Comparison of Two School-Based Smoking Prevention Programs among South African High School Students: Results of a Randomized Trial

Assessing the Feasibility of Economic Approaches to Prevent Substance Abuse Among Adolescents: Protocol for a Mixed Methods Study

BACKGROUND

Adolescent alcohol and drug use (ADU) is a significant public health challenge. Uganda, one of the poorest countries in Sub-Saharan Africa (SSA), has the second-highest rate of per capita alcohol consumption in SSA, and over one-third of Ugandan adolescents have used alcohol in their lifetime (over 50% of them engage in heavy episodic drinking). These estimates further increase in fishing villages, a key HIV-vulnerable population, where ADU is normative. However, few studies have assessed ADU among adolescents and youths living with HIV despite their increased risk for ADU and its impact on engagement in HIV care. Moreover, data on risk and resilience factors for ADU are scarce as only few studies evaluating ADU interventions in SSA have reported positive outcomes. The majority have been implemented in school settings, potentially excluding adolescents in fishing communities with high school dropout rates, and none have targeted risk factors including poverty and mental health, which are rampant among adolescents and youths living with HIV and their families, undermine their coping skills and resources, and have been associated with increased risk for ADU among them.

OBJECTIVE

We propose a mixed methods study with a sample of 200 adolescents and youths living with HIV (aged 18-24 years) seen at 6 HIV clinics in southwestern Uganda's fishing communities to (1) examine the prevalence and consequences of ADU and identify the multilevel risk and resilience factors associated with ADU among them and (2) explore the feasibility and short-term effects of an economic empowerment intervention on ADU among them.

METHODS

This study comprises four components: (1) focus group discussions (FGDs) with adolescents and youths living with HIV (n=20) and in-depth qualitative interviews with health providers (n=10) from 2 randomly selected clinics; (2) a cross-sectional survey with 200 adolescents and youths living with HIV; (3) a randomized controlled trial with a subgroup of adolescents and youths living with HIV (n=100); and (4) 2 postintervention FGD with adolescents and youths living with HIV (n=10 per group).

RESULTS

Participant recruitment for the first qualitative phase has completed. As of May 4, 2023, ten health providers from 6 clinics have been recruited, provided written consent to participate, and participated in in-depth qualitative interviews. Two FGDs was conducted with 20 adolescents and youths living with HIV from 2 clinics. Data transcription, translation, and analysis of qualitative data has commenced. The cross-sectional survey will commence shortly after and dissemination of the main study findings is targeted for 2024.

CONCLUSIONS

Our findings will advance our understanding of ADU among adolescents and youths living with HIV and inform the design of future interventions to address ADU among them.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05597865; https://clinicaltrials.gov/ct2/show/NCT05597865.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46486.

Systematic review of intervention functions, theoretical constructs and cultural adaptations of school-based smoking prevention interventions in low-income and middle-income countries

OBJECTIVE

To identify the approaches and strategies used for ensuring cultural appropriateness, intervention functions and theoretical constructs of the effective and ineffective school-based smoking prevention interventions that were implemented in low-income and middle-income countries (LMICs).

DATA SOURCES

Included MEDLINE, EMBASE, Global Health, PsycINFO, Web of Science and grey literature which were searched through August 2022 with no date limitations.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) with ≥6 months follow-up assessing the effect of school-based interventions on keeping pupils never-smokers in LMICs; published in English or Arabic.

DATA EXTRACTION AND SYNTHESIS

Intervention data were coded according to the Theoretical Domains Framework, intervention functions of Behaviour Change Wheel and cultural appropriateness features. Using narrative synthesis we identified which cultural-adaptation features, theoretical constructs and intervention functions were associated with effectiveness. Findings were mapped against the capability-motivation and opportunity model to formulate the conclusion. Risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS

We identified 11 RCTs (n=7712 never-smokers aged 11-15); of which five arms were effective and eight (four of the effective) arms had a low risk of bias in all criteria. Methodological heterogeneity in defining, measuring, assessing and presenting outcomes prohibited quantitative data synthesis. We identified nine components that characterised interventions that were effective in preventing pupils from smoking uptake. These include deep cultural adaptation; raising awareness of various smoking consequences; improving refusal skills of smoking offers and using never-smokers as role models and peer educators.

