School-based programmes for preventing smoking

Immigrant family skills-building to prevent tobacco use in Latino youth: study protocol for a community-based participatory randomized controlled trial

Background

Despite declines over recent years, youth tobacco and other substance use rates remain high. Latino youth are at equal or increased risk for lifetime tobacco, alcohol, marijuana, and other illicit drug use compared with their white peers. Family plays an important and influential role in the lives of youth, and longitudinal research suggests that improving parenting skills may reduce youth substance use. However, few interventions are oriented towards immigrant Latino families, and none have been developed and evaluated using a community-based participatory research (CBPR) process that may increase the effectiveness and sustainability of such projects. Therefore, using CBPR principles, we developed a randomized clinical trial to assess the efficacy of a family-skills training intervention to prevent tobacco and other substance use intentions in Latino youth.

Methods/Design

In collaboration with seven Latino community-serving agencies, we will recruit and randomize 336 immigrant families, into intervention or delayed treatment conditions. The primary outcome is youth intention to smoke 6 months post intervention. The intervention consists of eight parent and four youth sessions targeting parenting skills and parent–youth relational factors associated with lower smoking and other substance use in youth.

Discussion

We present the study protocol for a family intervention using a CBPR randomized clinical trial to prevent smoking among Latino youth. The results of this trial will contribute to the limited information on effective and sustainable primary prevention programs for tobacco and other substance use directed at the growing US Latino communities.

Trial registration

ClinicalTrials.gov: NCT01442753

A cluster randomised trial of a school-based resilience intervention to decrease tobacco, alcohol and illicit drug use in secondary school students: study protocol

Background

Whilst schools provide a potentially appropriate setting for preventing substance use among young people, systematic review evidence suggests that past interventions in this setting have demonstrated limited effectiveness in preventing tobacco, alcohol and other drug use. Interventions that adopt a mental wellbeing approach to prevent substance use offer considerable promise and resilience theory provides one method to impact on adolescent mental well-being. The aim of the proposed study is to examine the efficacy of a resilience intervention in decreasing the tobacco, alcohol and illicit drug use of adolescents.

Methods

A cluster randomised controlled trial with schools as the unit of randomisation will be undertaken. Thirty two schools in disadvantaged areas will be allocated to either an intervention or a control group. A comprehensive resilience intervention will be implemented, inclusive of explicit program adoption strategies. Baseline surveys will be conducted with students in Grade 7 in both groups and again three years later when the student cohort is in Grade 10. The primary outcome measures will include self-reported tobacco, alcohol, marijuana and other illicit drug use. Comparisons will be made post-test between Grade 10 students in intervention and control schools to determine intervention effectiveness across all measures.

Discussion

To the authors’ knowledge this is the first randomised controlled trial to evaluate the effectiveness of a comprehensive school-based resilience intervention, inclusive of explicit adoption strategies, in decreasing tobacco, alcohol and illicit drug use of adolescents attending disadvantaged secondary schools.

Trial registration

ACTRN12611000606987

Smoking prevention in school students: positive effects of a hospital-based intervention

BACKGROUND

Adolescents have smoked less in recent years, but 11.7% of 12-to-17-year-olds were still smokers in 2011. The prevalence of smoking has also remained high among 18-to-25-year-olds (36.8%). An intervention program called "Students in the Hospital" was developed in which the health aspects of smoking and its individual and societal consequences were presented in an interactive informational event. In this study, we determine the efficacy of the program.

METHODS

From September 2007 to July 2008, we performed an anonymous survey by questionnaire, with a quasi-experimental control-group design, two weeks before (t(1)) and six months after (t(2)) the intervention in a group of 760 participating school students in Berlin.

RESULTS

40.8% of the participants were smokers, among whom 79% stated that they smoked water pipe. Significantly fewer students in the intervention group than in the control group began smoking in the six months after the intervention (p<0.001). The chance of remaining a non-smoker was four times as high in the intervention group (OR, 4.14; CI, 1.66-10.36). Girls benefited from the intervention more than boys (OR 2.56, CI 1.06-6.19). 16.1% of smokers in the intervention group and 17.6% in the control group gave up smoking (p>0.05).

CONCLUSION

A clear primary preventive effect of the program was demonstrated, although it apparently did not induce persons who were already smokers to quit.

Pharmacological interventions for promoting smoking cessation during pregnancy

BACKGROUND

Smoking in pregnancy is a substantial public health problem. When used by non-pregnant smokers, pharmacotherapies [nicotine replacement therapy (NRT), bupropion and varenicline] are effective treatments for smoking cessation, however, their efficacy and safety in pregnancy remains unknown.

OBJECTIVES

To determine the efficacy and safety of smoking cessation pharmacotherapies, including NRT, varenicline and bupropion (or any other medications) when used to support smoking cessation in pregnancy.

SEARCH METHODS

We searched the Pregnancy and Childbirth Group's Trials Register (5 March 2012), checked references of retrieved studies and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with designs that permit the independent effects of any type of NRT (e.g. patch, gum etc.) or any other pharmacotherapy on smoking cessation to be ascertained were eligible for inclusion. Trials must provide very similar (ideally identical) levels of behavioural support or cognitive behaviour therapy (CBT) to participants in active drug and comparator trial arms.The following RCT designs are considered acceptable.Placebo RCTs: any form of NRT or other pharmacotherapy, with or without behavioural support/CBT, or brief advice compared with placebo NRT and additional support of similar intensity.RCTs providing a comparison between i) behavioural support/CBT or brief advice and ii) any form of NRT or other pharmacotherapy added to behavioural support of similar (ideally identical) intensity.Parallel- or cluster-randomised design trials are eligible for inclusion. However, quasi-randomised, cross-over and within-participant designs are not eligible for inclusion due to the potential biases associated with these designs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and extracted data. Two assessors independently extracted data and cross checked individual outcomes of this process to ensure accuracy. The primary efficacy outcome was smoking cessation in later pregnancy (in all but one trial, at or around delivery); safety was assessed by seven birth outcomes that indicated neonatal well being and we also collated data on adherence.

MAIN RESULTS

Six trials of NRT enrolling 1745 pregnant smokers were included; we found no trials of varenicline or bupropion. No statistically significant difference was seen for smoking cessation in later pregnancy after using NRT as compared to control (risk ratio (RR) 1.33, 95% confidence interval (CI) 0.93 to 1.91, six studies, 1745 women). Subgroup analysis comparing placebo-RCTs with those which did not use placebos found that efficacy estimates for cessation varied with trial design (placebo RCTs, RR 1.20, 95% CI 0.93 to 1.56, four studies, 1524 women; non-placebo RCTs, RR 7.81, 95% CI 1.51 to 40.35, two studies, 221 women; P value for random-effects subgroup interaction test = 0.03). There were no statistically significant differences in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care or neonatal death between NRT or control groups.

