Fifteen-year follow-up of smoking prevention effects in the North Karelia youth project

The Speed of Progression to Tobacco and Alcohol Dependence: A Twin Study

We investigated the etiological role of genetic and environmental influences for two milestones of tobacco and alcohol use: age of initiation, and speed of progression to dependence (latency). Study participants included 1352 monozygotic and 1422 dizygotic twins (mean age at assessment = 24.31). Earlier ages of initiation significantly increased the likelihood of developing dependence, but were associated with longer dependence latencies for tobacco and alcohol. Latencies to dependence were heritable traits for tobacco (a2 = 0.63) and alcohol (a2 = 0.64). Genetic influences contributing to early age of initiation were associated with faster latencies to dependence but sometimes were counteracted by environmental factors, the extent to which depended on substance and, sometimes, sex. Our findings may have important implications for public policy and add to the literature by characterizing the genetic and environmental contributions to the speed of progression to tobacco and alcohol dependence.

Mass media interventions for preventing smoking in young people

BACKGROUND

Mass media interventions can be used as a way of delivering preventive health messages. They have the potential to reach and modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To assess the effects of mass media interventions on preventing smoking in young people, and whether it can reduce smoking uptake among youth (under 25 years), improve smoking attitudes, intentions and knowledge, improve self-efficacy/self-esteem, and improve perceptions about smoking, including the choice to follow positive role models.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE and Embase in June 2016. This is an update of a review first published in 1998.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and interrupted time-series studies that assessed the effect of mass media campaigns (defined as channels of communication such as television, radio, newspapers, social media, billboards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person-to-person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years. We define smoking behaviour as the presence or absence of tobacco smoking or other tobacco use, or both, and the frequency of tobacco use. Eligible comparators included education or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risks of bias. We combined studies using qualitative narrative synthesis. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool, alongside additional domains to account for the nature of the intervention. We assessed the quality of evidence contributing to outcomes using GRADE.

MAIN RESULTS

We identified eight eligible studies reporting information about mass media smoking campaigns, one of which is new for this update. Seven of the studies used a controlled trial design and one an interrupted time-series analysis. Risks of bias were high across all included studies and there was considerable heterogeneity in study design, intervention and population being assessed.Three studies (n = 17,385), one of which compared a mass media intervention to no intervention and two of which evaluated mass media interventions as adjuncts to school-based interventions, found that the mass media interventions reduced the smoking behaviour of young people. The remaining five studies (n = 72,740) did not detect a significant effect on smoking behaviour. These included three studies comparing a mass media intervention to no intervention, one study evaluating a mass media intervention as an adjunct to a school-based intervention, and one interrupted time-series study of a social media intervention. The three campaigns which found a significant effect described their theoretical basis, used formative research in designing the campaign messages, and used message broadcast of reasonable intensity over extensive periods of time. However, some of the campaigns which did not detect an effect also exhibited these characteristics. Effective campaigns tended to last longer (minimum 3 years) and were more intense (more contact time) for both school-based lessons (minimum eight lessons per grade) and media spots (minimum four weeks' duration across multiple media channels with between 167 and 350 TV and radio spots). Implementation of combined school-based components (e.g. school posters) and the use of repetitive media messages delivered by multiple channels (e.g. newspapers, radio, television) appeared to contribute to successful campaigns.

AUTHORS' CONCLUSIONS

Certainty about the effects of mass media campaigns on smoking behaviour in youth is very low, due to inconsistency between studies in both design and results, and due to methodological issues amongst the included studies. It would therefore be unwise to offer firm conclusions based on the evidence in this review. Methodologically rigorous studies investigating the effect of social media and novel forms of technology as part of tobacco prevention campaigns for youth are needed.

Tobacco Use Prevention by Integrating Inside and Outside of School Based Programs: A Systematic Review Article

BACKGROUND

Experience of tobacco use in early ages will increase probability of addiction to nicotine therefore, efficient tobacco control programs for teenagers are crucial. This study was conducted to recognize elements of successful integrated inside and outside of school based smoking prevention programs.

METHODS

MeSH terms and related keywords were used to search PubMed, Cochrane, Medline, EMBASE, ERIC, SID databases from inception to 29th October 2013. Trials with random and non-random designs, systematic reviews and cohort studies that assessed or reported application of integrated tobacco control programs were included. Quality of the retrieved publications was checked independently by the authors and any disagreement was resolved by consensus.

RESULT

Among the 745 identified publications, only 15 studies had the inclusion criteria with a considerable methodological heterogeneity. While, precise out-come of integrated out of school/school-based interventions were not percepti-ble but this study's findings implied that outside of school intervention could strengthen school-based tobacco prevention programs. No study was found to examine school-based interventions integrated with primary health care such as anti-tobacco consultations, high-risk students screening and their referral to special centers.

CONCLUSION

Integration of outside and inside of school-based programs may boost probability of obtaining favorable outcomes and success rate in practice.

Systematic review of school-based interventions to prevent smoking for girls

BACKGROUND

The purpose of this review is to study the effect of school-based interventions on smoking prevention for girls.

METHODS

We performed a systematic review of articles published since 1992 on school-based tobacco-control interventions in controlled trials for smoking prevention among children. We searched the databases of PubMed, Embase, Web of Science, The Cochrane Databases, CINAHL, Social Science Abstracts, and PsycInfo. Two reviewers independently assessed trials for inclusion and quality and extracted data. A pooled random-effects estimate was estimated of the overall relative risk.

RESULTS

Thirty-seven trials were included, of which 16 trials with 24,210 girls were included in the pooled analysis. The overall pooled effect was a relative risk (RR) of 0.96 (95 % confidence interval (CI) 0.86-1.08; I (2)=75 %). One study in which a school-based intervention was combined with a mass media intervention showed more promising results compared to only school-based prevention, and four studies with girl-specific interventions, that could not be included in the pooled analysis, reported statistically significant benefits for attitudes and intentions about smoking and quit rates.

