[Effectiveness of a cannabis prevention program in school: results of a randomized prospective study]

BACKGROUND

In the current debate about legalized access to cannabis for adults in Germany, there is widespread agreement about the need for increased prevention among children and young people. The aim of this work is to examine the effectiveness of a school-based cannabis prevention program on knowledge, attitudes, and behavior.

METHOD

Cluster-randomized waiting list control group study with two study arms: "participation in the 'Der grüne Koffer' prevention program", a collection of methods for cannabis prevention, vs. "no participation" and two measurement time points before and four months after the intervention in four German states.

RESULTS

The mean age of the sample of 3976 adolescents from 280 school classes in grades 8 and 9 was 14.02 years (standard deviation = 0.89). The sex ratio was balanced (49.5% female). Cannabis-related knowledge increased significantly more in the intervention group compared to the control group from the first to the second measurement time point (adjusted beta = 0.25 [95% confidence interval: 0.14-0.37]). Attitudes toward cannabis use did not change significantly in either group. In the 8th grades of the intervention group, significantly fewer adolescents (2.9%) started experimenting with cannabis use for the first time during the observation period than in the control group (5.3%), whereas no group difference was detectable in the 9th grades (interaction grade level x group: odds ratio = 2.17 [1.13-4.15], p = 0.019).

DISCUSSION

The evidence of an effect of participation in the "Der grüne Koffer" prevention program on knowledge and first-time use of cannabis in the 8th grade can be considered promising against the background of previous national and international studies, which could not provide evidence of effects of school-based cannabis prevention in middle and late adolescence.

[Shaded places for skin cancer prevention in kindergartens and schools]

BACKGROUND

Excessive UV radiation from the sun may lead to skin cancer, the most common type of cancer in Germany. Therefore, among other things, the World Health Organization recommends seeking shade during the midday hours from a UV index of 3 (3 to 5 = "moderate"). However, this important preventive measure can only be taken if sufficient shaded areas are available. The aim of the study is to record shaded areas in kindergartens and schools nationwide.

METHODS

An epidemiological cross-sectional study with two samples was carried out. Management of kindergartens and schools were surveyed using online questionnaires about the provision of shading measures at their educational institution from May to August 2020 and from April to July 2021, respectively. The primary outcome was to record the presence of various structural shading measures in the outdoor area of their educational institutions. The secondary outcome was to estimate the size of the shaded exterior area.

RESULTS

From the nationwide population, 1042 kindergartens (1.9%) and 713 schools (2.3%) participated. Compared to schools, kindergartens had sun protection measures in the outdoor area significantly more often (99% vs. 82%; p < 0.001) and were able to shade a significantly larger outdoor area (43% vs. 26%; p < 0.001). Assuming a minimum required shaded outdoor area of 1 m2 per person, 45% of the schools and 10% of the kindergartens did not have sufficient shaded outdoor areas (p < 0.001).

CONCLUSION

Almost every fifth school in Germany had no shaded places in the outdoor area. Against the background of climatic changes, an urgent high need for improvements seems obvious.

Waterpipe smoking and subsequent cigarette and e-cigarette use: a cohort study

Aim

We tested the hypothesis that waterpipe smoking increases the likelihood to try conventional and electronic cigarettes.

Methods

In 2017 and 2018, 2752 German adolescents (mean age: 14.9 years), who had never tried conventional cigarettes or e-cigarettes, took part in a longitudinal survey with a 6-month observational period. Multiple regression analyses tested the association between waterpipe use at baseline and first experimentation with e-cigarettes at follow-up. The models adjusted for risk-taking propensity (sensation seeking and experimentation with alcohol and marijuana), age, sex, migration background, type of school and peer substance use.

Results

Some 381 adolescents (12.5% of the survey population) reported waterpipe smoking at baseline. The overall initiation rate during the 6 months was 4.9% (n=134) for conventional cigarettes and 10.5% (n=288) for e-cigarettes. Prior waterpipe smoking significantly predicted cigarette use (adjusted relative risk (ARR)=1.81, 95% CI 1.19-2.76), as well as e-cigarette use (ARR=3.29, 95% CI 2.53-4.28). In addition, a significant interaction between waterpipe use and sensation seeking was found (ARR=0.56, 95% CI 0.33-0.95), with waterpipe use being more predictive of later e-cigarette initiation for lower sensation-seeking individuals.

Discussion

Waterpipe use predicted both later cigarette and e-cigarette use independent of all other assessed risk factors, indicating that waterpipe use might be a risk factor on its own. The results suggest that the association was stronger for adolescents with a lower risk-taking propensity, which brings this group into focus for prevention efforts. However, further research is needed to understand whether these associations are causal.

Use of electronic cigarettes as a predictor of cannabis experimentation: A longitudinal study among German youth

INTRODUCTION

Experimentation with e-cigarettes is rising among youth, and there are concerns that e-cigarettes could be a new risk factor for initiating substance use. This study aimed to investigate whether e-cigarette use longitudinally predicts experimentation with cannabis.

METHODS

During 2017-2019, a prospective cohort study with an observation period of 18 months was conducted with 3,040 students from Germany who had never used cannabis (mean age = 14.8, range: 13-18 years). A multiple poisson regression was used to investigate whether e-cigarette use was an independent predictor of future cannabis use.

RESULTS

Lifetime e-cigarette use was reported by 29.4 % of the survey population (n = 894) at baseline, and 17.4 % (n = 529) initiated cannabis use during the observation period. Among e-cigarette ever users, the initiation rate was 34.5 % compared to 10.4 % of never users. Results were robust to adjustment for age, sex, migrant status, type of school, sensation seeking, peer cannabis use, the use of alcohol and conventional cigarettes (ARR = 1.83; 95 % CI: 1.48-2.25). Further analyses revealed that the association between e-cigarette use and cannabis experimentation was stronger among youth with low sensation seeking scores (ARR = .77, CI: .61-.97) and no conventional cigarette use (ARR = .48, CI: .37-.64) at baseline.

CONCLUSION

E-cigarette use is associated with a subsequent initiation of cannabis use. This association seems to be stronger for youth who have a lower risk for substance use in general. Future studies need to investigate whether this is only true for experimental or also more frequent cannabis use.

IMPLICATIONS

The study indicates a prospective association between e-cigarette use and initiation of cannabis experimentation independent of other risk factors. It suggests that e-cigarette use is more strongly associated with cannabis initiation for youth with a lower propensity to use substances (low sensation-seekers and non-smokers).