AUTHORS' CONCLUSIONS

Nicotine replacement therapy is the only pharmacotherapy for smoking cessation that has been tested in RCTs conducted in pregnancy. There is insufficient evidence to determine whether or not NRT is effective or safe when used to promote smoking cessation in pregnancy or to determine whether or not using NRT has positive or negative impacts on birth outcomes. Further research evidence of efficacy and safety is needed, ideally from placebo-controlled RCTs that investigate higher doses of NRT than were tested in the included studies.

Effectiveness of antismoking media messages and education among adolescents in Malaysia and Thailand: findings from the international tobacco control southeast Asia project

INTRODUCTION

Finding ways to discourage adolescents from taking up smoking is important because those who begin smoking at an earlier age are more likely to become addicted and have greater difficulty in quitting. This article examined whether anti smoking messages and education could help to reduce smoking susceptibility among adolescents in two Southeast Asian countries and to explore the possible moderating effect of country and gender.

METHODS

Data came from Wave 1 of the International Tobacco Control Southeast Asia Project (ITC-SEA) survey conducted in Malaysia (n = 1,008) and Thailand (n = 1,000) where adolescents were asked about receiving antismoking advice from nurses or doctors, being taught at schools about the danger of smoking, noticing antismoking messages, knowledge of health effects of smoking, beliefs about the health risks of smoking, smoking susceptibility, and demographic information. Data were analyzed using chi-square tests and logistic regression models.

RESULTS

Overall, significantly more Thai adolescents reported receiving advice from their nurses or doctors about the danger of smoking (p < .001), but no country difference was observed for reported antismoking education in schools and exposure to antismoking messages. Multivariate analyses revealed that only provision of antismoking education at schools was significantly associated with reduced susceptibility to smoking among female Malaysian adolescents (OR = 0.26). Higher knowledge of smoking harm and higher perceived health risk of smoking were associated with reduced smoking susceptibility among Thai female (OR = 0.52) and Malaysian male adolescents (OR = 0.63), respectively.

CONCLUSIONS

Educating adolescents about the dangers of smoking in schools appears to be the most effective means of reducing adolescents' smoking susceptibility in both countries, although different prevention strategies may be necessary to ensure effectiveness for male and female adolescents.

Results of a transtheoretical model-based alcohol, tobacco and other drug intervention in middle schools

BACKGROUND

Early use of alcohol, tobacco, and other drugs threatens the physical and mental well-being of students and continued use negatively affects many areas of development. An internet-based, tailored intervention based on the Transtheoretical Model of Behavior Change was delivered to middle school students to reduce alcohol, tobacco, and other drug use. This internet-based approach requires very little faculty and staff time, which is efficient given curricular demands.

METHODS

Twenty-two middle schools in the United States were matched and randomly assigned to either the intervention or control conditions (N=1590 students who had ever used substances). Participants received one pre-test assessment, three thirty-minute intervention sessions over three months, and two post-test assessments (3 and 14 months after pre-test, respectively).

RESULTS

Random effects logistic models showed significant treatment effects for the intervention group when compared to the control group at the 3-month post-test.

CONCLUSIONS

This program has the potential to be applied as stand-alone practice or as part of more intensive interventions to promote substance use cessation.

Interventions for tobacco use prevention in Indigenous youth

BACKGROUND

Tobacco use in Indigenous populations (people who have inhabited a country for thousands of years) is often double that in the non-Indigenous population. Addiction to nicotine usually begins during early adolescence and young people who reach the age of 18 as non-smokers are unlikely to become smokers thereafter. Indigenous youth in particular commence smoking at an early age, and a disproportionate burden of substance-related morbidity and mortality exists as a result.

OBJECTIVES

To evaluate the effectiveness of intervention programmes to prevent tobacco use initiation or progression to regular smoking amongst young Indigenous populations and to summarise these approaches for future prevention programmes and research.

SEARCH METHODS

The Cochrane Tobacco Addiction Group Specialised Register was searched in November 2011, with additional searches run in MEDLINE. Online clinical trial databases and publication references were also searched for potential studies.

SELECTION CRITERIA

We included randomized and non-randomized controlled trials aiming to prevent tobacco use initiation or progression from experimentation to regular tobacco use in Indigenous youth. Interventions could include school-based initiatives, mass media, multi-component community level interventions, family-based programmes or public policy.

DATA COLLECTION AND ANALYSIS

Data pertaining to methodology, participants, interventions and outcomes were extracted by one reviewer and checked by a second, whilst information on risk of bias was extracted independently by a combination of two reviewers. Studies were assessed by qualitative narrative synthesis, as insufficient data were available to conduct a meta-analysis. The review process was examined by an Indigenous (Aboriginal) Australian for applicability, acceptability and content.

MAIN RESULTS

Two studies met all of the eligibility criteria for inclusion within the review and a third was identified as ongoing. The two included studies employed multi-component community-based interventions tailored to the specific cultural aspects of the population and were based in Native American populations (1505 subjects in total). No difference was observed in weekly smoking at 42 months follow-up in the one study assessing this outcome (skills-community group versus control: risk ratio [RR] 0.95, 95% CI 0.78 to 1.14; skills-only group versus control: RR 0.86, 95% CI 0.71 to 1.05). For smokeless tobacco use, no difference was found between the skills-community arm and the control group at 42 weeks (RR 0.93, 95% CI 0.67 to 1.30), though a significant difference was observed between the skills-only arm and the control group (RR 0.57, 95% CI 0.39 to 0.85). Whilst the second study found positive changes for tobacco use in the intervention arm at post test (p < 0.05), this was not maintained at six month follow-up (change score -0.11 for intervention and 0.07 for control). Both studies were rated as high or unclear risk of bias in seven or more domains (out of a total of 10).

AUTHORS' CONCLUSIONS

Based on the available evidence, a conclusion cannot be drawn as to the efficacy of tobacco prevention initiatives tailored for Indigenous youth. This review highlights the paucity of data and the need for more research in this area. Smoking prevalence in Indigenous youth is twice that of the non-Indigenous population, with tobacco experimentation commencing at an early age. As such, a significant health disparity exists where Indigenous populations, a minority, are over-represented in the burden of smoking-related morbidity and mortality. Methodologically rigorous trials are needed to investigate interventions aimed at preventing the uptake of tobacco use amongst Indigenous youth and to assist in bridging the gap between tobacco-related health disparities in Indigenous and non-Indigenous populations.