CONCLUSIONS

There was no evidence that school-based smoking prevention programs have a significant effect on preventing adolescent girls from smoking. Combining school-based programs with mass media interventions, and developing girl-specific interventions, deserve additional study as potentially more effective interventions compared to school-based-only intervention programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42012002322.

Weaker Self-Esteem in Adolescence Predicts Smoking

BACKGROUND

To study whether weaker self-esteem in adolescence is connected with smoking behavior in adulthood.

METHODS

An age cohort born in 1979 responded to the Lawrence Self-Esteem Questionnaire (LAWSEQ) at the age of 16 (n = 1,072). Respondents' smoking behavior was monitored annually during adolescence and 75.3% (n = 813) of them remained nonsmokers during adolescence. A follow-up questionnaire eliciting smoking behavior was sent to the adolescent nonsmokers at the age of 29 years. Response rate at follow-up was 46.2% (n = 376).

RESULTS

Weaker self-esteem (LAWSEQ score ≥ 3) during the adolescence was not significantly associated with smoking in adulthood. However, those respondents who had weaker self-esteem in adolescence had increased risk of having been smoking regularly (adjusted OR 1.8, 95% CI 1.1-3.0) although not all of them were smokers at the time of the follow-up.

CONCLUSIONS

Those with weaker self-esteem in adolescence are more likely to smoke regularly in adulthood.

Flawed oral health of a non-smoking adolescent suggests smoking in adulthood

BACKGROUND

Smokers often have oral health problems. We studied whether poor oral health among non-smoking adolescents is connected to smoking behaviour in adulthood.

METHODS

We used an age cohort born in 1979 (n = 2582) taking part in annual oral health check-ups between the ages of 13 and 15. Self-reported non-smokers were used as the study population. As measures we used decayed, missing or filled teeth/surfaces (DMF) and decayed teeth (D) and smoking behaviour at ages 13-15 and the depending measure was smoking behaviour at the age of 29.

RESULTS

Those who were non-smokers at ages 13-15 and had tooth decay (D > 0) in an oral check-up during that period had higher risk (OR (Odds Ratio) 1.88, 95% confidence interval 1.2-2.9) of being a smoker by age 29. Tooth decay at age 15 predicted earlier onset of smoking for those, who became smokers later in life. Dental caries (DMF > 0) was not associated with higher risk of becoming a smoking adult, but those with dental caries at age 13 were more likely to start smoking earlier.

CONCLUSIONS

Poorer dental health, especially tooth decay in adolescence is a possible indicator of a greater likelihood of transforming from being a non-smoker to a smoker. Dentists should notice this for allocated health promotion.

Effectiveness of a complex intervention in reducing the prevalence of smoking among adolescents: study design of a cluster-randomized controlled trial

Background

The likelihood of an adolescent taking up smoking may be influenced by his or her society, school and family. Thus, changes in the immediate environment may alter a young person’s perception of smoking.

Methods/Design

The proposed multi-center, cluster-randomized controlled trial will be stratified by the baseline prevalence of smoking in schools. Municipalities with fewer than 100,000 inhabitants will be randomly assigned to a control or intervention group. One secondary school will be randomly selected from each municipality. These schools will be randomized to two groups: the students of one will receive any existing educational course regarding smoking, while those of the other school will receive a four-year, class-based curriculum intervention (22 classroom lessons) aimed at reinforcing a smoke-free school policy and encouraging smoking cessation in parents, pupils, and teachers. The intervention will also include annual meetings with parents and efforts to empower adolescents to change the smoking-related attitudes and behaviors in their homes, classrooms and communities.

We will enroll children aged 12-13 years as they enter secondary school during two consecutive school years (to obtain sufficient enrolled subjects). We will follow them for five years, until two years after they leave secondary school. All external evaluators and analysts will be blinded to school allocation.

The aim of this study is to analyze the effectiveness of a complex intervention in reducing the prevalence of smoking in the third year of compulsory secondary education (ESO) and two years after secondary school, when the participants are 14-15 and 17-18 years old, respectively.

Discussion

Most interventions aimed at preventing smoking among adolescents yield little to no positive long-term effects. This clinical trial will analyze the effectiveness of a complex intervention aimed at reducing the incidence and prevalence of smoking in this vulnerable age group.

Trial registration

Current Controlled Trials: NCT01602796.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

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.

Long-term effectiveness of adolescent brief tobacco intervention: a follow-up study

Background

Brief tobacco intervention has been used in promoting smoking cessation and preventing the initiation of smoking. We used a cohort born in 1979 (n = 2 586) from four cities in Finland. Those born on odd days received up to four brief tobacco interventions during their annual school dental check-ups in 1992-1994 (at the age of 13-15). Those who were born on even days were used as a control group. In 2008 a follow-up questionnaire was sent to the cohort. The aim of this study was to ascertain the long-term effectiveness of brief tobacco intervention given in dental health care during school age.

Findings

Responses were received from 529 people in the intervention group and 491 in the control group. In the intervention group and control group by the age of 29 there were 15.3% and 18.5% smokers respectively. This difference was not statistically significant. The difference between groups was similar to that observed when they were 14 years old.

Conclusions

Brief tobacco intervention performed in dental health care in adolescence did not show effectiveness in the long-term follow-up. This type of intervention alone is insufficient to prevent smoking but supports other anti-smoking activities.

Trial Registration

This study was registered at http://clinicaltrials.gov (NCT01348646).

Longitudinal evaluation of a smoking prevention program for adolescents

OBJECTIVE

To evaluate a smoking prevention program for adolescents.