Association between bullying victimization and e-cigarette use among German students

This study examined the association between bullying victimization and e-cigarette use. Data from a 2019-2020 German student survey were used (N = 16,476). The target population consisted of students enrolled in grades 5-10, with a mean age of 13.1 years (SD = 1.8), and equal gender distribution (49.5% female). Mixed-effect multivariable logistic regression models were used to examine the association between bullying victimization (attacked physically, assaulted verbally, experienced relational bullying, sexual harassment, cyberbullying) and current e-cigarette use. The multivariable analysis controlled for age, sex, sensation-seeking, socioeconomic status, school performance, type of school attended, and substance use (current cigarette smoking, hookah smoking, and alcohol drinking). Overall 510 (3.7%) students reported current use of e-cigarettes. The odds for using e-cigarettes increased each step of being bullied from "never," "rarely," "sometimes," "once a week," to "several times a week" by 2.03 (95% confidence interval [CI]: 1.81, 2.29) in the unadjusted model, and by 1.46 (95% CI: 1.24, 1.71) in the covariate-adjusted model. Data indicate an empirical association between victimization and e-cigarette use among German students. Design limitations prevent the conclusion of a causal relationship, calling for well-designed longitudinal studies to investigate the temporal sequence between victimization and e-cigarette use.

[Smoke-free Germany 2040: a discussion paper]

INTRODUCTION

A "smoke-free" society is assumed if less than 5 % of a population smoke. We predict when this goal could be reached in Germany. To reduce the proportion of smokers in the population, the World Health Organization recommends a bundle of measures (MPOWER) that should minimize both the supply of and the demand for tobacco. The current level of implementation of these recommendations in Germany is presented.

METHODS

A total of 21 representative cross-sectional surveys of the Drug Affinity Study and the Epidemiological Survey of Substance Abuse since 2000/2001 with adolescents and adults show the smoking behavior of the population until 2018. Per capita consumption of factory-built and self-made cigarettes during the same period is used as an objective data basis. Regression analyses are used to model the date at which less than 5 % of the German population smoke. A selective literature review is carried out to describe the implementation of the MPOWER program.

RESULTS

Before 2000 there was no trend in Germany towards non-smoking. After the implementation of various preventive measures such as price increases for tobacco products and the introduction of non-smoking protection laws, the spread of smoking among the population has steadily decreased since 2000. By 2018, the 5 % prevalence target among adolescents had almost been reached, as the relative proportion of adolescents who smoked fell by 20.9 percentage points to 6.6 %. The relative proportion of smoking in adult women fell by 12.1 percentage points to 18.5 %, the relative proportion of smoking in men by 14.8 percentage points to 24.2 %. Assuming a linear trend, the prevalence target of less than 5 % smoking adults can be reached by around 2043. Of the six recommended measures of the MPOWER program, Germany is currently only implementing the monitoring of tobacco consumption in society without compromises.

DISCUSSION

After various tobacco prevention measures were implemented, a trend towards non-smoking began in Germany. The continual price increase recommended by the World Health Organization, the further restriction of availability, the ban on all tobacco advertising and promotion, the support of smoking cessation as well as the education of the population appear to be necessary to reinforce this trend and to achieve the health policy goal of a smoke-free society in 2040.

[The Course of E-Cigarette Use in Adolescence: A Cohort Study over 18 Months]

AIM

 Description of adolescent e-cigarette use over time.

METHOD

 In 2017 and 2019, 261 adolescents from North Rhine-Westphalia who had used e-cigarettes at least once a month (mean age: 14.9 years; 33.5 % female) took part in a questionnaire study.

RESULTS

 In 2017, 84 adolescents (32.2 %) reported exclusive e-cigarette use (single users), 177 adolescents were classified as dual users (67.8 %) because they consumed a tobacco product (conventional cigarette and/or hookah) in addition to e-cigarettes. During the observation period of 18 months, 83 adolescents (31.8 %) quit nicotine products altogether. Dual users quit nicotine less often than single users (N = 39 or 22.0 % vs. N = 44 or 52.4 %, p < 0.001). Seven single users (8.3 %) did not change their behavior, 11 began to use tobacco exclusively (13.1 %), another 22 (26.2 %) started dual use. Seventy-eight dual users (44.1 %) did not change their behavior, 57 (32.1 %) switched to tobacco use only, 3 dual users (1.7 %) stopped tobacco use, but continued to use e-cigarettes. Taken together, at the end of the study, 10 (5.6 %) of the remaining 178 adolescents consumed only e-cigarettes, while 168 (94.4 %) smoked tobacco or were dual-users.

CONCLUSIONS

 More than two thirds of all young e-cigarette users and more than three quarters of dual users also used nicotine products 18 months later. The remaining consumers showed a less frequent stay or switch to single use, instead a more frequent use of tobacco or dual use.

[Smoking in Adolescence in England and Germany, 2001 - 2016]

AIM

 To describe the smoking behavior of adolescents from England and Germany over a period of 15 years.

METHODS

 Eleven repeated cross-sectional surveys involving a total of 107,485 persons aged 11 to 15 years were carried out between 2001 and 2016 in England and Germany. The following data were assessed: a) the relative proportion of young people who ever smoked a conventional tobacco product, and b) the relative proportion of adolescents, who were current smokers, i. e. teenagers who smoked "occasionally" or "constantly" or "regularly".

RESULTS

 In the observational period, there was a significant stronger reduction in the proportion of young people who ever smoked in Germany (from 52 % to 10 %) compared to England (from 44 % to 19 %). In the same period, the proportion of young people who smoked currently dropped by 16 percentage points to 3 % in Germany and by 12 percentage points to 7 % in England (no significant difference).

CONCLUSIONS

 Data indicate a stronger trend towards never smoking in Germany compared to England, and a similar falling trend on "current" smoking in both countries. Causal conclusions are not possible due to the study design.

Preventing Binge Drinking in Adolescents

BACKGROUND

In a survey taken in Germany in 2015, 14.1% of the 12- to 17-year-olds surveyed had practiced binge drinking at least once in the preceding 30 days. The school program "Klar bleiben" ("Keep a Clear Head") was designed for and implemented among 10th graders. The participants committed themselves to abstain from binge drinking for 9 weeks. We studied whether this intervention influenced the frequency and intensity of binge drinking.

METHODS

This cluster-randomized controlled trial was carried out in 196 classes of 61 schools, with a total of 4163 participants with a mean age of 15.6 years (standard deviation 0.73 years). Data were collected by questionnaire in late 2015, before the intervention and again six months later. The primary endpoints were the frequency of consumption of at least 4 or 5 alcoholic drinks (for girls and boys, respectively) and the typical quantity consumed. This trial was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien, DRKS) with the DRKS ID number DRKS00009424.

RESULTS

At the beginning of the trial, there was no difference between the intervention group and the control group with respect to the primary endpoints. After the intervention, differences were found among participants who had consumed alcohol before the trial (73.2% of the overall sample): binge drinking at least once in the preceding month was reported by 49.4% of the control group and by 44.2% in the intervention group (p = 0.028). The mean number of alcoholic drinks consumed in each drinking episode was 5.20 in the control group and 5.01 in the intervention group (p = 0.047).