A web-based computer-tailored smoking prevention programme for primary school children: intervention design and study protocol

BACKGROUND

Although the number of smokers has declined in the last decade, smoking is still a major health problem among youngsters and adolescents. For this reason, there is a need for effective smoking prevention programmes targeting primary school children. A web-based computer-tailored feedback programme may be an effective intervention to stimulate youngsters not to start smoking, and increase their knowledge about the adverse effects of smoking and their attitudes and self-efficacy regarding non-smoking.

METHODS & DESIGN

This paper describes the development and evaluation protocol of a web-based out-of-school smoking prevention programme for primary school children (age 10-13 years) entitled 'Fun without Smokes'. It is a transformation of a postal mailed intervention to a web-based intervention. Besides this transformation the effects of prompts will be examined. This web-based intervention will be evaluated in a 2-year cluster randomised controlled trial (c-RCT) with three study arms. An intervention and intervention + prompt condition will be evaluated for effects on smoking behaviour, compared with a no information control condition. Information about pupils' smoking status and other factors related to smoking will be obtained using a web-based questionnaire. After completing the questionnaire pupils in both intervention conditions will receive three computer-tailored feedback letters in their personal e-mail box. Attitudes, social influences and self-efficacy expectations will be the content of these personalised feedback letters. Pupils in the intervention + prompt condition will - in addition to the personalised feedback letters - receive e-mail and SMS messages prompting them to revisit the 'Fun without Smokes' website. The main outcome measures will be ever smoking and the utilisation of the 'Fun without Smokes' website. Measurements will be carried out at baseline, 12 months and 24 months of follow-up.

DISCUSSION

The present study protocol describes the purpose, intervention design and study protocol of 'Fun without Smokes'. Expectations are that pupils receiving tailored advice will be less likely to smoke after 24 months in contrast to pupils in the control condition. Furthermore, tailored feedback letters and prompting is expected to be more effective than providing tailored feedback letters only.

TRIAL REGISTRATION

Dutch Trial Register NTR3116.

The analysis of tobacco consumption in Croatia--are we successfully facing the epidemic?

Tobacco is the largest cause of morbidity and mortality. The aim of this study is to analyse several health and economically related indicators of tobacco consumption: smoking prevalence, standardized death rates (SDRs) from lung cancer and the proportion of GDP spent on tobacco in Croatia and other transitional countries--the Czech Republic, Slovakia, Poland, Hungary, Slovenia, Romania, and Bulgaria. The overall smoking prevalence in Croatia decreased by 5.2% during 1994-2005, more among females (-9.9%) than males (-0.3%). There is no significant difference in the smoking prevalence between Croatia (27.4%) and other countries. However, 33.8% of Croatian males smoked during 2002-2005, more than in Romania and the Czech Republic, and less than in Hungary and Poland. The prevalence of female smoking (21.7%) in Croatia is similar to the female smoking prevalence in Poland, the Czech Republic, and Hungary, but male smoking is predominant in all countries. The proportion of smokers among youth is above 20% and it is the highest in the Czech Republic (29.7%), followed by Hungary (26.7%), Slovenia (24.9%), Croatia (24.1%), and Poland (21.5%). The proportion of smokers among girls is higher than among boys in Slovenia, Hungary, the Czech Republic, and Croatia, contrary to Slovakia, Bulgaria, and Poland where boys smoke slightly more. There is no significant difference between the prevalence of smoking among girls in Croatia and Bulgaria, Poland, the Czech Republic, Hungary, Slovenia, and Slovakia. According to the SDR from lung cancer in males (70.3/100,000), Croatia is ranked high assuming the 3rd place, after Hungary (99.7) and Poland (72.0). With a SDR of 15.9/100,000 for females, Croatia is ranked slightly better--5th place. Tobacco consumption continues to be a major public health problem in transitional countries. Croatia conducted several campaigns and programmes in the past. However, results reveal that current anti-tobacco strategies are ineffective in reducing the smoking prevalence among men and youth. Men do not smoke less than a decade ago and, despite the observed decline among women, increasing trends are observed among teenage girls. Croatia should apply a comprehensive approach that would include raising awareness of health risks, restriction of smoking in public places, higher taxing, implementing stricter bans on advertising and promotion of tobacco as well as supporting smoking cessation. This last measure is believed to bring about some results in the medium term in targeted population groups, provided that it is supported by all health professionals. Otherwise, we may expect progress at the population level in the field of social stigmatization of smoking and wider intolerance to second-hand smoke. The full impact of smoking on the population health is yet to be seen and in the future it will undoubtedly remain one of the major contributors to the poor public health situation in Croatia.

Interventions to prevent substance use and risky sexual behaviour in young people: a systematic review

AIMS

To identify and assess the effectiveness of experimental studies of interventions that report on multiple risk behaviour outcomes in young people.

METHODS

A systematic review was performed to identify experimental studies of interventions to reduce risk behaviour in adolescents or young adults and that reported on both any substance (alcohol, tobacco and illicit drug) use and sexual risk behaviour outcomes. Two authors reviewed studies independently identified through a comprehensive search strategy and assessed the quality of included studies. The report was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

From 1129 papers, 18 experimental studies met our inclusion criteria, 13 of which were assigned a strong or moderate quality rating. The substantial heterogeneity between studies precluded the pooling of results to give summary estimates. Intervention effects were mixed, with most programmes having a significant effect on some outcomes, but not others. The most promising interventions addressed multiple domains (individual and peer, family, school and community) of risk and protective factors for risk behaviour. Programmes that addressed just one domain were generally less effective in preventing multiple risk behaviour.

CONCLUSIONS

There is some, albeit limited, evidence that programmes to reduce multiple risk behaviours in school children can be effective, the most promising programmes being those that address multiple domains of influence on risk behaviour. Intervening in the mid-childhood school years may have an impact on later risk behaviour, but further research is needed to determine the effectiveness of this approach.

Continued importance of family factors in youth smoking behavior

INTRODUCTION

Although it is known that levels of family factors (FF) such as parental monitoring and parent-adolescent connectedness vary during adolescence, it is unknown which factors remain protective, preventing smoking initiation, in youth of differing racial/ethnic groups. Using a longitudinal, nationally representative sample, we examined which FF protect against smoking initiation in White, Black, and Hispanic youth.