METHODS

The program was conducted between 1999 and 2002, in schools of the district of Lisbon, Portugal. The program integrated activities in the school, family and community. This was a longitudinal quasi-experimental study, based on Community Intervention Trial, with randomly defined control conditions (CC) and intervention conditions (IC). A total of four questionnaires were applied in the beginning of the 7th(T1), 8th(T2) and 9th(T3) and in the end of the 9th(T4) school grades, to 1,205 adolescents, aged 13 years on average, of which 57% were girls and 55% were included in the IC. Exposure to prevention activities, psychosocial determinants of smoking and behavior were the variables considered in the evaluation of the program. Variance analysis and logistic regression were used to test the differences between the two study conditions.

RESULTS

IC obtained better results in the smoking psychosocial determinants and in behavior. At the end of the project, 41.8% of participants in the IC and 53.3% of those in the CC had tried tobacco (OR = 0.62; CI95% 0.49;0.80), while those who became regular smokers totaled 8.0% and 12.4%, respectively (OR = 0.59; CI95% 0.40;0.87).

CONCLUSIONS

The program reduced the initiation of smoking and regular smoking. Results appeared in the second year and improved in the third. Effectiveness of smoking prevention programs depends on a continuous implementation throughout adolescence and on the integration of measures aimed to reach adolescents directly and indirectly through their social context (school, family and community).

Community interventions for preventing smoking in young people

BACKGROUND

Cigarette smoking is one of the leading causes of preventable death in the world. Decisions to smoke are often made within a broad social context and therefore community interventions using coordinated, multi-component programmes may be effective in influencing the smoking behaviour of young people.

OBJECTIVES

To determine the effectiveness of multi-component community based interventions in influencing smoking behaviour, which includes preventing the uptake of smoking in young people.

SEARCH STRATEGY

The Tobacco Addiction group's specialised register, Medline and other health, psychology and public policy electronic databases were searched, the bibliographies of identified studies were checked and raw data was requested from study authors. Searches were updated in August 2010.

SELECTION CRITERIA

Randomized and non randomized controlled trials that assessed the effectiveness of multi-component community interventions compared to no intervention or to single component or school-based programmes only. Reported outcomes had to include smoking behaviour in young people under the age of 25 years.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and the content of community interventions, participants, outcomes and methods of the study was extracted by one reviewer and checked by a second. Studies were combined in a meta-analysis where possible and reported in narrative synthesis in text and table.

MAIN RESULTS

Twenty-five studies were included in the review and sixty-eight studies did not meet all of the inclusion criteria. All studies used a controlled trial design, with fifteen using random allocation of schools or communities. One study reported a reduction in short-term smoking prevalence (twelve months or less), while nine studies detected significant long-term effects. Two studies reported significantly lower smoking rates in the control population while the remaining thirteen studies showed no significant difference between groups. Improvements were seen in secondary outcomes for intentions to smoke in six out of eight studies, attitudes in five out of nine studies, perceptions in two out of six studies and knowledge in three out of six studies, while significant differences in favour of the control were seen in one of the nine studies assessing attitudes and one of six studies assessing perceptions.

AUTHORS' CONCLUSIONS

There is some evidence to support the effectiveness of community interventions in reducing the uptake of smoking in young people, but the evidence is not strong and contains a number of methodological flaws.

Efetividade de uma intervenção educacional em tabagismo entre adolescentes escolares

O objetivo do estudo foi avaliar a efetividade de um programa educacional sobre tabagismo desenvolvido pelo Instituto Nacional do Câncer em adolescentes escolares de Pelotas, RS. Das 46 escolas públicas da cidade, 32 foram sorteadas aleatoriamente e, posteriormente, randomizadas em grupo controle ou intervenção. Em ambas as fases do estudo (pré e pós-intervenção), os estudantes de 7ª e 8ª série responderam a um questionário, e uma amostra de urina foi coletada para análise de cotinina. A intervenção educativa teve duração de seis meses. Os desfechos estudados foram: "auto-relato de uso de cigarros nos últimos 30 dias" e "concentração de cotinina na urina (categorizada em > 10 ng/ml e > 30 ng/ml)". A intervenção não provocou mudança na prevalência de tabagismo, tanto mensurado por auto-relato como pela concentração de cotinina. No entanto, o conhecimento dos alunos acerca dos malefícios do cigarro aumentou no grupo intervenção. Em resumo, não houve efetividade da intervenção educacional para mudanças de comportamento, mas houve melhora no conhecimento dos prejuízos do fumo.

The positive effect of an intervention program on the hypertension knowledge and lifestyles of rural residents over the age of 35 years in an area of China

Hypertension (HTN) is a leading cause of cardiovascular and cerebrovascular diseases. Lifestyle modification may be the preferential approach to prevent and control HTN. The purpose of this study was to evaluate the effects of a community intervention program, which focused on improving the HTN knowledge, diets and lifestyles in a rural Chinese area. The study was carried out in a rural area of the Hubei Province from May 2003 to April 2006. A total of 1632 participants were recruited. Of the participants, 826 from the town of Xiaoxita and 806 from the town of Fenxiang were assigned to the intervention group (group I) and to the control group (group C), respectively. Group I participants underwent an intervention that included HTN education and dietary and lifestyle guidance. Group C participants were not subjected to an intervention. The outcome measures included HTN knowledge, dietary and lifestyle behaviors, and prevalence, awareness, treatment and control rates of HTN. Along with the changes in HTN education (P<0.05), the participants in group I exhibited a significantly greater improvement in dietary habits and lifestyle behaviors, including reducing salty food intake (13.6%), fat intake (22.9%) and alcohol consumption (9.6%), after 3 years in comparison with those in group C (21.7, 31.9 and 18%, respectively). The prevalence of HTN was significantly lower in group I (22.5%) than in group C (36%) after the intervention strategies. The study showed that the implementation of a community intervention program involving HTN education and lifestyle modifications for rural residents is a powerful approach to reduce HTN prevalence and improve long-term health outcomes.