CONCLUSION

Interventions that had used deep cultural adaptation which incorporated cultural, environmental, psychological and social factors, were more likely to be effective. Effective interventions considered improving pupils' psychological capability to remain never-smokers and reducing their social and physical opportunities and reflective and automatic motivations to smoke. Future trials should use standardised measurements of smoking to allow meta-analysis in future reviews.

Adolescent health series - Alcohol, tobacco, and other drug use among adolescents in sub-Saharan Africa: A narrative review

Alcohol, tobacco, and other drug (ATOD) use by adolescents are major contributors to death and disability in sub-Saharan Africa (SSA). This paper reviews the extent of adolescents' ATOD use, risk and protective factors, and studies evaluating prevention interventions for adolescents in SSA. It also describes the harms associated with adolescents' ATOD use in SSA, which mainly include interpersonal violence, sexual risk behaviours, and negative academic outcomes. We use the socio-ecological model as our framework for understanding ATOD use risk and protective factors at individual, interpersonal, peer/school, and societal/structural levels. We used two strategies to find literature evaluating ATOD interventions for adolescents in SSA: (a) we sought systematic reviews of adolescent ATOD interventions in SSA covering the period 2000-2020; and (b) we used a comprehensive evidence review strategy and searched for studies that had evaluated ATOD interventions in all SSA countries between 2000 and 2020. Only two community interventions (a brief intervention and an HIV prevention intervention), out of four that were identified, were partially effective in reducing adolescent ATOD. Furthermore, only one school-based intervention (HealthWise), out of six that we uncovered, had any effect on ATOD use among adolescents. Possible reasons why many interventions were not effective include methodological limitations, involvement of non-evidence-based education-only approaches in some studies, and shortcomings in adaptations of evidence-based interventions. The scale of ATOD and related problems is disproportionate to the number of evaluated interventions to address them in SSA. More ATOD interventions need to be developed and evaluated in well-powered and well-designed studies.

Substance use prevention interventions for children and young people in Sub-Saharan Africa: A systematic review

BACKGROUND

Different techniques and approaches have been used for substance use prevention worldwide. No reviews of prevention interventions in Africa exist; hence this study aimed to systematically review interventions undertaken in Sub-Saharan Africa to prevent substance use in children and young people.

METHODS

MEDLINE, EMBASE, Cochrane Central, CAB, PsycINFO, CINAHL, SCOPUS, ERIC, and Web of Science databases were searched. Studies were included if they evaluated a substance use prevention intervention for children and young people in a Sub-Saharan African Country between 2000 and 2020. A narrative synthesis was used to explore and describe the data.

RESULTS

Eighteen studies, mostly from South Africa, were included. Most (10/18) of the interventions were school-based. Only two of the included studies were considered having a strong quality concerning the risk of bias, and some studies poorly reported the interventions. School-based interventions, although successful in improving knowledge, had little or no effects on substance use. Overall, most studies that reported a statistically significant reduction in substance use-related outcomes were brief interventions, individual-focused, and involved participants who were already exposed to substance use. These were mostly delivered by trained professionals using motivational interviewing or cognitive behavioural therapy or both.

CONCLUSION

School-based programs present an opportunity for substance use prevention efforts in the Sub-Saharan region in Africa. Such programs may benefit from an improved focus on individual students. There is a need for improving the quality of design, implementation, and reporting of substance use interventions within the region.