METHODS

A total of 3,473 parent-nonsmoking youth dyads from Round 1 (T1) of the National Survey of Parents and Youth were followed to Round 3 (T2). Youth smoking status at T2 was assessed as the primary outcome. We examined changes in FF (T2 - T1) and the protection afforded by these factors at T1 and T2 for smoking initiation, both by race/ethnicity and overall.

RESULTS

There were statistically significant decreases in levels of protective FF from T1 to T2 across all racial/ethnic groups; however, FF levels were higher in never-smokers compared with smoking initiators at both T1 and T2 (p < .05). Separate models by race/ethnicity showed the protective effect of increased perceived punishment in all racial/ethnic groups and protection against initiation by increased parental monitoring in Black and Hispanic youth. Overall, higher parental monitoring at T1 was associated with decreased odds of smoking initiation (33%); decreased parental monitoring and perceived punishment from T1 to T2 were associated with increased odds of smoking initiation (55% and 17%, respectively).

CONCLUSIONS

Smoking prevention interventions should encourage parents to both enforce consistent consequences of smoking behavior, and continue monitoring, especially in minority groups.

A randomized, controlled trial of a school-based intervention to reduce violence and substance use in predominantly Latino high school students

PURPOSE

Few studies have rigorously evaluated school-based interventions to reduce violence and substance use in high school students, especially Latinos. This study assessed the effects of a school-based program on reducing violence and substance use among primarily Latino high school students.

METHODS

Ninth-grade students at risk for violence and substance use were randomized to intervention or control groups. The intervention was based on an existing program developed for white and African American youth. Data on smoking, alcohol and drug use, fighting, and grades were collected at baseline and 4 and 8 months post enrollment.

RESULTS

There were 55 students in the control and 53 in the intervention group; 74% of controls and 78% of intervention students were Latino. There were no significant changes in fighting, smoking, or alcohol or drug use, from baseline to 8-month follow-up, between the intervention and control group. Pre and post grade point average (GPA) decreased from 2.3 at baseline to 1.8 at follow-up (p<.01) in the intervention group, with no significant between-group changes in GPA from baseline to follow-up.

CONCLUSIONS

This school-based program showed no reduction in violence or substance use. The findings suggest that a program targeting non-Latino youth may not be optimal for reducing violence and substance use in Latinos; greater attention to cultural appropriateness and racial/ethnic differences may be needed. There was a decrease in intervention-group GPA but no significant change compared with controls. Further studies of the impact of school-based substance use and violence prevention programs on academics, and the effectiveness of afterschool or community-based programs compared to school-based programs are needed.

Comparison of tobacco control scenarios: quantifying estimates of long-term health impact using the DYNAMO-HIA modeling tool

BACKGROUND

There are several types of tobacco control interventions/policies which can change future smoking exposure. The most basic intervention types are 1) smoking cessation interventions 2) preventing smoking initiation and 3) implementation of a nationwide policy affecting quitters and starters simultaneously. The possibility for dynamic quantification of such different interventions is key for comparing the timing and size of their effects.

METHODS AND RESULTS

We developed a software tool, DYNAMO-HIA, which allows for a quantitative comparison of the health impact of different policy scenarios. We illustrate the outcomes of the tool for the three typical types of tobacco control interventions if these were applied in the Netherlands. The tool was used to model the effects of different types of smoking interventions on future smoking prevalence and on health outcomes, comparing these three scenarios with the business-as-usual scenario. The necessary data input was obtained from the DYNAMO-HIA database which was assembled as part of this project. All smoking interventions will be effective in the long run. The population-wide strategy will be most effective in both the short and long term. The smoking cessation scenario will be second-most effective in the short run, though in the long run the smoking initiation scenario will become almost as effective. Interventions aimed at preventing the initiation of smoking need a long time horizon to become manifest in terms of health effects. The outcomes strongly depend on the groups targeted by the intervention.

CONCLUSION

We calculated how much more effective the population-wide strategy is, in both the short and long term, compared to quit smoking interventions and measures aimed at preventing the initiation of smoking. By allowing a great variety of user-specified choices, the DYNAMO-HIA tool is a powerful instrument by which the consequences of different tobacco control policies and interventions can be assessed.

Reducing smoking in adolescents: cost-effectiveness results from the cluster randomized ASSIST (A Stop Smoking In Schools Trial)

Introduction:

School-based smoking prevention programmes can be effective, but evidence on cost-effectiveness is lacking. We conducted a cost-effectiveness analysis of a school-based “peer-led” intervention.

Methods:

We evaluated the ASSIST (A Stop Smoking In Schools Trial) programme in a cluster randomized controlled trial. The ASSIST programme trained students to act as peer supporters during informal interactions to encourage their peers not to smoke. Fifty-nine secondary schools in England and Wales were randomized to receive the ASSIST programme or usual smoking education. Ten thousand seven hundred and thirty students aged 12–13 years attended participating schools. Previous work has demonstrated that the ASSIST programme achieved a 2.1% (95% CI = 0%–4.2%) reduction in smoking prevalence. We evaluated the public sector cost, prevalence of weekly smoking, and cost per additional student not smoking at 24 months.

Results:

The ASSIST programme cost of £32 (95% CI = £29.70–£33.80) per student. The incremental cost per student not smoking at 2 years was £1,500 (95% CI = £669–£9,947). Students in intervention schools were less likely to believe that they would be a smoker at age 16 years (odds ratio [OR] = 0.80; 95% CI = 0.66–0.96).

Conclusions:

A peer-led intervention reduced smoking among adolescents at a modest cost. The intervention is cost-effective under realistic assumptions regarding the extent to which reductions in adolescent smoking lead to lower smoking prevalence and/or earlier smoking cessation in adulthood. The annual cost of extending the intervention to Year 8 students in all U.K. schools would be in the region of £38 million and could result in 20,400 fewer adolescent smokers.

Adolescent smoking behavior and outcome expectancies

Adolescent smoking behavior is assumed to be associated with smoking outcome expectancies. Results in this paper are based on data from the control group of two data collections among Norwegian secondary school students taken approximately 30 months apart (T1 and T2). The dimensionality of smoking outcome expectancies was the same at both time points, revealing three components ("Addicted", "Not harmful" and "Social"). After correction for attenuation, the Pearson's correlation between T1 and T2 was 0.41 for the total sumscore, indicating low to moderate relative stability. When examining smoking expectancy sumscore means by smoking habits at T1 and T2, never smokers were different from smokers on both occasions. Never smokers scored low on "Social" and "Not harmful", and high on "Addictive". All associations were statistically significant (p < 0.001). The "Social" dimension was the strongest predictor of smoking behavior at T1 and T2. One of the outcome expectancy sumscores ("Addictive") at T1 predicted smoking habits at T2 after controlling for smoking habits at T1 (p < 0.01). This predictor was significant also after entering outcome expectancy sumscores at T2 into the model (p < 0.05). These results indicate that outcome expectations other than the health-related ones should be paid attention to when planning new prevention programs.