Mass media interventions for preventing smoking in young people

BACKGROUND

The mass media have been used as a way of delivering preventive health messages. They have the potential to reach and to modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To evaluate the effectiveness of mass media interventions to prevent smoking in young people in terms of reduced smoking uptake, in addition to secondary outcomes including improved smoking outcomes, attitudes, behaviours, knowledge, self-efficacy and perception.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of MEDLINE and EMBASE in July 2010.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and time series studies that assessed the effectiveness of mass media campaigns (defined as channels of communication such as television, radio, newspapers, bill boards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person to person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risk of bias was abstracted by two independent reviewers. Studies were combined using qualitative narrative synthesis.

MAIN RESULTS

Seven out of a total of 84 studies reporting information about mass media smoking campaigns met all of the inclusion criteria. All seven studies used a controlled trial design. Three studies concluded that mass media reduced the smoking behaviour of young people. All of the effective campaigns had a solid theoretical basis, used formative research in designing the campaign messages, and message broadcast was of reasonable intensity over extensive periods of time.

AUTHORS' CONCLUSIONS

There is some evidence that mass media can prevent the uptake of smoking in young people, however the evidence is not strong and contains a number of methodological flaws.

Evaluating the risk of hypertension using an artificial neural network method in rural residents over the age of 35 years in a Chinese area

Hypertension (HTN) has been proven to be associated with an increased risk of cardiovascular diseases. The purpose of the study was to examine risk factors for HTN and to develop a prediction model to estimate HTN risk for rural residents over the age of 35 years. This study was based on a cross-sectional survey of 3054 rural community residents (N=3054). Participants were divided into two groups: a training set (N1=2438) and a validation set (N2=616). The differences between the training set and validation set were not statistically significant. The predictors of HTN risk were identified from the training set using logistic regression analysis. Some risk factors were significantly associated with HTN, such as a high educational level (EL) (odds ratio (OR)=0.744), a predominantly sedentary job (OR=1.090), a positive family history of HTN (OR=1.614), being overweight (OR=1.525), dysarteriotony (OR=1.101), alcohol intake (OR=0.760), a salty diet (OR=1.146), more vegetable and fruit intake (OR=0.882), meat consumption (OR=0.787) and regular physical exercise (OR=0.866). We established the predictive models using logistic regression model (LRM) and artificial neural network (ANN). The accuracy of the models was compared by receiver operating characteristic (ROC) when the models were applied to the validation set. The ANN model (area under the curve (AUC)=0.900+/-0.014) proved better than the LRM (AUC=0.732+/-0.026) in terms of evaluating the HTN risk because it had a larger area under the ROC curve.

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.

Smoking patterns in Oregon youth: effects of funding and defunding of a comprehensive state tobacco control program

PURPOSE

Comprehensive tobacco control programs have included school-based prevention programs as a key strategy to reach adolescents. Unfortunately, these programs have undergone extensive budget reductions in recent years. In 2003, funding for the Oregon Tobacco Prevention and Education Program was reduced by about 70%, and the school component was entirely defunded. To assess the effects of program funding and subsequent defunding on smoking prevalence within targeted Oregon schools, we compared the change in 30-day smoking prevalence between grades 8 and 11 in school districts in two periods: namely, during funding and after funding was eliminated.

METHODS

We used annual school-based survey data for grades 8 and 11 to describe district-level changes in smoking prevalence in five age cohorts: two during the funding period and three after defunding. Each cohort was comprised of districts whose 8th-graders completed the survey and participated again 3 years later. Using mixed models, we compared the change in 30-day adjusted smoking prevalence among cohorts in funded districts, defunded districts, and districts that never received funding.

RESULTS

Smoking prevalence growth was significantly higher among cohorts from the defunded period than for cohorts from the funded period (p=.04) and was not significantly different from schools that were never-funded (p=.79).

CONCLUSIONS

In Oregon, funding a school component of a comprehensive tobacco control strategy was associated with depressed uptake of smoking. Gains were quickly lost upon program defunding. School programs are an important strategy if they are long term, comprehensive, and reinforced in the larger environment.

Evolving prosocial and sustainable neighborhoods and communities

In this review, we examine randomized controlled trials of community interventions to affect health. The evidence supports the efficacy of community interventions for preventing tobacco, alcohol, and other drug use; several recent trials have shown the benefits of community interventions for preventing multiple problems of young people, including antisocial behavior. However, the next generation of community intervention research needs to reflect more fully the fact that most psychological and behavioral problems of humans are interrelated and result from the same environmental conditions. The evidence supports testing new comprehensive community interventions that focus on increasing nurturance in communities. Nurturing communities will be ones in which families, schools, neighborhoods, and workplaces (a) minimize biologically and socially toxic events, (b) richly reinforce prosocial behavior, and (c) foster psychological acceptance. Such interventions also have the potential to make neighborhoods more sustainable.

Longitudinal effects of the European smoking prevention framework approach (ESFA) project in Spanish adolescents

BACKGROUND

To describe the effects of a Spanish smoking prevention programme in the context of an European project on regular smoking, in a sample of Barcelona adolescents.

METHOD

A quasi-experimental design was conducted. An experimental group (EG) (1080 pupils) was exposed to programme and compared with a control group (CG) (872 students). The intervention included a school-based programme (16 sessions in 3 years), reinforcement of a smoke-free school policy, smoking cessation for teachers, brochures for parents and other community-based activities involving youth clubs and tobacco sales.

RESULTS

At 12 months, 4.5% of boys and 5.6% of girls were new smokers in the EG versus 6.7% and 11.7% in the CG (P < 0.001). At 36 months, 18.6% of boys and 31.2% of girls in the EG were regular smokers versus 21.6% of boys and 38.3% of girls in the CG (P < 0.001). The main factors associated with progression to regular smoking at 36 months were to be girl, to attend to a public school and to belong to the CG.