CONCLUSION

The intervention was effective only in the large subgroup of adolescents who had previously consumed alcohol: they drank alcohol less often and in smaller amounts than their counterparts in the control group.

[School-based tobacco prevention: the "Be Smart - Don't Start" program]

The competition for smoke-free classes, the "Be Smart - Don't Start" program has been implemented in Germany since 1997. Using contract management techniques, school classes participating in the competition commit themselves to abstain from smoking for six months. Classes report on a regular basis whether they have stayed smoke-free or not. After the end of the competition period, successful classes participate in a prize draw. The competition aimes to influence social norms.Over the past 20 years, the competition has become a major school-based intervention to prevent smoking in Germany. Several studies addressed process and outcome evaluation, cost-benefit efficacy and iatrogenic effects. Following the evidence so far, the intervention is feasible for implementation in school routines, evokes positive feedback in teachers and students, and reveals a positive cost-benefit ratio. Findings from controlled studies imply that negative side-effects are unlikely to occur and that participation in the competition affects the progression of smoking positively at least in the short term.

Effects of a School-Based Pedometer Intervention in Adolescents: 1-Year Follow-Up of a Cluster-Randomized Controlled Trial

BACKGROUND

Physical activity (PA) is one of the most important health behaviors that may be modified by each individual. To foster PA in adolescents, a school-based intervention was evaluated.

METHODS

A cluster-randomized controlled trial with preassessment in 2014 and follow-up assessment in 2015 included 29 schools with 1020 students (47.6% girls, mean age = 13.69 years). Intervention students received pedometers and monitored their steps for 12 weeks. Classes with the most steps were awarded. Primary outcomes included moderate-to-vigorous PA, out-of-school sports activities, active transport assessed through questionnaires, as well as cardiorespiratory fitness measured using the 20-m shuttle-run test and anthropometric data (weight, height, body fat, and waist circumference) assessed by study staff.

RESULTS

Significant interaction terms between group and time were found for all 3 indicators of PA; intervention students showed a higher increase of PA than control students. The same pattern was shown for cardiorespiratory fitness, but the effect missed significance. A more favorable development for the intervention students was shown for body fat and waist-to-height ratio, while there was no effect on body mass index percentile.

CONCLUSIONS

An easy way to administer school-based PA program may enhance students' leisure-time PA even 1 year after the intervention has ended.

[Prediction of binge drinking in young adults: a cohort study over nine years]

Prediction of binge drinking in young adults: a cohort study over nine years Abstract.

OBJECTIVE

Which person characteristics and environmental factors predict binge drinking at age 21?

METHOD

A longitudinal observational study with a nine-year follow-up. A total of 5,176 adolescents from the German states Schleswig-Holstein and Saxony-Anhalt were surveyed in 2006 with paper-pencil questionnaires (mean age 12.6 years, SD = 0.6). A follow-up assessment was conducted in the year 2015. Baseline predictors were age, gender, school type, school performance, parenting style, early experience with alcohol, alcohol use of parents, alcohol use of friends, and sensation seeking. Primary outcome in 2015 was binge drinking at least once a month (six or more alcoholic drinks during one drinking occasion).

RESULTS

A subsample of 1,087 (20.9 %) of the former students could be surveyed nine years after baseline (mean age 21.6 years, SD = 0.8). One out of four (25.4 %) reported binge drinking at least once in a month. A multiple regression model revealed three significant predictors of binge drinking: male gender, early experience with alcohol and frequency of parental alcohol use at baseline.

CONCLUSIONS

Perceived frequency of parental alcohol use might be an important risk factor for children's alcohol use in early adulthood. Parents need to reflect their role as alcohol-specific socialization agents.

„Be Smart – Don’t Start“: Untersuchung langfristiger Effekte eines schulbasierten Präventionsprogramms

Zusammenfassung. Zielsetzung: Zur Beeinflussung der sozialen Norm verpflichten sich beim schulischen Nichtraucherwettbewerb „Be Smart – Don’t Start“ Schulklassen für 6 Monate nicht zu rauchen. Ziel der Studie war, die langfristige Wirksamkeit des Wettbewerbs zu untersuchen. Methodik: 2006 nahmen 3.490 Schüler der 7. Klassenstufe aus 84 Schulen des Landes Sachsen-Anhalt an einer cluster-randomisierten Begleitstudie teil. Diese Stichprobe wurde 2015, neun Jahre nach der Eingangserhebung, erneut kontaktiert und zu ihrem Rauchverhalten befragt. Endpunkte der Untersuchung waren Nierauchen, tägliches Rauchen, Rauchbeginn und Rauchstopp. Ergebnisse: 58 Schulen (69,0 %) erklärten sich zur Teilnahme an der Folgeuntersuchung bereit. Daraus resultierten 688 (19,7 %) Fragebogen von ehemaligen Schülern, die der Eingangserhebung zugeordnet werden konnten (mittleres Alter in 2015: 21,2 Jahre). Personen mit niedrigerem Risiko für das Rauchen wurden bei der Nachuntersuchung häufiger erreicht. Es zeigte sich darüber hinaus, dass in der Kontrollgruppe überzufällig häufig Gymnasiasten erreicht wurden. Nahezu alle Analysen wiesen auf numerisch günstigere Werte in der Interventions- im Vergleich zur Kontrollgruppe hin; dieser Unterschied wurde für den Rauchstopp auch statistisch bedeutsam. Schlussfolgerungen: Aufgrund der geringen Stichprobengröße sowie der differentiellen Attrition sind Schlussfolgerungen zu langfristigen Effekten einer Wettbewerbsteilnahme nur mit großer Vorsicht zu ziehen.

Longitudinal Relationships of Fitness, Physical Activity, and Weight Status With Academic Achievement in Adolescents

BACKGROUND

To examine associations of cardiorespiratory fitness, physical activity (PA) and weight status with academic achievement 1 year later. In addition, the mediating role of psychological variables was tested.

METHODS

Longitudinal analyses included 1011 German students (M = 14.1 years, SD = 0.6 years). Cardiorespiratory fitness was determined with the 20 m shuttle run test. Compliance with PA guidelines was assessed through questionnaire. Weight status was based on body mass index percentiles. As proxy of academic achievement students' self-reported grades in Mathematics and German in their midterm report were averaged. Mediation analyses were conducted at follow-up testing general self-efficacy, depressed affect, and attention/hyperactivity problems.

RESULTS

High levels of cardiorespiratory fitness predicted higher educational attainment (p = .007), while we found no longitudinal association for PA and weight status (p > .253). However, students being insufficiently physically active at baseline but meet PA guidelines at follow-up showed a significant improvement in educational attainment. The cross-sectional association between PA and academic achievement was mediated by students' general self-efficacy.

CONCLUSION

High fitness in adolescence is associated with higher subsequent academic achievement. The promotion of PA might benefit school performance because of enhanced fitness levels in the long-term and positive influences of PA in the shortterm. The association between weight status and educational attainment remains controversial.