Distal and proximal family predictors of adolescents' smoking initiation and development: a longitudinal latent curve model analysis

Background

Studies on adolescent smoking indicate that the smoking behaviours of their parents, siblings and friends are significant micro-level predictors. Parents' socioeconomic status (SES) is an important macro-level predictor. We examined the longitudinal relationships between these predictors and the initiation and development of adolescents' smoking behaviour in Norway.

Methods

We employed data from The Norwegian Longitudinal Health Behaviour Study (NLHB), in which participants were followed from the age of 13 to 30. We analysed data from the first 5 waves, covering the age span from 13 to 18, with latent curve modeling (LCM).

Results

Smoking rates increased from 3% to 31% from age 13 to age 18. Participants' smoking was strongly associated with their best friends' smoking. Parental SES, parents' smoking and older siblings' smoking predicted adolescents' initial level of smoking. Furthermore, the same variables predicted the development of smoking behaviour from age 13 to 18. Parents' and siblings' smoking behaviours acted as mediators of parents' SES on the smoking habits of adolescents.

Conclusions

Parents' SES was significantly associated, directly and indirectly, with both smoking initiation and development. Parental and older siblings' smoking behaviours were positively associated with both initiation and development of smoking behaviour in adolescents. There were no significant gender differences in these associations.

A school-based resilience intervention to decrease tobacco, alcohol and marijuana use in high school students

Background

Despite schools theoretically being an ideal setting for accessing adolescents and preventing initiation of substance use, there is limited evidence of effective interventions in this setting. Resilience theory provides one approach to achieving such an outcome through improving adolescent mental well-being and resilience. A study was undertaken to examine the potential effectiveness of such an intervention approach in improving adolescent resilience and protective factor scores; and reducing the prevalence of adolescent tobacco, alcohol and marijuana use in three high schools.

Methods

A non-controlled before and after study was undertaken. Data regarding student resilience and protective factors, and measures of tobacco, alcohol and marijuana use were collected from grade 7 to 10 students at baseline (n = 1449) and one year following a three year intervention (n = 1205).

Results

Significantly higher resilience and protective factors scores, and significantly lower prevalence of substance use were evident at follow up.

Conclusions

The results suggest that the intervention has the potential to increase resilience and protective factors, and to decrease the use of tobacco, alcohol and marijuana by adolescents. Further more rigorous research is required to confirm this potential.

The Minnesota Adolescent Community Cohort Study: design and baseline results

The Minnesota Adolescent Community Cohort (MACC) Study is a population-based, longitudinal study that enrolled 3,636 youth from Minnesota and 605 youth from comparison states ages 12 to 16 years in 2000-2001. Participants have been surveyed by telephone semi-annually about their tobacco-related attitudes and behaviors. The goals of the study are to evaluate the effects of the Minnesota Youth Tobacco Prevention Initiative and its shutdown on youth smoking patterns, and to better define the patterns of development of tobacco use in adolescents. A multilevel sample was constructed representing individuals, local jurisdictions and the entire state, and data are collected to characterize each of these levels. This paper presents the details of the multilevel study design. We also provide baseline information about MACC participants including demographics and tobacco-related attitudes and behaviors. This paper describes variability in smoking prevalence and demographic characteristics for local units, and compares MACC participants to the state as a whole.

School-related predictors of smoking, drinking and drug use: evidence from the Belfast Youth Development Study

OBJECTIVE

To examine whether students' school engagement, relationships with teachers, educational aspirations and involvement in fights at school are associated with various measures of subsequent substance use.

METHODS

Data were drawn from the Belfast Youth Development Study (n = 2968). Multivariate logistic models examined associations between school-related factors (age 13/14) and substance use (age 15/16).

RESULTS

The two factors which were consistently and independently associated with regular substance use among both males and females were student-teacher relationships and fighting at school: positive teacher-relationships reduced the risk of daily smoking by 48%, weekly drunkenness by 25%, and weekly cannabis use by 52%; being in a fight increased the risk of daily smoking by 54%, weekly drunkenness by 31%, and weekly cannabis use by 43%. School disengagement increased the likelihood of smoking and cannabis use among females only.

CONCLUSION

Further research should focus on public health interventions promoting positive relationships and safety at school.

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.

Protocol for a systematic review of the effects of schools and school-environment interventions on health: evidence mapping and syntheses

BACKGROUND

Schools may have important effects on students' and staff's health. Rather than treating schools merely as sites for health education, 'school-environment' interventions treat schools as settings which influence health. Evidence concerning the effects of such interventions has not been recently synthesised.

METHODS/DESIGN

Systematic review aiming to map and synthesise evidence on what theories and conceptual frameworks are most commonly used to inform school-environment interventions or explain school-level influences on health; what effects school-environment interventions have on health/health inequalities; how feasible and acceptable are school-environment interventions; what effects other school-level factors have on health; and through what processes school-level influences affect health.We will examine interventions aiming to promote health by modifying schools' physical, social or cultural environment via actions focused on school policies and practices relating to education, pastoral care and other aspects of schools beyond merely providing health education. Participants are staff and students age 4-18 years.We will review published research unrestricted by language, year or source. Searching will involve electronic databases including Embase, ERIC, PubMed, PsycInfo and Social Science Citation Index using natural-language phrases plus reference/citation checking.Stage 1 will map studies descriptively by focus and methods. Stage 2 will involve additional inclusion criteria, quality assessment and data extraction undertaken by two reviewers in parallel. Evidence will be synthesised narratively and statistically where appropriate (undertaking subgroup analyses and meta-regression and where no significant heterogeneity of effect sizes is found, pooling these to calculate a final effect size).

DISCUSSION

We anticipate: finding a large number of studies missed by previous reviews; that non-intervention studies of school effects examine a greater breadth of determinants than are addressed by intervention studies; and that intervention effect estimates are greater than for school-based health curriculum interventions without school-environment components.