Evaluation of a multimedia youth anti-smoking and girls' empowerment campaign: SKY Girls Ghana

BACKGROUND

Given the long-term health effects of smoking during adolescence and the substantial role that tobacco-related morbidity and mortality play in the global burden of disease, there is a worldwide need to design and implement effective youth-focused smoking prevention interventions. While smoking prevention interventions that focus on both social competence and social influence have been successful in preventing smoking uptake among adolescents in developed countries, their effectiveness in developing countries has not yet been clearly demonstrated. SKY Girls is a multimedia, empowerment and anti-smoking program aimed at 13-16-year old girls in Accra, Ghana. The program uses school and community-based events, a magazine, movies, a radio program, social media and other promotional activities to stimulate normative and behavioral change.

METHODS

This study uses pre/post longitudinal data on 2625 girls collected from an interviewer-administered questionnaire. A quasi-experimental matched design was used, incorporating comparison cities with limited or no exposure to SKY Girls (Teshie, Kumasi and Sunyani). Fixed-effects modeling with inverse probability weighting was used to obtain doubly robust estimators and measure the causal influence of SKY Girls on a set of 15 outcome indicators.

RESULTS

Results indicate that living and studying in the intervention city was associated with an 11.4 percentage point (pp) (95% CI [2.1, 20.7]) increase in the proportion of girls perceiving support outside their families; an 11.7 pp. decrease (95% CI [- 20.8, - 2.6]) in girls' perception of pressure to smoke cigarettes; a 12.3 pp. increase (95% CI [2.1, 20.7]) in the proportion of girls who had conversations with friends about smoking; an 11.7 pp. increase (95% CI [3.8, 20.8]) in their perceived ability to make choices about what they like and do not like, and 20.3 pp. (95% CI [- 28.4, - 12.2]) and 12.1 pp. (95% CI [- 20.7, - 3.5]) reductions in the proportion agreeing with the idea that peers can justify smoking shisha and cigarettes, respectively. An analysis of the dose-effect associations between exposure to multiple campaign components and desired outcomes was included and discussed.

CONCLUSION

The study demonstrates the effectiveness of a multimedia campaign to increase perceived support, empowerment and improve decision-making among adolescent girls in a developing country.

The Effect of a "Class Smoke Free Pledge" on Breath Carbon Monoxide in Arabic Male Adolescents

Introduction

Arabic male adolescents have a high smoking prevalence. Introduction of "Class smoke-free" pledges have been successful amongst European adolescents but have not been evaluated using objective valid measures. We tested the impact of adding a smoke free pledge strategy to a proven peer-led asthma and smoking prevention program on breath carbon monoxide level (BCO) in male high-school students in Jordan.

Methods

We enrolled male students from four high-schools in Irbid, Jordan. Schools were randomly assigned to receive either TAJ (Triple A in Jordan, n = 218) or TAJ-Plus (with added class smoke-free pledge, n = 215). We hypothesized that students receiving TAJ-Plus would have greater reduction in BCO levels than those only receiving the TAJ intervention. Asthma and smoking status were assessed by self-administered questionnaires. Smoking outcomes were collected using a BCO Monitor.

Results

Both groups had significant reductions in BCO levels post-intervention (p < .0001), however, decreases were greater in TAJ-Plus group (3.9 ± 0.2 vs. 4.8 ± 0.2, p < .0001). Intervention effects on BCO over time did not vary by smoking status (p = .085), asthma status (p = .602), or a combination of the two (p = .702).

Conclusions

An added smoke-free pledge strategy to a proven peer-led asthma education program appears to be a promising approach to motivate adolescents to abstain from smoking in Jordan. Future research is required to determine if these results can be extended to Jordanian adolescent females.

Implications

A commitment by students via a "class smoke-free" pledge can be an added incentive to motivate adolescents in Arabic-speaking countries to abstain from smoking. Social influence approaches in schools can be useful in countering the aggressive tobacco marketing campaigns targeting Jordanian and other Arabic-speaking youth. The combination of "class smoke-free" pledges and an evidence-based peer-led asthma and smoking education can be implemented in schools to influence adolescents with asthma to abstain from smoking.