Motivational Aspects and Critical Issues of a Pedometer Intervention in Adolescents

BACKGROUND

Existing research shows significant effects of pedometer interventions on students' physical activity (PA). The current study investigates motivational aspects of quantitative increases in PA in the course of a school-based pedometer intervention for adolescents using qualitative data analysis. In addition, critical issues regarding pedometer use in adolescence were examined.

METHOD

Data were obtained in the "läuft." evaluation trial. Students of the intervention group received pedometers and took part in class competitions over a time period of 12 weeks. Qualitative data were collected through focus groups (n = 34) with students of the intervention group as well as through in-depth interviews with teachers (n = 33) who implemented the intervention. A grounded theory approach was used to analyze qualitative data.

RESULTS

Five major motivational aspects for subsequent increases in PA were examined among students participating in the "läuft." PA program issues: (1) affordance of the pedometer, (2) awareness of the own PA, (3) self-determination with regard to time and type of PA, (4) individual goal setting, and (5) social comparison and competition.

CONCLUSIONS

Findings provide a deeper understanding of which aspects of pedometer interventions might be especially important in adolescence and help design effective future interventions for the promotion of PA.

[Sedentary Behavior and the health of adolescents]

BACKGROUND

In modern societies, adolescents spend about half of their waking hours with sedentary behavior (SB). Therefore, the current study aims at investigating the relationship between SB and adolescents' health.

METHODS

A cross-sectional sample of 1296 students (8(th) grade) from 29 schools in Schleswig-Holstein, Germany was surveyed. Mean age was 13.75 years (SD = 0.67), 47.0 % were female. To asses screen-based and non-screen-based SB, moderate to vigorous physical activity as well as further indicators of health behavior (tobacco and alcohol use, diet) a questionnaire was used. Anthropometric data and blood pressure at rest were assessed during a medical testing and cardiorespiratory fitness was assessed by the 20 m-Shuttle-Run-Test.

RESULTS

The students spent almost 7 hours a day sedentary. Total SB was positively associated with behavior that is detrimental to health. These associations were detectable only for screen-based SB, not for non-screen-based SB. Cardiorespiratory fitness was associated negatively with total SB, screen-based as well as non-screen-based SB. Associations remained widely stable when moderate to vigorous physical activity was controlled for. There were almost no associations between SB and blood pressure.

DISCUSSION

Total SB, but especially screen-based SB seems to be a health risk factor in adolescence independent of physical activity. Besides fostering physical activity, reduction of SB should be a core target behavior in prevention and health promotion.

Polysubstance use patterns and trajectories in vocational students--a latent transition analysis

BACKGROUND

The transition from late adolescence to early adulthood (16-20 years) represents a time of exploration and self-discovery for many young people. As such, it is often associated with experimentation in substance use. Vocational students in particular report high substance use. Thus, the aim of this study is to examine patterns and trajectories of their substance use behavior.

METHODS

On two occasions (interval 18 months), we investigated 5214 students (M=19.39 years; 54% male) from 49 vocational schools in seven German federal states. We identified classes of substance use and trajectories via latent transition analysis, controlling for gender, age, and socio-economic status. Additionally, we investigated work-related (job demands/stress/satisfaction) and psychopathological (depressive symptoms) predictors of substance use via multinomial regressions.

RESULTS

We found three latent stages of substance use: low use (baseline: 43%/follow-up: 44%), mainly alcohol use (50%/45%), and polysubstance use (7%/11%). Over time, 10% of alcohol users at baseline transitioned to polysubstance use at follow-up, while there were smaller transition rates (2-9%) between the other stages. Compared to low use, polysubstance use at follow-up was predicted by high job stress (aOR=1.45, 1.07-1.96) at baseline.

CONCLUSIONS

High alcohol use is associated with bidirectional transitions in young adults. Hence, future research needs to identify mechanisms of change to identify protective factors. Regarding vocational practice, early stress management seems to be a viable path to prevent polysubstance use in vocational students.

Latent classes of polysubstance use among adolescents-a systematic review

BACKGROUND

This systematic review aims to summarize latent classes of polysubstance use in adolescents (10-19 years), and to describe predictors of polysubstance use.

METHODS

A systematic literature review was conducted in three databases (PUBMED, PsycINFO, PsycARTICLES) to identify peer-reviewed articles on latent classes of adolescent polysubstance use (published through June 30, 2015), and to assess the comparability of their results.

RESULTS

23 studies (N=450-N=419,698) met the inclusion criteria. The studies showed predominantly (18 studies) average to low risk of bias. 17 studies (74%) identified between three or four latent classes, with "no use" or "low use" classes being the largest and "polysubstance use" being the smallest ones. Intermediate classes included extensive single substance use, such as "alcohol only" classes. Polysubstance use classes were unanimously predicted by higher age, higher parental and peer substance use, and poor academic performance, other predictors were highly heterogeneous.

CONCLUSIONS

Latent classes deliver solid information on polysubstance use in adolescence. Despite their sample sensitivity, the studies possess manifold similarities, hence, modeling latent classes seems to be an ecologically valid approach to further research, e.g., for subgroup analyses or on substance use trajectories. Finally, latent classes may help to illustrate differential effects and special groups in prevention and treatment that depend on the actual consumption pattern. However, there are certain methodological recommendations to be considered in order to obtain reliable results.

Prospective effects of pedometer use and class competitions on physical activity in youth: A cluster-randomized controlled trial

OBJECTIVE

To evaluate the immediate effects of a school-based multi-component program to foster a physically active lifestyle in adolescence.

DESIGN/PARTICIPANTS

In a cluster-randomized controlled trial with pre- and post-assessment in 2014, 29 schools with 1162 8th grade students (48% girls) from Germany were included. Age ranged from 12 to 17 years (M=13.74; SD=0.67).

INTERVENTION

While the control group attended education as usual, students in the intervention group received pedometers and took part in a class competition over a time period of 12 weeks. Classes with the most steps and best creative ideas to promote physical activity in everyday life were awarded.

MAIN OUTCOME MEASURES

Primary outcomes included out-of-school sports activities (h/week), moderate to vigorous physical activity (days/week with a minimum of 60 min), active commuting (min/day), doing chores (min/day), and sedentary behavior (h/day) assessed through self-administered questionnaires as well as cardiorespiratory fitness measured using the 20-m shuttle-run test (completed laps).

RESULTS

Significant interaction terms between group and wave of assessment were found on out-of-school sports activities (b=-1.09 [-1.89; -0.29], p=0.008), moderate to vigorous physical activity (b=-0.29 [-0.47; -0.10], p=0.002), and active commuting (b=-20.41 [-32.32; -8.49], p=0.001): students in the intervention group showed a higher increase of physical activity levels than students in the control group. The intervention effect on cardiorespiratory fitness missed significance marginally (b=-1.52 [-3.14; 0.98], p=0.065), There was no effect on students' sedentary behavior (b=0.06 [-0.72; 0.84], p=0.881).