Social environmental and individual factors associated with smoking among a panel of adolescent girls

This study assessed changes in the influence of social environmental and individual factors-and the interaction of these factors with time-on smoking prevalence for girls. Longitudinal panel surveys of adolescent girls (N = 921 in both 2000 and 2004) from schools in Louisiana were completed in the ninth grade (2000) and then again in the twelfth grade (2004). A fixed effects hierarchical multiple regression model assessed the relation of changes in social environmental and individual factors to smoking prevalence. Increases in smoking prevalence over time among adolescent girls were associated with their perceptions of themselves as overweight and perceiving low risk associated with smoking. Increases in smoking prevalence over time were also associated with having friends who smoked, perceptions of friends' approval of smoking, having family members who smoked, and having monetary discretionary spending. Having friends who smoked was more strongly associated with smoking in the twelfth grade than in the ninth grade. While more black adolescent girls smoked than did white girls in the ninth grade, by the twelfth grade, more white adolescents girls smoked than did black girls. Interventions that target adolescent girls should consider the temporal variability of individual and social environmental factors.

Student drug testing in the context of positive and negative school climates: results from a national survey

Positive school climates and student drug testing have been separately proposed as strategies to reduce student substance use in high schools. However, the effects of drug testing programs may depend on the favorability of school climates. This study examined the association between school drug testing programs and student substance use in schools with different climates. The analysis was based on a nationally representative sample of 943 high school students (48% female) ranging from 14 to 19 years of age (62% identifying as white, 18% Hispanic, 13% African American, and 7% in other categories). Results showed that both male and female students in schools with positive climates reported lower levels of personal substance use. Drug testing was associated with lower levels of personal substance use in positive school climates, but only for female students. There was no relationship between drug testing and male students' substance use. The results are discussed in terms of the importance of considering school climates before implementing drug-testing programs in high schools.

Addiction as a systems failure: focus on adolescence and smoking

OBJECTIVE

Scientific advances in the field of addiction have forever debunked the notion that addiction reflects a character flaw under voluntary control, demonstrating instead that it is a bona fide disease of the brain. The aim of this review is to go beyond this consensus understanding and explore the most current evidence regarding the vast number of genetic, developmental, and environmental factors whose complex interactions modulate addiction risk and trajectory.

METHOD

Focusing on childhood and adolescent smoking as a paradigm, we review the important risk factors for the development of addictions, starting at the level of genetics and closing with a focus on sociocultural and policy factors.

RESULTS

A critical review of the pertinent literature provides a detailed view of the cumulative power of risk and protection factors across different phenomenological levels to modulate the risk of undesirable outcomes, particularly for young people. The result represents a compelling argument for the need to engage in comprehensive, multilevel approaches to promoting health.

CONCLUSIONS

Today, the field of medicine understands more about disease than about health; however it need not be that way. The view of drug addiction as a systems failure should help refocus our general approach to developing dynamic models and early comprehensive interventions that optimize the ways in which we prevent and treat a complex, developmental disorder such as drug addiction.

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.

Tobacco prevention education in schools for the deaf: the faculty perspective

We report results of a survey of tobacco education practices and perspectives among faculty at four Schools for the Deaf participating in the trial of a tailored tobacco prevention curriculum. Few faculty (20.4%) included tobacco use among the three most important health problems facing their students, although 88.8% considered tobacco education to be worthwhile. Despite perceived unmet needs among their students, classroom or school-wide attention to tobacco prevention was limited. Only 13.9% reported delivering tobacco programming in the prior year, most often reporting lack of deaf-friendly curriculum and materials (60.9%), time (47.8%), and training (43.5%) as barriers to program delivery. Perceptions, attitudes, and institutional issues, including lack of tailored curriculum, were seen as contributing to the limited focus on this important health problem.

The Role of the Self in Smoking Initiation and Smoking Cessation: A Review and Blueprint for Research at the Intersection of Social-Cognition and Health

The self-concept is recognized as important to both smoking initiation and cessation. However, most of extant research has viewed the self-concept as a static, monolithic construct. It has not drawn on contemporary social-cognitive theories of the self-concept, which view the self-concept as a dynamic, multi-faceted cognitive structure that regulates behavior in context. This paper discusses a contemporary social cognitive framework that can be used to understand the role of the self-concept in smoking.

Pilot multimethod trial of a school-ethos intervention to reduce substance use: building hypotheses about upstream pathways to prevention

PURPOSE

Interventions to improve school ethos can reduce substance use but "upstream" causal pathways relating to implementation and school-level changes are uncertain. We use qualitative and quantitative data from a pilot trial to build hypotheses regarding these.

METHODS

The Healthy School Ethos intervention involved two schools being provided with facilitation, training, and funding to plan and implement actions (some mandatory and some locally determined) to improve school ethos over one year. The evaluation involved a pilot-trial with two intervention and two comparison schools; semi-structured interviews with facilitators, staff, and students; and baseline and follow-up surveys with students aged 11 to 12 years.

RESULTS

Student accounts linked participation in planning or delivering intervention activities with improved self-regard and relationships with staff and other students. Some activities such as re-writing school rules involved broad participation. Students in receipt of actions such as peer-mediation or motivational sessions reported benefits such as improved safety and relationships. Some student accounts linked improved self-regard and relationships with increased engagement and aspirations, and reduced substance use. At 9-month follow-up, students in intervention schools reported less hurting and teasing of others and feeling unsafe at school. Other outcomes suggested intervention benefits but were not significant.

CONCLUSIONS

School-ethos interventions may reduce substance use through upstream pathways involving the aforementioned factors. Future phase-III trials should quantitatively model the extent to which these mediate intervention effects.

Evaluating depressive symptom interactions on adolescent smoking prevention program mediators: a mediated moderation analysis

INTRODUCTION

Smoking prevention interventions have been shown to be effective in reducing smoking prevalence in the United States. Further work is needed to address smoking in China, where over one third of the world's current smokers reside. China, with more than 60% of the male population being smokers, also presents a unique opportunity to test cognitive processes involved in depression, social influences, and smoking. Adolescents at-risk for developing depression may process social information differently from low-risk counterparts.

METHODS

The Wuhan Smoking Prevention Trial was a school-based longitudinal randomized controlled trial aimed at preventing initiation and escalation of adolescent smoking behaviors. Thousand three hundred and ninety-one male seventh-grade students were assessed with a 200-item paper-and-pencil baseline survey, and it was readministered 1 year later following program implementation.

RESULTS

Friend prevalence estimates were significantly higher among 30-day smokers and among those at highest risk for depression symptoms. The program appeared to be successful in changing the perception of friend smoking prevalence only among adolescents with a comorbidity of high scores of depression symptoms and who have experimented previously with smoking. This Program x Comorbidity interaction on perceived friend smoking prevalence was significant in predicting 30-day smoking 1 year after program implementation.