CONCLUSION

These results endorse the effectiveness of multi-modal smoking prevention programmes, which include strategies with adults who influence adolescents.

Impact of the 1976 Tobacco Control Act in Finland on the proportion of ever daily smokers by socioeconomic status

OBJECTIVE

To assess the impact of the 1976 Tobacco Control Act (TCA) on smoking initiation across socioeconomic groups.

METHODS

Nationwide data from independent annual cross-sectional postal surveys in 1978-2002 in Finland. Subjects were 25-64-year-old men and women born 1926-1975 (n=68 071). Socioeconomic status was derived individually from population census data. Logistic regression was applied to assess the impact of the 1976 TCA on the prevalence of ever daily smoking in birth cohorts and socioeconomic groups.

RESULTS

Clear socioeconomic differences in ever daily smoking among men and women were found. In all socioeconomic groups a declining cohort trend was observed among men whereas women showed an increasing trend in early cohorts and a declining one thereafter. A statistically significant decline in the proportion of ever daily smokers compatible with the impact of the TCA was found in all socioeconomic groups except farmers. Among women the decline was roughly similar in each socioeconomic group, while among men it varied and was most pronounced among white collar employees.

CONCLUSIONS

The impact of the 1976 TCA was less pronounced among male lower socioeconomic groups. In spite of the even impact of the TCA on female smoking across socioeconomic groups, large socioeconomic disparities remain. Tobacco control policy measures specifically directed at lower socioeconomic groups are needed.

The multiple baseline design for evaluating population-based research

There is a need for pragmatic and rigorous research designs to evaluate the effectiveness of population-based health interventions. The randomized controlled trial (RCT) has limitations in its practicality, ethical appropriateness, and cost when evaluating population-based interventions. Like RCTs, the multiple baseline design can demonstrate that a change in behavior has occurred, the change is a result of the intervention, and the change is significant. Especially important practical advantages over the RCT are that this design requires fewer population groups and communities may act as their own controls. Advantages and methodologic limitations of the multiple baseline design are discussed, and where feasible, strategies to minimize the impact of its limitations are suggested. Recommendations for future research are included.

Community-based interventions and alcohol, tobacco and other drugs: foci, outcomes and implications

The social, health and economic burdens from alcohol, tobacco and other drugs have impacts globally, national and locally. Effective interventions are needed at each level in order to reduce the extensive harm and attendant costs. This paper examines four topics: options available to the local community, evidence of effectiveness, links between local experiences and national and regional initiatives and implications for future research and intervention. It appears that there are a substantial number of options available at the local level. However, evaluation of them is not standard practice, and the results of the higher quality evaluations indicate that many, but not all, interventions have modest or equivocal impact. There is also not a consistent relationship between local and national interventions, although some themes are apparent: in tobacco control there may be good synergy across jurisdictional levels, for alcohol there is evidence that as national control measures are eroded local communities are encouraged or required to take up these agendas, and with regard to illicit drugs there may be tension between law enforcement priorities at the national level and harm reduction orientations locally. Future initiatives need to have appropriate evaluations as a standardised part of prevention initiatives, and include the development of national databases of what is going on locally. These initiatives should promote national policies that include setting parameters and guidelines, but nevertheless do not dictate specific steps and strategies how to achieve local goals in reducing risk and harm.

Environmental factors as predictors of smoking among ninth-grade adolescents in Pitkäranta (Russian Karelia) and in eastern Finland

The purpose of this study was to assess whether similar environmental factors predict adolescents' smoking in two different cultures: in the Pitkäranta district in Russian Karelia and in eastern Finland. The data were gathered by self-administered questionnaires from ninth-grade students in 10 comprehensive schools in Pitkäranta (n = 385) and from age-matched students in 24 schools in eastern Finland (n = 2,098). Structural equation modeling (SEM) was used to test whether similar path structures fit for boys and for girls in Pitkäranta and in eastern Finland, and to test whether regression coefficients were similar between the cultures by sex. Smoking by family members and best friends was positively related to adolescents' smoking both directly and indirectly. Environmental factors were similar predictors of smoking between the cultures for boys. For girls, different regression coefficients in Pitkäranta and in eastern Finland were found. Best friend's smoking was the most important predictor of adolescents' own smoking in every sub-sample. When indirect relationships were identified, the significance of parents' and siblings' smoking, in addition to smoking by best friends, was strongly supported.

It takes two: reducing adolescent smoking uptake through sustainable adolescent-adult partnership

PURPOSE

To assess the effects of a long-term intervention for tobacco use prevention that targets adolescents (Tobacco Free Duo).

METHODS

School-based community intervention combined with repeated cross-sectional surveys over 7 years. The intervention was performed in the County of Västerbotten, Sweden, where survey data were collected in grade seven to nine schools on an annual basis for 7 years. Data for comparison were collected in grade nine on the national level in Sweden. In the intervention area, the annual number of seventh to ninth grade students participating in the study varied between 1300 and 1650. In the reference data, the number of participating ninth grade students approximated 4500 annually.

RESULTS

A significant decrease of nearly 50% was seen in smoking prevalence in the intervention area. The decrease was evident in grades eight and nine (ages 14-15 years) in both boys and girls. At the start of the intervention, smoking prevalence in grade nine was 16.1% in the intervention area and 23% in the national reference group. Although the prevalence in the national sample remained stable, there was a decrease to 9.0% in the intervention area at the end of the study period.