CONCLUSIONS

An easy to administer school-based physical activity program (12 weeks) may enhance students' leisure-time physical activity.

TRIAL REGISTRATION NUMBER

ISRCTN49482118.

'Klar bleiben': a school-based alcohol prevention programme for German adolescents-study protocol for a cluster randomised controlled trial

INTRODUCTION

There is a noticeable increase in hazardous alcohol use during adolescence, which is significantly associated with adverse consequences. In Germany, up to 30% of adolescents report regular heavy episodic drinking. However, only a few German prevention programmes target adolescents of legal drinking age (16 years and above); thus, this trial aims to develop, implement and evaluate 'Klar bleiben' ('Stay clearheaded'), a school-based prevention programme for grade 10 students.

METHODS AND ANALYSIS

'Klar bleiben' consists of a class commitment to drink responsibly and refrain from hazardous consumption patterns for 9 weeks. The commitment is accompanied by educational lessons on alcohol-related cognitions and consequences. It will be evaluated in a sample of approximately 3000 students (150 classes) from two German federal states (Schleswig-Holstein and Lower Saxony) via a two-armed cluster randomised controlled trial with baseline and postassessment 6 months apart. The intervention group (75 classes) will participate in 'Klar bleiben', whereas the control group (75 classes) will receive education as usual. 'Klar bleiben' addresses classes, individuals, teachers and parents. It is based on a social norms approach and aims to reduce hazardous drinking and drinking-related consequences in adolescents. Secondary outcomes include general drinking behaviour, use of other substances, alcohol-related cognitions and social factors. Covariates include sociodemographic characteristics, environmental and individual (vulnerability) factors.

ETHICS AND DISSEMINATION

'Klar bleiben' provides a multicomponent school-based programme that bridges a gap in alcohol prevention. Similar class-level and social norms-based prevention programmes have already been proven to be successful for other substances among adolescents. Thus, dissemination to other federal states as well as longer term follow-up testing of the robustness of effects is to be anticipated. The study was approved by the Ethics Committee of the German Psychological Society (RH_0620152), and study findings will be disseminated through peer-reviewed publications and conference contributions.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register: DRKS00009424.

Multiple substance use patterns in adolescents-A multilevel latent class analysis

BACKGROUND

Multiple substance use among adolescents is associated with a number of negative consequences. Therefore, we aim to investigate multiple substance use patterns among young adolescents and identify possible multilevel predictors.

METHODS

We analyzed a longitudinal sample of 2490 German students (51% male; Mage=13.32, SD=0.57) at 45 schools in four German states (Bremen, Hesse, North Rhine-Westphalia, Schleswig-Holstein), who completed two assessments in fall, 2010 and fall, 2013. We conducted multilevel latent class analysis for follow-up data on a variety of outcomes, and tested our final 3-class-model for possible baseline predictors. Follow-up substance use measures included lifetime use, current use, and amount of substance for cigarettes and alcohol. Baseline covariates comprised age, gender, socio-economic status, bullying, victimization, peer and parental use, type of school, and health certification of school.

RESULTS

We identified three latent classes: non-users (n=1541; 61.9%), experimenters (n=722; 29.0%), and multiusers (n=227; 9.1%). Experimental consumption was predicted by higher baseline age (OR=1.71; 1.31-2.24), paternal drinking (OR=2.89; 1.23-6.79), and school type (OR=2.57; 1.83-3.61), while multiuse was predicted by peer smoking (OR=2.94; 1.80-4.80) and drinking (OR=2.13; 1.32-3.44), maternal drinking (OR=6.26; 2.02-19.43), bullying (OR=1.69; 1.15-2.48), higher age (OR=1.92; 1.40-2.62), and school type (OR=4.76; 2.75-8.24) compared to the non-users class.

CONCLUSIONS

Prevention and further research on multiple substance use need to concentrate on social influence models and behavior-related interventions, especially at schools without a college-preparatory track.

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.

The Role of Substance-Specific Skills and Cognitions in the Effectiveness of a School-Based Prevention Program on Smoking Incidence

"Eigenständig werden 5+6" (Becoming independent 5+6) is a German school-based smoking prevention program that draws on social competence and social influence approaches. It was investigated whether the program's effect on smoking onset is mediated by substance-specific skills and cognitions such as knowledge, attitudes/risk perception, normative expectations, resistance skills, and refusal self-efficacy. Multiple mediation analyses revealed a statistically significant total indirect effect that accounted for 30.8% of the total effect. When considered separately, significant indirect effects could be found for normative expectations concerning peer smoking and the resistance skill of saying 'no'. Between these two mediators, the percentage of total effect mediated varied between 9.8% and 10.3%. Results of the current study emphasize the importance of substance-specific skills and cognitions in the effectiveness of school-based programs combining social competence and social influence curricula in preventing adolescent smoking onset.

Characteristics of initial fearful spells and their associations with DSM-IV panic attacks and panic disorder in adolescents and young adults from the community

BACKGROUND

Few studies examined characteristics of initial fearful spells (FS) or panic attacks (PA) and their relation to DSM-IV PA and panic disorder (PD).

METHODS

A community sample of adolescents and young adults (N=3021) was followed up in 4 waves (T0-T3) over up to 10 years. FS, PA, and PD were assessed at each wave using the DSM-IV/M-CIDI. Characteristics of the initial FS/PA including perceived reasons/triggers, appraisal, duration, and behavioral/emotional consequences of the initial FS/PA were retrospectively assessed at T1 and T2 in those reporting the experience of lifetime FS or PA at these waves (N=363). Multinomial logistic regressions adjusted for sex and age were used to reveal associations of initial FS/PA characteristics (aggregated data from T1 and T2) with PA only (N=88) and PD (N=62; lifetime incidences cumulated across assessment waves) (reference group: No PA/PD).

RESULTS

Alcohol consumption, drugs/medication, and physical illness as perceived reasons for the initial FS/PA were associated with PA-only (OR 2.46-5.44), while feelings of depression, feelings of anxiety, and having always been anxious/nervous as perceived reasons for the initial FS/PA, appraising the initial FS/PA as terrible and long-term irritating/burdensome, subsequent feelings of depression, subsequent avoidance, and subsequent consumption of medication, alcohol, or drugs were associated with PD (OR 2.64-4.15). A longer duration until "feeling okay again" was associated with both PA-only (OR=1.29 per category) and PD (OR=1.63).

LIMITATIONS

Initial FS/PA characteristics were necessarily assessed retrospectively by self-report only. Thus, our data might be subject to recall/evaluation biases. Aggregated data were used and strictly prospective-longitudinal studies are necessary that replicate our findings.

CONCLUSION

Assessing initial FS/PA characteristics might be useful to identify individuals at increased risk for more severe panic pathology.

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.