CONCLUSIONS

This study provides evidence that those adolescents with high levels of depressive symptoms may be more sensitive to social influences associated with smoking prevalence. Individual Disposition x Social Environmental Influences may be important when developing future effective prevention programming.

Stacked Deck: an effective, school-based program for the prevention of problem gambling

School-based prevention programs are an important component of problem gambling prevention, but empirically effective programs are lacking. Stacked Deck is a set of 5-6 interactive lessons that teach about the history of gambling; the true odds and "house edge"; gambling fallacies; signs, risk factors, and causes of problem gambling; and skills for good decision making and problem solving. An overriding theme of the program is to approach life as a "smart gambler" by determining the odds and weighing the pros versus cons of your actions. A total of 949 grade 9-12 students in 10 schools throughout southern Alberta received the program and completed baseline and follow-up measures. These students were compared to 291 students in 4 control schools. Four months after receiving the program, students in the intervention group had significantly more negative attitudes toward gambling, improved knowledge about gambling and problem gambling, improved resistance to gambling fallacies, improved decision making and problem solving, decreased gambling frequency, and decreased rates of problem gambling. There was no change in involvement in high risk activities or money lost gambling. These results indicate that Stacked Deck is a promising curriculum for the prevention of problem gambling.

The effectiveness of a school-based substance abuse prevention program: 18-month follow-up of the EU-Dap cluster randomized controlled trial

AIM

To evaluate the effectiveness of a school-based substance abuse prevention program developed in the EU-Dap study (EUropean Drug Addiction Prevention trial).

MATERIALS AND METHODS

Cluster Randomized Controlled Trial. Seven European countries participated in the study; 170 schools (7079 pupils 12-14 years of age) were randomly assigned to one of three experimental conditions or to a control condition during the school year 2004/2005. The program consisted of a 12-h curriculum based on a comprehensive social influence approach. A pre-test survey assessing past and current substance use was conducted before the implementation of the program, while a post-test survey was carried out about 18 months after the pre-test. The association between program condition and change in substance use at post-test was expressed as adjusted prevalence odds ratio (POR), estimated by multilevel regression models.

RESULTS

Persisting beneficial program effects were found for episodes of drunkenness (any, POR=0.80; 0.67-0.97; frequent, POR=0.62; 0.47-0.81) and for frequent cannabis use in the past 30 days (POR=0.74; 0.53-1.00), whereas daily cigarette smoking was not affected by the program as it was at the short-term follow-up. Baseline non-smokers that participated in the program progressed in tobacco consumption to a lower extent than those in the control condition, but no difference was detected in the proportion of quitters or reducers among baseline daily smokers.

CONCLUSION

The experimental evaluation of an innovative school curriculum based on a comprehensive social influence approach, indicated persistent positive effects over 18 months for alcohol abuse and for cannabis use, but not for cigarette smoking.

Two-year effects of a school-based prevention programme on adolescent cigarette smoking in Guangzhou, China: a cluster randomized trial

BACKGROUND

The prevalence of adolescent smoking has been increasing rapidly in China. Theory-based smoking prevention programmes in schools may be an effective approach in preventing smoking among Chinese adolescents.

METHODS

A school-level cluster randomized controlled trial was conducted among 7th and 8th grade students (N = 2343) in four junior high schools in southern China during 2004-06. The theory-based, multi-level intervention was compared with the standard health curriculum. Outcome measures comprised changes in students' smoking-related knowledge, attitudes and behaviour.

RESULTS

The mean knowledge scores from baseline to the 1- and 2-year follow-ups increased more in the intervention group than in the control group, whereas there was little change in attitude scores. At the 1-year follow-up (the total sample), the interventions reduced the probability of baseline experimental smokers' escalating to regular smoker [7.9 vs 18.3%; adjusted odds ratio (OR) 0.34, 95% confidence interval (CI) 0.12-0.97, P = 0.043], but did not reduce the probability of baseline non-smokers' initiating smoking (7.9 vs 10.6%; adjusted OR 0.86, 95% CI 0.54-1.38, P = 0.538). At the 2-year follow-up (only 7th grade students), similar proportions of baseline non-smokers initiated smoking in the intervention group and the control group (13.5 vs 13.1%), while a possibly lower proportion of baseline experimental smokers escalated to regular smoking in the intervention group than the control group (22.6 vs 40.0%; adjusted OR 0.43, 95% CI 0.12-1.57, P = 0.199).

CONCLUSIONS

This multi-level intervention programme had a moderate effect on inhibiting the escalation from experimental to regular smoking among Chinese adolescents, but had little effect on the initiation of smoking. The programme improved adolescents' smoking-related knowledge, but did not change their attitudes towards smoking.

A framework for public health action: the health impact pyramid

A 5-tier pyramid best describes the impact of different types of public health interventions and provides a framework to improve health. At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socioeconomic determinants of health. In ascending order are interventions that change the context to make individuals' default decisions healthy, clinical interventions that require limited contact but confer long-term protection, ongoing direct clinical care, and health education and counseling. Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort. Implementing interventions at each of the levels can achieve the maximum possible sustained public health benefit.

Intervention effects on tobacco use in Arab and non-Arab American adolescents

A quasi-experimental design was used to test a modified Project Towards No Tobacco (TNT) use program on cigarette smoking in 380 Arab American and 236 non-Arab American 9th graders in the Midwest. Tenth grade Non-Arab American students given the intervention as 9th graders were 23% less likely to experiment (Odds Ratio=1.31, 95% CI: 1.05, 1.64) or to have smoked cigarettes in the past 30 days (Odd Ratio=1.43 times, 95% CI: 1.03, 2.01) compared to Arab American youth. Arab American students reported greater experimentation with water pipe smoking than cigarettes (38% vs. 22%), and more current (16% vs. 6%) and regular (7% vs. 3%) use of water pipes than cigarettes, respectively. The intervention designed to focus on cigarette smoking had non-significant effects on water pipe smoking. These findings provide support for a school-based intervention revised to focus on prevention as well as cessation and to be culturally consistent. They also call for further research and intervention tailoring to address the problem of water pipe smoking in a growing Arab American adolescent population.

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

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

Targeting high-risk neighborhoods for tobacco prevention education in schools

OBJECTIVES

We examined whether individual and neighborhood characteristics associated with smoking were also predictive of exposure to smoking prevention education in schools, to determine whether education programs were targeted appropriately to reach neighborhoods with the greatest need.

