of articles was performed by both authors.

RESULTS

Of 24 records identified, five fulfilled the inclusion criteria. These studies were conducted in three European countries (Finland, The Netherlands and Germany) and recruited 16,302 students altogether. A random effects meta-analysis of these five studies revealed a pooled risk ratio of 0.86 (95% CI 0.79-0.94; z = 3.44, p = 0.001) on current smoking at follow-up by participation in the competition.

CONCLUSION

SFC appears to be an effective tool in school-based smoking prevention.

The 'Eigenstandig werden' prevention trial: a cluster randomised controlled study on a school-based life skills programme to prevent substance use onset

Objective To implement and evaluate 'Eigenständig werden 5+6' ('Becoming Independent 5+6'), a school-based curriculum for grades 5 and 6 developed on the basis of evidence-based criteria for effective drug prevention curricula in schools. Evaluation of the programme includes efficacy, feasibility and practicability in daily school routine. Methods and results The intervention 'Eigenständig werden 5+6' consists of 14 teaching units evenly distributed over grades 5 and 6 which are interactively delivered, and a parent component. Programme effects are studied in a four wave cluster randomised controlled trial with two arms, an intervention and a control group. Self-completed questionnaires from students and teachers are collected by trained research staff. 45 schools, 172 classes and 3444 students with a mean age of 10.37 years (SD=0.59) and 47.9% girls from four federal states in Germany were assessed at baseline. 1685 students in 81 classes were assigned to intervention classes, 1759 students in 91 classes to the control arm. No differences between conditions were found for age, gender, immigration background, socioeconomic status, substance use or life skills at baseline. Exceptions were higher self-efficacy (t(3438)=2.34, p=0.02, d=0.08) and empathy (t(3302)=2.4, p=0.02, d=0.09) in the control group, whereas class climate seemed better in the intervention group (t(3037)=2.01, p=0.05, d=0.07), but effect sizes state marginal differences. Conclusion Baseline data suggest that the initial conditions are favourable for testing programme efficacy since distribution of baseline levels of the outcomes did not differ in the intervention and control groups, except for negligible differences between self-efficacy and empathy, which were higher in the control group, and class climate, which was higher in the intervention group. Trial registration number Current Controlled Trials ISRCTN99442407.

Does a smoking prevention program in elementary schools prepare children for secondary school?

INTRODUCTION

A smoking prevention program was developed to prepare children in elementary school for secondary school. This study assessed the effects on smoking in secondary school.

METHODS

In 2002, 121 schools in The Netherlands were randomly assigned to the intervention or control group. The intervention group received 3 lessons in 5th grade of elementary school and a second 3 lessons in 6th grade. The control group received "usual care". Students completed 5 questionnaires: before and after the lessons in 5th and 6th grade and in the first class of secondary school. At baseline, 3173 students completed the questionnaire; 57% completed all questionnaires.

RESULTS

The program had limited effect at the end of elementary school. One year later in secondary school significant effects on behavioral determinants and smoking were found. The intervention group had a higher intention not to smoke (β=0.13, 95% confidence interval=0.01-0.24) and started to smoke less often than the control group (odds ratio=0.59, 95% confidence interval=0.35-0.99): smoking increased from 2.5% to 3.6% in the intervention group and from 3.2% to 6.5% in the control group. Girls showed the largest differences in smoking between intervention and control condition.

CONCLUSIONS

A prevention program in elementary school seems to be effective in preventing smoking.

Process evaluation of a tobacco prevention program in Indian schools--methods, results and lessons learnt

In India, 57% of men between 15 and 54 years and 10.8% of women between 15 and 49 years use tobacco. A wide variety of tobacco gets used and the poor and the underprivileged are the dominant victims of tobacco and its adverse consequences. Project MYTRI (Mobilizing Youth for Tobacco-Related Initiatives in India) was a tobacco prevention intervention program, a cluster-randomized trial in 32 Indian schools which aimed to decrease susceptibility to tobacco use among sixth- to ninth-grade students in urban settings in India. This culture-specific intervention, which addressed both smokeless and smoked forms of tobacco, was Indian in content and communication. We qualitatively developed indicators which would help accurately measure the dose of the intervention given, received and reached. A multi-staged process evaluation was done through both subjective and objective measures. Training the teachers critically contributed toward a rigorous implementation and also correlated with the outcomes, as did a higher proportion of students participating in the classroom discussions and better peer-leader-student communication. A sizeable proportion of subjective responses were 'socially desirable', making objective assessment a preferred methodology even for 'dose received'. The peer-led health activism was successful. Teachers' manuals need to be concise.

Prevalence and associated factors of smoking among secondary school students in Harare Zimbabwe

Background

There is a growing epidemic of tobacco use among adolescents in the developing world. However, there is no up to date information on smoking among adolescents. Although in the developing world concerted efforts are being made to control tobacco use, Zimbabwe does not have any documented tobacco control programmes. We estimated the prevalence of smoking among school going secondary school students in Harare, Zimbabwe.

Methods

A 3-stage stratified random sampling was employed to select six participating schools and students. A descriptive analysis was conducted to describe the demographic characteristics of the participants. The prevalence of smoking was estimated and the comparison of prevalence was performed according to its associated factors. Logistic regression analysis was used to identify risk factors for smoking.

Results

650 students with a mean age 16 years and 47% of them female participated. Prevalence of ever-smoked was 28.8% (95% CI 25.3 to 32.3). Prevalence of ever-smoked among males (37.8%) was significantly (p < 0.001) much higher than among females (18.5%). In the multivariate analysis, smoking was found to be statistically associated with having friends that smoke (OR 2.8), getting involved in physical fights (OR 2.3), alcohol use (OR 5.7), marijuana use (OR 8.1) and having had sexual intercourse (OR 4.4).