"läuft."--a school-based multi-component program to establish a physically active lifestyle in adolescence: study protocol for a cluster-randomized controlled trial

BACKGROUND

Physical activity during childhood and adolescence is associated with substantial health benefits and tracks into adulthood. Nevertheless, only 22.7% of German adolescents are sufficiently physically active. Thus, the promotion of an active lifestyle in youth is an essential issue of public health.This study will evaluate the implementation and efficacy of the "läuft." program to enhance physical activity in adolescence. "läuft." is a multicomponent school-based program developed on the basis of effective strategies for health interventions and behavioral change.

METHODS/DESIGN

The "läuft." physical activity program targets four different levels. (a) Each student receives a pedometer and documents his/her steps over 12 weeks using an interactive user account on the "läuft." homepage. (b) For classes there will be different competitions, with achieving the most steps in selected weeks, the highest increases of steps and developing the most inventive ideas to promote physical activity in school. Besides, the intervention includes four educational lessons. (c) The headmasters and teaching staff of the participating schools will get information material with suggestions and encouragement to enhance physical activity in school. Participating teachers will be invited to an introductory seminar. (d) Parents will be provided with informational material about the program and will be invited to a parent-teacher conference about the benefits of being physically active and how they can support their children in engaging in a physically active lifestyle.To evaluate the efficacy of the "läuft." physical activity program, a two-arm cluster randomized controlled trial will be conducted in three waves: (1) baseline assessment, January/February 2014, (2) post assessment, June/July 2014 and (3) 12-month follow-up assessment, June/July 2015. Data collection will include physical and medical testing, self-administered questionnaires, group discussions and document analyses.

DISCUSSION

"läuft." aims at fostering a physically active lifestyle in adolescence while a considerable decline of physical activity is present. Physical activity programs based in the school setting and following a multicomponent approach have been proven to be most successful. Furthermore, the use of pedometers is promising to enhance physical activity during the entire day and targets a wide range of adolescents regarding fitness and weight.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49482118.

From never to daily smoking in 30 months: the predictive value of tobacco and non-tobacco advertising exposure

OBJECTIVE

To test the specificity of the association between tobacco advertising and youth smoking initiation.

DESIGN

Longitudinal survey with a 30 month interval.

SETTING

21 public schools in three German states.

PARTICIPANTS

A total of 1320 sixth-to-eighth grade students who were never-smokers at baseline (age range at baseline, 10-15 years; mean, 12.3 years).

EXPOSURES

Exposure to tobacco and non-tobacco advertisements was measured at baseline with images of six tobacco and eight non-tobacco advertisements; students indicated the number of times they had seen each ad and the sum score over all advertisements was used to represent inter-individual differences in the amount of advertising exposure.

PRIMARY AND SECONDARY OUTCOME MEASURES

Established smoking, defined as smoked >100 cigarettes during the observational period, and daily smoking at follow-up. Secondary outcome measures were any smoking and smoking in the last 30 days.

RESULTS

During the observation period, 5% of the never-smokers at baseline smoked more than 100 cigarettes and 4.4% were classified as daily smokers. After controlling for age, gender, socioeconomic status, school performance, television screen time, personality characteristics and smoking status of peers and parents, each additional 10 tobacco advertising contacts increased the adjusted relative risk for established smoking by 38% (95% CI 16% to 63%; p<0.001) and for daily smoking by 30% (95% CI 3% to 64%; p<0.05). No significant association was found for non-tobacco advertising contact.

CONCLUSIONS

The study confirms a content-specific association between tobacco advertising and smoking behaviour and underlines that tobacco advertising exposure is not simply a marker for adolescents who are generally more receptive or attentive towards marketing.

Seeing and liking cigarette advertisements: is there a 'mere exposure' effect?

AIMS

We aimed to explain the association between exposure to a cigarette advertisement and favorable attitudes towards the advertisement.

METHODS

We used data from an observational cross-sectional study with a sample of 3,415 German schoolchildren aged 10-17 years. Cigarette advertising exposure was assessed with an image of a Marlboro ad, asking for contact frequency (number of times seen the ad) and brand name. Liking of the ad was measured with two items (alpha = 0.78).

RESULTS

We found a positive linear association between exposure to the Marlboro ad and liking it. This association remained significant (standardized β = 0.09; p < 0.001) even after statistical control for smoking status, smoking of friends and parents, attitudes towards smoking in general, cigarette advertising receptivity (having a favorite cigarette ad), exposure to other advertisings, age, sex, socioeconomic status, rebelliousness and sensation seeking, self-reported school performance, and study region.

CONCLUSIONS

The association between exposure to an advertisement and liking it was robust and could not be fully explained without referring to either unmeasured confounding or implicit advertising effects (e.g. mere exposure). Implicit effects have implications for prevention strategies as it may be very difficult to counteract unconscious advertising effects.

Psychometric properties of the Autonomy over Tobacco Scale in German

BACKGROUND/AIMS

We investigated the psychometric properties of a German translation of the 12-item Autonomy over Tobacco Scale (AUTOS) among 1,195 eighth-grade students.

METHODS

Data for this study were collected as part of the fourth wave of data collection of the Smokefree Class Competition intervention in the Saxony-Anhalt region of Germany. Students from the control arm of the Smokefree Class Competition study who indicated that they had ever smoked 'at least a few puffs' on a cigarette were classified as ever-smokers. They self-completed questionnaires distributed by teachers.

RESULTS

AUTOS scores ranged from 0 to 36 with a distribution highly skewed toward lower-response categories. Inter-item correlations ranged from 0.65 to 0.89 (mean = 0.79, SD = 0.06). Composite reliability for the AUTOS was high (Ω = 0.96) and 3 lower-order factors were also reliable (withdrawal: 0.89, psychological dependence: 0.91, cue-induced cravings: 0.87). Concurrent validity was supported by strong relationships between the AUTOS and both lifetime cigarette consumption and current smoking frequency. Youths were 18 times more likely to be current smokers (95% CI = 11.9-27.2, p < 0.001) if they endorsed any AUTOS item.

CONCLUSION

The German AUTOS is reliable and valid, and the results are consistent with the English AUTOS for use with adolescents.

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.

Tobacco marketing and susceptibility to smoking: cross-sectional survey of Polish children

Susceptibility to smoking has been identified as predictor of smoking onset in adolescence. Aim of the study was to investigate whether receptivity to tobacco marketing, for which a link to adolescent smoking already could be shownin the past, was also associated with susceptibility to smoking. A cross-sectional survey of 1,478 Polish students who reported having never smoked wasconducted. Mean age was 10.1 years and about 53.3% were female. Overall, 84 (5.7%) students were classifiedas susceptible to smoking, and 33 (2.3%) were considered as receptiveto tobacco marketing, operationalised by asking students to name a brand of their favourite cigarette advertisement. Crude logistic regression analyses as well as logistic regression analyses adjusting for socio-demographic characteristics, personality characteristics, factors of social influence and smoking-related cognitions revealed a positive association between receptivity to tobacco marketing and susceptibility to smoking (adjusted odds ratio=3.49 [95% confidence interval: 1.28-9.46], p=0.014). In conclusion, this study revealed that receptivityto tobacco marketing increases susceptibility to smoking. Results providesupport for the almost comprehensive ban of tobacco marketing as existing in Poland and recommend its further expansion towards a total ban including e.g. ban of promotion at point of sale.