CONCLUSIONS

These results suggest that the Tobacco Free Duo program contributed to a reduction in adolescent smoking among both boys and girls. Using a multi-faceted intervention that includes adolescent-adult partnership can reduce adolescent smoking uptake, and the intervention has been proven to be sustainable within communities.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomized controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomized controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomized to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomized controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we computed pooled estimates only for those trials that could be analyzed together and for which statistical data were available. We predominantly synthesized the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence; multi-modal programmes). Within each group, we placed them into three categories (low, medium and high risk of bias) according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 94 randomized controlled trials identified, we classified 23 as category one (most valid). There was one category one study of information-giving and two of teaching social comeptence. There were thirteen category one studies of social influences interventions. Of these, nine found some positive effect of intervention on smoking prevalence, and four failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive eight-year programme on smoking behaviour. There were three category one RCTs of combined social influences and social competence interventions: one provided significant results and one only for instruction by health educators compared to self-instruction. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was one category one study providing data on social influences compared with information giving. There were four category one studies of multi-modal approaches but they provided limited evidence about the effectiveness of multi-modal approaches including community initiatives.

AUTHORS' CONCLUSIONS

There is one rigorous test of the effects of information-giving about smoking. There are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies failed to detect an effect of the intervention. There are only three high quality RCTs which test the effectiveness of combinations of social influences and social competence interventions, and four which test multi-modal interventions; half showed significant positive results.

Normative processes and adolescents’ smoking behaviour in Norway: A multilevel analysis

Currently, smoking prevalence is still high among adolescents. This is of major concern for public health organizations. Factors that influence adolescent smoking behaviour need to be identified and addressed. Research in this area has identified attitudes, subjective norms and perceived behavioural control as some of the contributing factors, but subjective norms have often been the weakest predictor of smoking behaviour. This could be due to inadequate measurement. The current paper suggests that examining different types of norms and their relationship with smoking behaviour could help increase the contribution of norms. The paper set out to identify other normative concepts, such as the subjective estimate of smoking prevalence, and descriptive and desired societal norms that are not captured by subjective norms but that could be related to adolescents' smoking behaviour. Data were collected from 15-year-old students from Norway (n = 1670 in 89 grade 10 school classes). Multilevel logistic regression analysis was used to determine how the various concepts of norms relate to each other and their relationship with adolescent smoking behaviour. The findings of the study showed that an individual's opinion of societal norms, and the expectations of significant others as well as their behaviour all seem significantly related to adolescent smoking behaviour, either as an individual or as a school class predictor. Hence, rather than playing down the role of norms, the addition of a subjective estimate of smoking prevalence, and descriptive and desired societal norms could extend the normative concept as well as increase its predictive power. Future intervention could address different types of norms as well as the effect of shared context to help prevent adolescents from smoking.

Factors associated with adoption of evidence-based substance use prevention curricula in US school districts

This paper examines factors associated with the adoption of evidence-based substance use prevention curricula (EBC) in a national sample of school districts. Substance abuse prevention coordinators in public school districts (n = 1593), which were affiliated with a random sample of schools that served students in Grades 5-8, completed a written survey in 1999. Results indicated that 47.5% of districts used at least one EBC in their schools with middle school grades. Substance use prevention coordinators reported they had the greatest input in decisions about curricula. In a multivariate analysis of factors positively associated with district-level decisions to adopt evidence-based programs, significant factors included input from a state substance use prevention group, use of information disseminated by the National Institute on Drug Abuse or Center for Substance Abuse Prevention, use of local needs assessment data, consideration of research showing which curricula are effective and allocation of a greater proportion of the coordinator's time to substance use prevention activities. State and federal agencies should increase their efforts to disseminate information about evidence-based programs, targeting in particular the district substance use prevention coordinator.

Community and School Drug Prevention Strategy Prevalence: Differential Effects by Setting and Substance

This study used key informant interviews and student survey data in 508 U.S. communities to examine relationships between the prevalence of community and non-classroom-based school substance prevention strategies and teen substance use rates. After controlling for covariates, analyses indicated that: (1) adult-supervised after-school activities were significantly related to lower past 30-day cigarette smoking and both past 30-day alcohol use and binge drinking; (2) unsupervised after-school recreational facilities were significantly associated with both lower past 30-day cigarette smoking and current daily smoking; (3) community activities to reduce substance use were significantly related to lower binge drinking; and (4) student organizations to prevent alcohol abuse were significantly related to lower binge drinking. Communities need a broad spectrum of strategies to address variation in substance use among youth. EDITORS' STRATEGIC IMPLICATIONS: Policymakers at the school, community, state, and federal levels will benefit from knowing that after-school activities for teens typically result in reliable (though often modest) reductions in substance use in this large national sample. This is a strategy that works, but the effects are likely to vary by setting, level of supervision, substance, and program implementation.

Evaluation of the school-based smoking-prevention program "BE smokeFREE"

This article examines the impact of the school-based smoking-prevention program "BE smokeFREE" on adolescent smoking. A national representative sample of 99 schools (195 classes, 4,441 students) was used when the intervention started in November 1994. Schools were allocated to one of four groups: a comparison group (A) and three intervention groups (B, C, and D). Group B received the most comprehensive intervention. A baseline (autumn 1994) and three follow-up data collections (1995, 1996, and 1997) were conducted. There were no significant differences in smoking habits among the four groups at baseline. The smoking habits in the group that was involved in the most comprehensive intervention (group B) changed more favourably than those of students in the comparison schools over the three follow-up data collections. At the third follow-up, the proportion of students smoking weekly or more in the comparison group was 29.2%, compared with 19.6% in the model intervention group. The two less comprehensive interventions (no teacher in-service courses in group C, and no involvement of parents in group D) appeared to be less effective than the model intervention. Multilevel multiple logistic regression analyses, comparing changes in smoking habits between students in group B with those among students in the comparison schools, confirm the conclusion that the comprehensive intervention was the most effective. This school-based intervention, based on a social influence approach, proved to be effective at reducing smoking rates among participants.