Evaluation of an infused alcohol and drug prevention programme

Purpose

Alcohol, tobacco, marijuana and other drugs use typically increases in prevalence and frequency during middle and late adolescence. School health instruction often focusses on providing facts and rarely provides tools for addressing the psychosocial risk factors needed to prevent substance use. The purpose of this paper is to report about the effectiveness of a prevention programme delivered in US high school health classes. The intervention augments typical instruction by providing teachers with activities that can be infused in their daily teaching.

Design/methodology/approach

In total, 26 schools were randomly assigned to receive the intervention or serve as controls. Pupils were pretested near the beginning of the school year, posttest near the end of the school year and administered a final test near the beginning of the following school year. Teachers in treatment schools were provided with activities designed to target psychosocial variables known to mediate substance use onset and self-initiated cessation. These include normative beliefs, intentionality, lifestyle incongruence, beliefs about consequences of use, peer pressure resistance skills, decision-making skills, goal setting skills and stress management skills.

Findings

Hierarchical modelling analytic strategies revealed the intervention to have definable positive impacts on alcohol and cigarette use. Moreover, the intervention had strongest effects on alcohol and cigarette use among pupils who were identified at pretest as being lower-than-average risk.

Originality/value

This research provides support for providing teachers with a strategy for preventing alcohol, tobacco and other drugs that can be used in a flexible manner to augment the instruction they are already mandated to provide.

Systematic review of school tobacco prevention programs in African countries from 2000 to 2016

BACKGROUND

The World Bank has reported that global smoking rates declined from 2000 to 2012, with the only exception found in males in Sub-Saharan Africa. Sub-Saharan Africa is considered to be in stage one of the tobacco epidemic continuum. To address this problem, school-based programs for smoking prevention are considered cost-effective and promising. Since tobacco prevention programs are influenced by social competence or customs of each country, tobacco prevention programs that have success in Western countries are not always effective in African countries. Therefore, the current study systematically reviewed relevant literature to examine the effects of these types of programs in African countries.

METHOD

Online bibliographic databases and a hand search were used. We included the studies that examined the impact of school-based programs on preventing tobacco use in Africa from 2000 to 2016.

RESULTS

Six articles were selected. Four were conducted in South Africa and two were performed in Nigeria. Four programs were systematically incorporated into annual curriculums, targeting 8th to 9th graders, while the other two were temporary programs. All programs were based on the hypothesis that providing knowledge and/or social skills against smoking would be helpful. All studies utilized smoking or polydrug use rates to compare outcomes before/after intervention. There were no significant differences between intervention and control groups in three studies, with the other three demonstrating only partial effectiveness. Additionally, three studies also examined change of knowledge/attitudes towards smoking as an outcome. Two of these showed significant differences between groups.

CONCLUSION

All RCTs studies showed no significant change of smoking-rate by the intervention. The effectiveness of intervention was observed only in some sub-group. The cohort studies showed school-based interventions may be effective in improving knowledge and attitudes about smoking. However, they reported no significant change of smoking-rate by the intervention.

Systematic review of universal school-based 'resilience' interventions targeting adolescent tobacco, alcohol or illicit substance use: A meta-analysis

Universal school-based interventions that address adolescent 'resilience' may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based 'resilience' interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994-2015) of randomised controlled trials including participants aged 5-18years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based 'resilience' intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n=15, alcohol: n=17, illicit: n=11). An overall intervention effect was found for binary measures of illicit substance use (n=10; OR: 0.78, 95%CI: 0.6-0.93, p=0.007,Tau²=0.0, I²=0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address 'resilience' protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

Multilevel analysis of school anti-smoking education and current cigarette use among South African students

INTRODUCTION

South Africa (SA) implemented the Global Youth Tobacco Survey (GYTS) four times between 1999 and 2011. Data from the four surveys indicated that downward trends in cigarette use among students may have stalled. Understanding the effect of school anti-smoking education on current smoking among students within schools and variability across schools may provide important insights into policies aimed at preventing or reducing tobacco use among students. The objective was to assess the student- and school-level effects of students' exposure to school anti-smoking education on current cigarette use among the study population using the most recent wave of GYTS data in SA (2011).