Universelle Prävention des Substanzkonsums: Effekte des Grundschulprogramms Klasse2000

Fragestellung: Wie wirkt sich das Grundschulprogramm Klasse2000 auf den Einstieg in den Zigaretten- und/oder heimlichen Alkoholkonsum aus? Methodik: Aufgeteilt auf die beiden Bedingungen „Teilnahme an Klasse2000“ vs. „Keine Teilnahme an Klasse2000“ wurden Schüler (MAlter = 9,0, SD = 0,5), die am Ende der dritten Klasse als Nie-Raucher (N = 1.027), als Nie-Trinker (N = 1.072) bzw. sowohl als Nie-Raucher und -Trinker (N = 979) identifiziert wurden, zum Ende der vierten Klasse hinsichtlich der Inzidenz des Substanzkonsums verglichen. Multiple hierarchische Poisson-Regressionen unter Kontrolle soziodemgraphischer Charakteristika sowie sozialer Einflussfaktoren wurden berechnet. Ergebnisse: Es konnte ein signifikanter Effekt von Klasse2000 auf den Einstieg in den Zigarettenkonsum sowie den Konsum mindestens einer der beiden Substanzen gefunden werden (p = 0,031 bzw. p = 0,010). Die Number needed to treat betrug für den Einstieg in den Zigarettenkonsum 28, für den Einstieg in den Substanzkonsum allgemein 19. Bezüglich des Einstiegs in den heimlichen Alkoholkonsum konnten keine Programmeffekte gefunden werden. Schlussfolgerungen: Es deutet sich ein primärpräventiver Effekt von Klasse2000 auf den Konsum psychotroper Substanzen an.

Attitudes as mediators of the longitudinal association between alcohol advertising and youth drinking

OBJECTIVE

To test the hypothesis that changes in alcohol-related attitudes and expectancies mediate the effect of alcohol advertising on youth drinking.

DESIGN

Longitudinal survey with a 9-month interval.

SETTING

Twenty-nine public schools in 3 German states.

PARTICIPANTS

A total of 2130 sixth- to eighth-grade students (age range, 11-17 years; mean, 12.2 years) who were nondrinkers at baseline.

MAIN EXPOSURES

Exposure to alcohol and nonalcohol advertising was measured at baseline with masked images of 17 commercial advertisements with all brand information digitally removed; students indicated contact frequency and brand names.

OUTCOME MEASURES

Positive attitudes toward alcohol, current alcohol use, lifetime binge drinking.

RESULTS

A total of 581 of the students (28%) started to drink alcohol during the observation period. Alcohol use initiation was positively related to baseline alcohol advertisement exposure. This effect of alcohol advertisement exposure on alcohol use was partially mediated by a change in alcohol-related attitudes, which explained about 35% of the total effect after controlling for baseline covariates and exposure to other advertising contents. The analysis revealed similar results for binge-drinking initiation.

CONCLUSION

More favorable attitudes about alcohol may be one path through which alcohol advertising exerts behavioral influence.

Cigarette advertising and teen smoking initiation

OBJECTIVE

To test the specificity of the association between cigarette advertising and adolescent smoking initiation.

METHODS

A longitudinal survey of 2102 adolescents, aged 10 to 17 years at baseline, who never smoked was conducted by using masked images of 6 cigarette advertisements and 8 other commercial products with all brand information digitally removed. The exposure variable was a combination of contact frequency and cued recall of brands for cigarette and other advertisements. Multilevel mixed-effects Poisson regressions were used to assess smoking initiation 9 months after the baseline assessment as a function of cigarette-advertisement exposure, other advertisement exposure, and baseline covariates.

RESULTS

Thirteen percent (n = 277) of students initiated smoking during the observation period. Although the incidence of trying smoking was associated with increased exposure to cigarette advertisements (10% in the low, 12% in the medium, and 19% in the high cigarette-advertisement exposure tertile initiated smoking), exposure to other advertisements did not predict smoking initiation. Compared with low exposure to cigarette advertisements, high exposure remained a significant predictor of adolescent smoking initiation after controlling for baseline covariates (adjusted relative risk: 1.46 [95% confidence interval: 1.08-1.97]; P < .05).

CONCLUSIONS

Our results support the notion of a content-related effect of cigarette advertisements and underlines the specificity of the relationship between tobacco marketing and teen smoking; exposure to cigarette advertisements, but not other advertisements, is associated with smoking initiation.

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.

Influencing antecedents of adolescent risk-taking behaviour in elementary school: results of a 4-year quasi-experimental controlled trial

Effects of the life skills programme 'Eigenständig werden' (Becoming independent) on life skills and on identified antecedents of adolescent health risk behaviour, childhood internalizing and externalizing behaviour were tested in an elementary school setting. A quasi-experimental controlled trial with five repeated measures was conducted. Participants were 919 students from 50 elementary schools in Saxony, Germany. Outcomes were assessed by teachers' ratings. Growth-curve models revealed that the rate of decline in internalizing and externalizing behaviour was significantly higher in the intervention group-especially for students with high baseline levels of externalizing behaviour (P < 0.01). No general programme effects on the development of skills could be found (P = 0.22). The current study provides evidence that life skills programmes in elementary school may be an effective strategy in reducing antecedents of adolescent risk-taking behaviour.

Effect of an antismoking advertisement on cinema patrons' perception of smoking and intention to smoke: a quasi-experimental study

AIMS

To assess the effect of an antismoking advertisement under real-world conditions. Design Quasi-experimental study.

SETTING/PARTICIPANTS

Multiplex cinema in Kiel, Germany; 4073 patrons were surveyed after having viewed a movie. Some 4005 patrons were > or = 10 years old (28.7% between 10 and 17 years). A total of 654 subjects (16.3%) were smokers.

INTERVENTION

In the intervention condition (weeks 1 and 3), a 30-second antismoking advertisement-accentuating long-term health consequences of smoking and promoting cessation-was shown prior to all movies; in the control condition (weeks 2 and 4) no such spot was shown.

MAIN OUTCOME MEASURES

(i) Awareness of smoking in the movie, (ii) approval of smoking in the movie, (iii) attitude towards smoking, (iv) intention to smoke in the future and (v) desire to smoke among smokers. Findings Patrons who were exposed to the antismoking advertisement were more likely to be female, but did not differ with respect to smoking status. After controlling for gender differences, patrons exposed to the antismoking advertisement had (i) higher awareness of smoking in the movies, (ii) lower levels of approval of smoking in the movies, and (iii) a more negative attitude towards smoking in general compared with those not exposed. Among smokers, smoking in the movies increased urge to smoke, but there was no interaction between smoking in the movies and experimental condition.