The influence of tobacco smoking on the onset of periodontitis in young persons

This paper reviews the evidence for cigarette smoking as a risk factor for the development of severe destructive periodontal disease in young adults. A high prevalence of cigarette smoking has been identified among young individuals with aggressive periodontitis and tobacco usage increases the risk of periodontal destruction most significantly in young populations. The effect appears to be dose related and is independent of levels of plaque accumulation. Young smokers have more alveolar bone loss and attachment loss than non smoking equivalents. Prolonged and heavy smoking can reduce gingival bleeding and therefore mask the clinical marker of bleeding on probing often used by dentists to monitor periodontal health. This has implications for potential misdiagnosis and failure to detect periodontitis at an early stage. Nicotine metabolites concentrate in the periodontal tissues and can have local effects as well as the potential to affect the systemic host response. Dentists are well placed to assess the smoking status of their young patients and have a role to play in the delivery of smoking cessation advice especially as it pertains to periodontal health. In this way the dental profession can also make a significant contribution to the general health and well being of our youth and future generations.

Impact of the life skills training curriculum on middle school students tobacco use in Marion County, Indiana, 1997-2000

Evaluation of school-based tobacco prevention and control programs have yielded mixed results. This study assessed the impact of the Life Skills Training curriculum on Marion County, Ind., middle school students' knowledge, attitudes, and ability to make good lifestyle decisions. From 1997 to 2000, students in grades six to eight in the study schools received the Life Skills Training curriculum. Survey data (n = 1,598) were used to compare tobacco use behavior, attitudes, and knowledge of those exposed with those not exposed to the program. Of the students surveyed, 12.5% were currently smoking. There were significantly fewer current smokers, and more students exposed to the program indicated they intended to stay smoke-free. Fewer of those participating in the program "hung out" with smokers and more said they could easily refuse a cigarette if offered one. Students completing the Life Skills Training curriculum were more knowledgeable about the health effects of smoking. Program effects were different for male and female students as well as for White and Black students.

A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations

BACKGROUND

Although the initial effectiveness of psychosocial strategies programming in preventing smoking and other drug abuse among adolescents has been well established through literature reviews and meta-analyses, much less evidence exists for the long-term follow-up success of these interventions. The primary goal of this paper, therefore, is to summarize the effectiveness of published program evaluation studies that have followed adolescents across the transitional period between junior high and high school for a period of at least 2 years.

METHODS

Studies for inclusion in this review were accessed primarily through a computerized search of Medline, Healthstar, and PsychINFO databases. Intervention studies that met five core criteria were retained for review. Two authors independently abstracted data on study characteristics, methodology, and program outcomes.

RESULTS

Search results yielded 25 studies suitable for examination. The majority of these studies reported significant program effects for long-term smoking, alcohol, and marijuana outcomes, while indicating a fairly consistent magnitude of program effects.

CONCLUSIONS

This review provides long-term empirical evidence of the effectiveness of social influences programs in preventing or reducing substance use for up to 15 years after completion of programming. However, this conclusion is still somewhat tenuous given the lack of significant program effects reported in several studies and the great variability that existed in the level of internal and external validity across all studies.

Methodologic advances and ongoing challenges in designing community-based health promotion programs

Community intervention trials continue to attract researchers as potential ways to achieve widespread, long-term change in health behaviors. The first generations of community studies were somewhat unsophisticated in design and analysis, and their promise may have been overstated. As design and analysis issues were better defined, as secular trends caught up with the behaviors that researchers were trying to change, or as other unknown variables affected community studies, small effects of interventions were observed in community trials. Discussions were held in professional meetings and reported in the literature: Should community trials be discontinued? In general, the answer was a qualified no. In this paper, we briefly review some of the many advances made in community intervention trials, and address in more detail the challenges ahead.

Role of the media in influencing trajectories of youth smoking

This paper summarizes results of empirical studies on cigarette advertising and promotions, antismoking advertising, product placement in movies, on television and in music media and news coverage about smoking. In addition, we provide an overview of some of the theoretical literature relevant to the study of media uses and effects. Finally, we discuss empirical findings in the context of these theories to draw some conclusions about media influences on smoking and identify issues for further research. We conclude that (a) the media both shape and reflect social values about smoking; (b) the media provide new information about smoking directly to audiences; (c) the media act as a source of observational learning by providing models which teenagers may seek to emulate; (d) exposure to media messages about smoking also provides direct reinforcement for smoking or not smoking; (e) the media promote interpersonal discussion about smoking; (f) the media can influence "intervening" behaviors that may make teenage smoking less likely; and (g) antismoking media messages can also set the agenda for other change at the community, state or national level. We outline priorities for further research which emphasize the need for longitudinal studies, multi-level studies, an awareness of the probably dynamic relationship between tobacco advertising and antismoking advertising, the importance of determining appraisal of tobacco industry youth smoking prevention efforts and the dearth of research on news coverage about smoking.

Possible lessons from the tobacco experience for obesity control

Although obesity is increasing to epidemic proportions in many developed countries, some of these same countries are reporting substantial reductions in tobacco use. Unlike tobacco, food and physical activity are essential to life. Yet similar psychological, social, and environmental factors as well as advertising pressures influence the usage patterns of all 3. These similarities suggest that there may be commonalities between factors involved in controlling obesity and tobacco. This review, therefore, seeks to draw lessons from the tobacco experience for the organization of more successful obesity control. Smoking cessation counseling by physicians has been found to be one of the most clinically effective and cost-effective of all disease prevention interventions. When used alone, however, it cannot decrease the cultural acceptability of tobacco and the pressures and cues to smoke. Research and evaluation have shown the key elements of tobacco control to be (1) clinical intervention and management, (2) educational strategies, (3) regulatory efforts, (4) economic approaches, and (5) the combination of all of these into comprehensive programs that address multiple facets of the environment simultaneously. For each element, we present the evidence outlining its importance for tobacco control, discuss its application to date in obesity control, and suggest areas for further research. Viewing all of the elements involved and recognizing their synergistic effects draws researchers and practitioners back from an exclusive concentration on their particular setting to consider how they might seek to influence other settings in which individuals and populations must negotiate desired changes in nutrition and physical activity.