METHODS

An analytic sample of students 13-15 years of age was selected (n=3,068) from the SA GYTS 2011. A taxonomy of two-level logistic regression models was fit to assess the relationship of various tobacco use, control, and exposure predictor variables on current cigarette smoking among the study population.

RESULTS

At the student-level in the full model, secondhand smoke (SHS) exposure, peer smoking, and ownership of a promotional item were significantly associated with higher risk of current smoking. At the school-level in the full model, average exposure to peer smoking was associated with significant increases in the prevalence of current cigarette use, while average family anti-smoking education was significantly associated with decreases in the outcome variable. School anti-smoking education was not a statistically significant predictor at the student- or school-levels.

CONCLUSION

in this study, exposure to school anti-smoking education had no association with current cigarette smoking among the study population. Consistent with previous studies, having peers that smoked was highly associated with a student being a current smoker. Interestingly, at the school-level in the multilevel analysis, schools with higher rates of average family anti-smoking education had lower prevalence of current smoking. This finding has potential implications for tobacco control in SA, particularly if the school-level, family-centered protective effect can be operationalized as a prevention tool in the country's tobacco control program.

Harm reduction for young people who use prescription opioids extra-medically: Obstacles and opportunities

Extra-medical prescription opioid (EMPO) use - intentional use without a prescription or outside of prescribed parameters - is a public health crisis in the United States and around the world. Epidemiological evidence suggests that the prevalence of EMPO use and adverse sequelae, including opioid overdose and hepatitis C infection, are elevated among people aged 18-25. Despite these preventable health risks, many harm reduction interventions are underutilized by, or inaccessible to, EMPO-using youth. In this commentary, we describe key harm reduction strategies for young people who use prescription opioids. We examine individual, social, and policy-level barriers to the implementation of evidence-based approaches that address EMPO use and related harms among young people. We highlight the need for expanded services and new interventions to engage this diverse and heterogeneous at-risk population. A combination of medical, social, and structural harm reduction interventions are recommended. Furthermore, research to inform strategies that mitigate particularly high-risk practices (e.g., polysubstance use) is warranted. Finally, we discuss how the meaningful involvement of youth in the implementation of harm reduction strategies is a critical component of the public health response to the prescription opioid epidemic.

Health Promotion Methods for Smoking Prevention and Cessation: A Comprehensive Review of Effectiveness and the Way Forward

Tobacco smoking is one of the greatest causes of mortality in the world, responsible for over 5 million deaths per annum. The prevalence of smoking is over 1 billion people, with the majority coming from low or middle income countries. Yet, the incidence of smoking varies vastly between many countries. Some countries have been able to decline the smoking and tobacco related morbidity and mortality through the introduction of health promotion initiatives and effective policies in order to combat tobacco usage. However, on the other hand, in some countries, the incidence of smoking is increasing still further. With the growing body of evidence of detriment of tobacco to health, many control policies have been implemented as health promotion actions. Such methods include taxation of smoking, mass advertising campaigns in the media, peer education programs, community mobilization, motivational interviewing, health warnings on tobacco products, marketing restrictions, and banning smoking in public places. However, the review of the effectiveness of various health promotion methods used for smoking prevention and cessation is lacking. Therefore, the aim of this review is to identify and critically review the effectiveness of health promotion methods used for smoking prevention and cessation. All available studies and reports published were considered. Searches were conducted using PubMed, MEDLINE, Ovid, Karger, ProQuest, Sage Journals, Science Direct, Springer, Taylor and Francis, EMBASE, CINAHL, and Cochrane and Wiley Online Library. Various relevant search terms and keywords were used. After considering the inclusion and exclusion criteria, we selected 23 articles for the present review.