Conclusions

The study provides recent estimates of prevalence of smoking, and indicates that there is still a high prevalence of smoking among urban secondary school students. Exposure to friends who smoke, risky behaviour like substance abuse, premarital sex and physical fights are significantly associated with smoking. Interventions to stop or reduce the habit should be implemented now and future studies should monitor and evaluate the impact of the interventions.

Mass media interventions to reduce youth smoking prevalence

BACKGROUND

Mass media interventions for reduction of youth cigarette smoking have been recommended based on a broad array of evidence, although few randomized community trials have been reported.

DESIGN

Four matched pairs of independent media markets were identified; one member of each pair was randomized to receive the intervention. School surveys were conducted in all markets, in 2001 before (n=19,966) and in 2005 after (n=23,246) the interventions were completed.

SETTING/PARTICIPANTS

Grade 7-12 students from public schools in these eight medium-sized metropolitan areas participated in the summative evaluations; Grades 4-12 students were targeted to receive mass media interventions in four of these markets.

INTERVENTION

Four simultaneous campaigns consisting of specially developed messages based on behavioral theory and targeted to defined age groups of racially and ethnically diverse young people were placed in popular TV, cable, and radio programming using purchased time for 4 years.

MAIN OUTCOME MEASURES

Prevalence of youth smoking and psychosocial mediators of smoking.

RESULTS

No significant impacts of these interventions on smoking behaviors or mediators were found for the overall samples. A positive effect was found for one mediator in subgroups. Among Hispanic participants a marginally favorable effect on smoking prevalence and significant effects on mediators were found. General awareness of smoking prevention TV messages was slightly higher over time in the intervention areas.

CONCLUSIONS

Mass media interventions alone were unable to induce an incremental difference in youth smoking prevalence, probably because of a relatively strong tobacco control environment that included a substantial national smoking prevention media campaign.

Impact of a social-emotional and character development program on school-level indicators of academic achievement, absenteeism, and disciplinary outcomes: A matched-pair, cluster randomized, controlled trial

This paper reports the effects of a comprehensive elementary school-based social-emotional and character education program on school-level achievement, absenteeism, and disciplinary outcomes utilizing a matched-pair, cluster randomized, controlled design. The Positive Action Hawai'i trial included 20 racially/ethnically diverse schools (mean enrollment = 544) and was conducted from the 2002-03 through the 2005-06 academic years. Using school-level archival data, analyses comparing change from baseline (2002) to one-year post trial (2007) revealed that intervention schools scored 9.8% better on the TerraNova (2^nd ed.) test for reading and 8.8% on math; 20.7% better in Hawai'i Content and Performance Standards scores for reading and 51.4% better in math; and that intervention schools reported 15.2% lower absenteeism and fewer suspensions (72.6%) and retentions (72.7%). Overall, effect sizes were moderate to large (range 0.5-1.1) for all of the examined outcomes. Sensitivity analyses using permutation models and random-intercept growth curve models substantiated results. The results provide evidence that a comprehensive school-based program, specifically developed to target student behavior and character, can positively influence school-level achievement, attendance, and disciplinary outcomes concurrently.

A concise history of school-based smoking prevention research: a pendulum effect case study

School-based cigarette smoking prevention was initiated shortly after the first Surgeon General's Report in 1964. This article highlights a sequence of events by which school-based tobacco use prevention research developed as a science, and illustrates a pendulum effect, with confidence in tobacco use prevention increasing and decreasing at/different points in time. Suggestions are offered to advance school-based smoking prevention research.

The promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews

I provide a review and critique of meta-analyses and systematic reviews of school-based smoking prevention programs that focus on long-term effects. Several of these reviews conclude that the effects of school-based smoking prevention programs are small and find no evidence that they have significant long-term effects. I find that these reviews all have methodological problems limiting their conclusions. These include severe limiting of the studies included because of performance bias, student attrition, non-reporting of ICCs, inappropriate classification of intervention approach, and inclusion of programs that had no short-term effects. The more-inclusive meta-analyses suggest that school-based smoking prevention programs can have significant and practical effects in both the short- and the long-term. Findings suggest that school-based smoking prevention programs can have significant long-term effects if they: 1) are interactive social influences or social skills programs; that 2) involve 15 or more sessions, including some up to at least ninth grade; that 3) produce substantial short-term effects. The effects do decay over time if the interventions are stopped or withdrawn, but this is true of any kind of intervention.

School-based smoking prevention programs with the promise of long-term effects

I provide a systematic review of trials of school-based smoking prevention programs that had at least 15 sessions, preferably with some in high school, that reported significant short-term effects, and that included long-term follow-up. This is supplemented with a description of some other programs that produce short-term effects that portend large long-term effects. I conclude that school-based programs can have long-term effects of practical importance it they: include 15 or more sessions over multiple years, including some in high school; use the social influence model and interactive delivery methods; include components on norms, commitment not to use, intentions not to use, and training and practice in the use of refusal and other life skills; and use peer leaders in some role. School-based programs of this type can reduce smoking onset by 25-30%, and school plus community programs can reduce smoking onset by 35-40% by the end of high school. Some early childhood programs that do not have smoking prevention as their main aim, including home nursing, the Good Behavior Game, the Positive Action program and others, seem to change the developmental trajectories of children so that they are less likely to engage in multiple problem behaviors, including smoking, as adolescents. This review makes it clear that effective school-based smoking prevention programs exist and can be adopted, adapted and deployed with success - and should be.