METHODS

We merged data from 2 sources-the 2005 Virginia Youth Tobacco Survey (n=2208) and the Census 2000 School District Demographics Project-and used binary multilevel models with random effects to determine whether the same demographic characteristics and neighborhood characteristics predicted both adolescent smoking and exposure to prevention programs.

RESULTS

We found that although light, medium, and heavy smoking rates were higher in neighborhoods of lower socioeconomic status (relative risk ratio=1.49, 1.36, and 1.65, respectively), prevention programs were less available in those areas (odds ratio=0.82).

CONCLUSIONS

Our study indicates that school prevention programs are not being effectively targeted and that more effective ways to reach high-risk and disadvantaged neighborhoods are needed.

TABADO: "evaluation of a smoking cessation program among adolescents in vocational training centers": study protocol

BACKGROUND

Most of the efforts to reduce teenagers' tobacco addiction have focused on smoking prevention and little on smoking cessation. A smoking cessation program (TABADO study), associating pharmacologic and cognitive-behavioural strategy, on a particularly vulnerable population (vocational trainees), was developed. This study aims to evaluate the efficacy of the program which was offered to all smokers in a population aged 15 to 20 years in Vocational Training Centers (VTC). This paper presents the TABADO study protocol.

METHODS

The study is quasi-experimental, prospective, evaluative and comparative and takes place during the 2 years of vocational training. The final population will be composed of 2000 trainees entering a VTC in Lorraine, France, during the 2008-2009 period. The intervention group (1000 trainees) benefited from the TABADO program while no specific intervention took place in the "control" group (1000 trainees) other than the treatment and education services usually available. Our primary outcome will be the tobacco abstinence rate at 12 months.

DISCUSSION

If the program proves effective, it will be a new tool in the action against smoking in populations that have been seldom targeted until now. In addition, the approach could be expanded to other young subjects from socially disadvantaged backgrounds in the context of a public health policy against smoking among adolescents.

TRIAL REGISTRATION

Clinical trial identification number is NTC00973570.

Contribution of parental and school personnel smoking to health risk behaviours among Finnish adolescents

BACKGROUND

This study compared parental smoking with school personnel smoking in relation to adolescents' smoking behaviours, alcohol use, and illicit drug use.

METHODS

A cross-sectional survey for 24,379 adolescents was linked to a survey for 1946 school employees in 136 Finnish schools in 2004-2005. Surveys included smoking prevalence reported by school staff, adolescents' reports of school staff and parental smoking, adolescents' own smoking behaviours, alcohol use, and illicit drug use. Multilevel analyses were adjusted for individual and school-level confounding factors.

RESULTS

Parental smoking was associated with all health risk behaviours among both sexes (risk range 1.39 to 1.95 for other outcomes; Odds Ratio OR for smoking cessation 0.64, 95% Confidence Interval CI: 0.57, 0.72 among boys, 0.72; 0.64, 0.81 among girls). Among boys, high vs. low smoking prevalence among school personnel was associated with higher probability of smoking (OR 1.19; 95% CI 1.01,1.41), higher frequency of smoking during school time (Cumulative Odds Ratio COR 1.81; 95% CI 1.32, 2.48), frequent alcohol use (OR 1.23; 95% CI 1.01, 1.50), illicit drug use (OR 1.40; 95% CI 1.16, 1.69), and higher odds of reporting adults smoking at school (COR 1.51; 95% CI 1.09, 2.09). Among girls, high smoking prevalence among school personnel was related to higher odds of smoking (OR 1.18; 95% CI 1.02, 1.37) and lower odds of smoking cessation (OR 0.84; 95% CI 0.72, 0.99).

CONCLUSION

Parental smoking and school personnel smoking are both associated with adolescents' health risk behaviours but the association of parental smoking seems to be stronger.

How confident should we be that smoking cessation treatments work?

AIM

To determine (i) the concordance among recent meta-analyses about which treatments for smoking cessation are efficacious; (ii) the similarity of odds ratios (ORs) across meta-analyses; and (iii) among the validated treatments, the proportion of studies that found higher quit rates.

METHODS

Computerized literature search for meta-analyses during the last 5 years in PubMed and PsychInfo. Data were extracted from summary tables of overall effect of validated treatments.

RESULTS

Fourteen meta-analyses agreed 100% on the presence/absence of efficacy of 17 proven treatments. The ORs differed by <0.5 in 72/76 of the comparisons of meta-analyses. Among 37 comparisons in 33 comparisons, >85% of the studies reported numerical superiority for the active treatment.

CONCLUSIONS

The efficacy of treatments for smoking cessation are extremely reliable. This argues for inclusion of treatment as an essential feature of tobacco control and clinical practice and argues for reimbursement of smoking cessation treatments on a par with other medical and behavioral disorders.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.

Effective elements of school health promotion across behavioral domains: a systematic review of reviews

BACKGROUND

Most school health education programs focus on a single behavioral domain. Integrative programs that address multiple behaviors may be more efficient, but only if the elements of change are similar for these behaviors. The objective of this study was to examine which effective elements of school health education are similar across three particular behavioral domains.

METHODS

A systematic review of reviews of the effectiveness of school-based health promotion programs was conducted for the domains of substance abuse, sexual behavior, and nutrition. The literature search spanned the time period between 1995 and October 2006 and included three databases, websites of review centers and backward search. Fifty-five reviews and meta-analyses met predetermined relevance and publication criteria and were included. Data was extracted by one reviewer and checked by a second reviewer. A standardized data extraction form was used, with detailed attention to effective elements pertaining to program goals, development, content, methods, facilitator, components and intensity. Two assessors rated the quality of reviews as strong, moderate or weak. We included only strong and moderate reviews in two types of analysis: one based on interpretation of conflicting results, the other on a specific vote-counting rule.

RESULTS

Thirty six reviews were rated strong, 6 moderate, and 13 weak. A multitude of effective elements was identified in the included reviews and many elements were similar for two or more domains. In both types of analysis, five elements with evidence from strong reviews were found to be similar for all three domains: use of theory; addressing social influences, especially social norms; addressing cognitive-behavioral skills; training of facilitators; and multiple components. Two additional elements had positive results in all domains with the rule-based method of analysis, but had inconclusive results in at least one domain with the interpretation-based method of analysis: parent involvement and a larger number of sessions.

CONCLUSION

Five effective elements of school health promotion were found to be similar across the three behavioral domains examined (substance abuse, sexual behavior, nutrition). An integrative program that addresses the three domains seems feasible. The five elements are primary candidates to include in programs targeting these behaviors.