Six-months follow-up of a cluster randomized trial of school-based smoking prevention education programs in Aceh, Indonesia

BACKGROUND

Smoking prevention programs have been taught in schools to reduce the high smoking prevalence and its related problems among adolescent populations. Although short-term benefits have been observed, the long-term effectiveness of such programs appear to be inconsistent. This study aims at investigating the long-term impact of both health and Islamic focused interventions amongst students in Indonesia.

METHODS

At 6 months after completion of the interventions, 427 of the original 447 participants (control group = 128, intervention groups = 299) from a school-based cluster randomized control trial were re-assessed for their smoking knowledge, attitudes, intentions and behaviours using a self-report questionnaire. Data was analyzed according to the study's 2 × 2 factorial design with adjustment for baseline scores, school and classroom clustering effects and multiple comparisons.

RESULTS

Compared to the control group, significant long term effects were found for the health-based intervention program in improved health (β = 4.3 ± 0.4, p < 0.001), Islamic (β = 1.1 ± 0.4, p = 0.01) knowledge and a reduction of smoking attitudes (β = -11.5 ± 1.8, p < 0.001). For the Islamic-based intervention programs there was an improvement of health (β = 3.7 ± 0.4, p < 0.001) and Islamic (β = 2.2 ± 0.5, p < 0.001) knowledge and a reduction towards smoking attitude (β = -6.0 ± 1.9, p < 0.01) and smoking behaviors in the past month (OR = 0.1, 95 % CI = 0.0-0.8, p = 0.03). The effects were greater but less than additive in the combined group for health (β = -3.2 ± 0.9, p < 0.001 for interaction) and Islamic knowledge (β = -2.3 ± 0.9, p = 0.01 for interaction) but were additive for smoking attitudes (β = 6.1 ± 3.2, p = 0.07 for interaction). No significant effects on smoking intentions were observed at 6 months follow-up in the health or Islamic-based intervention programs.

CONCLUSION

School-based programs can provide long term benefits on Indonesian adolescents' smoking knowledge and attitudes. Tailoring program intervention components with participants' religious background might maximise program effectiveness. A larger and more encompassing study is now required to confirm the effectiveness of this new Indonesia culturally-based program. Adolescents in similar areas might also benefit from this type of school-based smoking cessation program.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry, ACTRN12612001070820.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42012002322.

Effectiveness of school-based smoking prevention curricula: systematic review and meta-analysis

OBJECTIVE

To assess effectiveness of school-based smoking prevention curricula keeping children never-smokers.

DESIGN

Systematic review, meta-analysis.

DATA

MEDLINE (1966+), EMBASE (1974+), Cinahl, PsycINFO (1967+), ERIC (1982+), Cochrane CENTRAL, Health Star, Dissertation Abstracts, conference proceedings.

DATA SYNTHESIS

pooled analyses, fixed-effects models, adjusted ORs. Risk of bias assessed with Cochrane Risk of Bias tool.

SETTING

50 randomised controlled trials (RCTs) of school-based smoking curricula.

PARTICIPANTS

Never-smokers age 5-18 (n=143,495); follow-up ≥6 months; all countries; no date/language limitations.

INTERVENTIONS

Information, social influences, social competence, combined social influences/competence and multimodal curricula.

OUTCOME MEASURE

Remaining a never-smoker at follow-up.

RESULTS

Pooling all curricula, trials with follow-up ≤1 year showed no statistically significant differences compared with controls (OR 0.91 (0.82 to 1.01)), though trials of combined social competence/social influences curricula had a significant effect on smoking prevention (7 trials, OR 0.59 (95% CI 0.41 to 0.85)). Pooling all trials with longest follow-up showed an overall significant effect in favour of the interventions (OR 0.88 (0.82 to 0.95)), as did the social competence (OR 0.65 (0.43 to 0.96)) and combined social competence/social influences curricula (OR 0.60 (0.43 to 0.83)). No effect for information, social influences or multimodal curricula. Principal findings were not sensitive to inclusion of booster sessions in curricula or to whether they were peer-led or adult-led. Differentiation into tobacco-only or multifocal curricula had a similar effect on the primary findings. Few trials assessed outcomes by gender: there were significant effects for females at both follow-up periods, but not for males.