Community interventions for preventing smoking in young people

BACKGROUND

Decisions to smoke are made within a broad social context. Community interventions use co-ordinated, widespread, multi-component programmes to try and influence behaviour.

OBJECTIVES

To determine the effectiveness of community interventions in preventing the uptake of smoking in young people.

SEARCH STRATEGY

The Tobacco Addiction group specialised register, Medline and other health, psychology and public policy electronic databases were searched, the bibliographies of identified studies were checked and contact was made with content area specialists. Searches were updated in September 2002.

SELECTION CRITERIA

Randomised and non randomised controlled trials that assessed the effectiveness of multi-component community interventions compared to no intervention or to single component or school-based programmes only. Reported outcomes had to include smoking behaviour in young people under the age of 25 years.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and the content of community interventions, participants, outcomes and methods of the study was extracted by one reviewer and checked by a second. Studies were combined using qualitative narrative synthesis.

MAIN RESULTS

Seventeen studies were included in the review, 46 studies did not meet all of the inclusion criteria. All studies used a controlled trial design, with six using random allocation of schools or communities. Of thirteen studies which compared community interventions to no intervention controls, two, which were part of cardiovascular disease prevention programmes, reported lower smoking prevalence. Of three studies comparing community interventions to school-based programmes only, one found differences in reported smoking prevalence. One study reported a lower rate of increase in prevalence in a community receiving a multi-component intervention compared to a community exposed to a mass media campaign alone. One study reported a significant difference in smoking prevalence between a group receiving a media, school and homework intervention compared to a group receiving the media component only.

REVIEWER'S CONCLUSIONS

There is some limited support for the effectiveness of community interventions in helping prevent the uptake of smoking in young people.

Effective ingredients of school-based drug prevention programs. A systematic review

Drug prevention in schools is a top priority in most Western countries and several well-designed studies have shown that prevention programs have the potential of reducing drug use in adolescents. However, most prevention programs are not effective and there are no general criteria available for deciding which program is effective and which is not. In this systematic review of the literature, the current scientific knowledge about which characteristics determine the effectiveness of drug prevention programs is examined. Three types of studies are reviewed: meta-analyses (3 studies were included), studies examining mediating variables of interventions (6 studies), and studies directly comparing prevention programs with or without specific characteristics (4 studies on boosters, 12 on peer-versus adult-led programs, and 5 on adding community interventions to school programs). Seven evidence-based quality criteria were formulated: the effects of a program should have been proven; interactive delivery methods are superior; the "social influence model" is the best we have; focus on norms, commitment not to use, and intentions not to use; adding community interventions increases effects; the use of peer leaders is better; and adding life skills to programs may strengthen effects.

Evaluations of dieting prevention messages by adolescent girls

BACKGROUND

Dieting prevention interventions have been relatively unsuccessful and may be more effective if they concentrate on messages known to be relatively high on persuasive properties. We aimed to identify anti-dieting messages rated most strongly on persuasive dimensions and participant characteristics that predicted message evaluations in adolescent girls.

METHODS

Grade 7 and 8 girls completed questionnaires assessing risk factors for, and early symptoms of, eating disorders. Two weeks later, participants viewed on video seven messages (each 2-3 minutes long) frequently used to dissuade against dieting in prevention interventions and one control message. After viewing each message, participants rated it on a scale assessing the persuasive dimensions of Relevance, Believability, Emotional Response, and Intention to Diet.

RESULTS AND CONCLUSIONS

A quarter to a third of participants felt less likely to go on a diet after viewing the messages. "Skipping meals makes you feel starved so you overeat and feel bad" and "Don't be fooled by the fad diets promoted in the media" were rated most strongly. Higher dieting, body dissatisfaction, and negative affect were generally associated with lower persuasive ratings, suggesting the importance of intervention prior to the establishment of dieting behaviors after which there is more message resistance. Age was also a predictor of Believability for some messages, supporting the importance of ensuring the age appropriateness of messages.

Effectiveness of the "Smoke-Free Class Competition" in delaying the onset of smoking in adolescence

BACKGROUND

This paper examines the effectiveness of the "Smoke-Free Class Competition" in delaying the onset of smoking in adolescence. Each participating class must decide if they want to be a "smoke-free class" for the 6-month period from fall to spring. Classes monitor their (non-)smoking behavior and report it to the teacher regularly. Classes in which pupils refrain from smoking for this period of time participate in a prize draw, in which they can win a number of attractive prizes.

METHODS

To evaluate the effectiveness of the competition, a sample of 131 participating and nonparticipating classes (number of pupils 2,142; mean age 12.9 years, SD = 0.98) was compared with regard to their smoking behavior. Smoking status was determined by self-assessment on three occasions: (a) prior to the beginning of the competition, (b) 1 month after the competition, and (c) 1 year after the start of the competition.

RESULTS

From pretest to posttest smoking increased by 7.5% in the comparison group, while it decreased by 0.2% in the intervention group (OR = 2.19; P < 0.001). In the follow-up measurement, a clear increase in smoking prevalence occurs in all groups; however, the pupils in the intervention condition still have a significant lower increase of smoking (OR = 1.45; P < 0.01). Moreover, with regard to the nonsmokers at baseline, pupils in the comparison group showed significantly higher prevalences in smoking than the intervention group in the postmeasurement, 7.8 versus 13.9% (OR = 1.98; P < 0.001), as well as in the in the follow-up-measurement, 17 versus 21.3% (OR = 1.36; P < 0.05).

CONCLUSIONS

The results suggest that the participation in the competition could delay the onset of smoking in adolescence.