CONCLUSIONS

Study results suggest that placing an antismoking advertisement before movies can affect attitudes towards smoking, bolstering evidence in support of such policies.

Cigarette advertising and adolescent smoking

BACKGROUND

Although most agree that the association between tobacco marketing and youth smoking is causal, few studies have assessed the specificity of this association.

PURPOSE

This study aims to examine the specificity of the association between cigarette advertising and teen smoking.

METHODS

A cross-sectional survey of 3415 German schoolchildren aged 10-17 years was conducted using masked images of six cigarette brands and eight other commercial products in 2008. The exposure variable was a combination of contact frequency (recognition) and brand names (cued recall). Sample quartile (Q) exposure to advertisement exposure was calculated in 2009. Outcome variables were ever tried and current (monthly) smoking, and susceptibility to smoking among never smokers.

RESULTS

The prevalence of ever smoking was 31.1% and that of current smoking was 7.4%, and 35.3% of never smokers were susceptible to smoking. Ad recognition rates ranged from 15% for a regionally advertised cigarette brand to 99% for a sweet. Lucky Strike and Marlboro were the most highly recognized cigarette brands (with ad recognition rates of 55% and 34%, respectively). After controlling for a range of established influences on smoking behaviors, the adjusted ORs for having tried smoking were 1.97 (95% CI=1.40, 2.77) for Q4 exposure to cigarette ads compared with adolescents in Q1, 2.90 (95% CI=1.48, 5.66) for current smoking, and 1.79 (95% CI=1.32, 2.43) for susceptibility to smoking among never smokers. Exposure to ads for commercial products other than cigarettes was significantly associated with smoking in crude but not multivariate models.

CONCLUSIONS

This study underlines the specificity of the relationship between tobacco marketing and youth smoking, with exposure to cigarette ads, but not other ads, being associated with smoking behavior and intentions to smoke. This finding suggests a content-related effect of tobacco advertisements.

Gender, smoking and weight concerns: relationship to self-reported body mass index (BMI)

Concerns about weight have been identified as one motive for cigarette smoking among adolescents, especially females. In this paper we describe a study that links smoking related weight concerns with actual weight, testing if smoking adolescents' weight concerns are reflected in actual weight differences. We surveyed 1738 students (age 11-20) from 12 public schools in Kiel, Germany, assessing smoking status, weight concerns, body satisfaction as well as height and weight. Height and weight measures were transformed into age and sex adjusted body mass index (BMI percentiles). We confirmed a positive association between smoking and weight concerns as well as a profound gender difference in the absolute frequency of weight concerns, with female students having weight concerns almost 4-times as often as male students. However, we found no gender-specific association between smoking and weight concerns. In addition, smoking was completely unrelated to actual weight. If female students had no weight concerns, they were strongly biased towards reporting BMIs far below their respective age group. Unlike weight concerns of males, female weight concerns did not vary with actual deviations from the BMI norm. Together, this study indicates that females are less realistic than males regarding their weight appraisals. One supplementary strategy of preventing females from starting to smoke should be an adjustment of these weight appraisals.

Movie smoking and urge to smoke among adult smokers

INTRODUCTION

Few studies have assessed the association between exposure to movie smoking and urge to smoke under real-world conditions.

METHODS

We conducted exit interviews with 4,073 movie patrons, of whom 2,817 were aged 18 years or older. Some 536 were smokers and had complete data. Subjects had exited 26 movies, of which 12 contained smoking. We used least squares regression to assess the association between exposure to movie smoking and urge to smoke (scale range 0-10), controlling for movie rating, age, sex, heaviness of smoking index (HSI, range 0-6), and time since last cigarette smoked.

RESULTS

Median age was 27 years and 52% were female. Median urge to smoke level at movie exit was 7. The dose-response between higher categories of movie smoking and median urge to smoke was one point for two lower categories (1-11 and 11-54 s) and two for the highest category (>or=55 s), but these differences were not statistically significant. In the multivariate analysis, attendance of a movie with smoking was associated with a 0.81-point increase (95% CI = 0.46-1.16) in urge to smoke. For comparison, an HSI score of 3 (vs. 0) was associated with a 2-point increase in urge to smoke.

DISCUSSION

In this sample of adult smokers, exposure to movie smoking was associated with higher urge to smoke after the movie, independent of movie rating. The effect size was consistent with responses seen in cue reactivity experiments. Exposure to movie smoking may affect urge to smoke among adult smokers.

School-based alcohol education: results of a cluster-randomized controlled trial

OBJECTIVE

This study aimed to examine the effects of a school-based alcohol education intervention.

DESIGN

Two-arm three-wave cluster-randomized controlled trial, with schools as the unit for randomization. Surveys were conducted prior to intervention implementation, then 4 and 12 months after baseline.

SETTING

A total of 30 public schools in Schleswig-Holstein, Germany. Participants Baseline data were obtained from 1686 7th graders. The retention rate was 85% over 12 months. Intervention The intervention consisted of four interactive lessons conducted by teachers, booklets for students and booklets for parents.

MEASURES

Knowledge, attitudes, life-time alcohol consumption (ever use alcohol without parental knowledge, ever been drunk and ever binge drinking) and past-month alcohol use.

RESULTS

Intention-to-treat analyses revealed that intervention status was associated with more general knowledge about alcohol and lower levels of life-time binge drinking. No effects were found with respect to students' self-reported attitudes, intentions to drink, life-time alcohol use and past-month alcohol use.

CONCLUSIONS

The results indicate that this brief school-based intervention had a small short-term preventive effect on alcohol misuse.

Movie smoking, movie horror, and urge to smoke

It is known that exposure to smoking cues increases urge to smoke (UTS), but little is known about other media factors that might also increase UTS. We hypothesized that horror/ thriller movies might also increase UTS by increasing negative affect. We surveyed 536 movie patrons who were smokers aged 18 years or older. Subjects had exited 26 movies, of which 12 contained smoking and two were horrorfilms, one with and one without smoking. We used random effects regression to assess the association between exposure to movie smoking, movie horror, both and UTS, controlling for confounding factors. Median age was 26 years and 52% were female. Mean UTS was 5.9, 6.6, 6.6, and 8.7 for smokers exiting movies without smoking, with smoking, horror without smoking and horror with smoking respectively. Smoking in movies was associated with a significantly higher UTS (0.63 [95% CI 0.31-0.94]). Horror with smoking increased UTS by 2.8 points (95% C.I. 2.3, 3.5); the horror without smoking estimate was 0.88, but not statistically significant. This short report offers preliminary evidence that movie horror as one factor besides visual smoking cues that could increase UTS in a community setting.