CONCLUSIONS

RCTs of baseline never-smokers at longest follow-up found an overall significant effect with average 12% reduction in starting smoking compared with controls, but no effect for all trials pooled at ≤1 year. However, combined social competence/social influences curricula showed a significant effect at both follow-up periods.

SYSTEMATIC REVIEW REGISTRATION

Cochrane Tobacco Review Group CD001293.

Enhancing the Emotional and Social Skills of the Youth to Promote their Wellbeing and Positive Development: A Systematic Review of Universal School-based Randomized Controlled Trials

Background:

The acquisition of social and emotional skills is associated with positive youth development, character education, healthy lifestyle behaviours, reduction in depression and anxiety, conduct disorders, violence, bullying, conflict, and anger. School-based interventions aimed to enhance these skills go beyond a problem-focused approach to embrace a more positive view of health; they could also improve the youth’s wellbeing.

Aim:

To describe the main features and to establish the effectiveness of universal school-based RCTs for children and the youth, aimed to promote their psychosocial wellbeing, positive development, healthy lifestyle behaviours and/or academic performance by improving their emotional and social skills.

Methods:

Systematic review by searching for relevant papers in PubMed/Medline with the following key words: “mental health” OR “wellbeing” OR “health promotion” OR “emotional learning” OR “social learning” OR “emotional and social learning” OR “positive youth development” OR “life skills” OR “life skills training” AND “school”. Interval was set from January 2000 to April 2014.

Results:

1,984 papers were identified through the search. Out of them 22 RCTs were included. While most interventions were characterized by a whole-school approach and SAFE practices, few studies only used standardized measures to assess outcomes, or had collected follow-up data after ≥ 6 months. The results of all these trials were examined and discussed.

Conclusion:

Universal school-based RCTs to enhance emotional and social skills showed controversial findings, due to some methodological issues mainly. Nevertheless they show promising outcomes that are relatively far-reaching for children and youth wellbeing and therefore are important in the real world.

Universal school-based prevention for illicit drug use

BACKGROUND

Drug addiction is a chronic, relapsing disease. Primary interventions should aim to reduce first use or to prevent the transition from experimental use to addiction. School is the appropriate setting for preventive interventions.

OBJECTIVES

To evaluate the effectiveness of universal school-based interventions in reducing drug use compared to usual curricular activities or no intervention.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group's Trials Register (September 2013), the Cochrane Central Register of Controlled Trials (2013, Issue 9), PubMed (1966 to September 2013), EMBASE (1988 to September 2013) and other databases. We also contacted researchers in the field and checked reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCT) evaluating school-based interventions designed to prevent illicit drugs use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 51 studies, with 127,146 participants. Programmes were mainly delivered in sixth and seventh grade pupils. Most of the trials were conducted in the USA. Social competence approach versus usual curricula or no intervention Marijuana use at < 12 months follow-up: the results favoured the social competence intervention (risk ratio (RR) 0.90; 95% confidence interval (CI) 0.81 to 1.01, four studies, 9456 participants, moderate quality evidence). Seven studies assessed this outcome (no data for meta-analysis): two showed a positive significant effect of intervention, three showed a non-significant effect, one found a significant effect in favour of the control group and one found a trend in favour of the control group.Marijuana use at 12+ months: the results favoured the social competence intervention (RR 0.86; 95% CI 0.74 to 1.00, one study, 2678 participants, high quality evidence). Seven studies assessed this outcome (no data for meta-analysis): two showed a significant positive effect of intervention, three showed a non-significant effect, one found a significant effect in favour of the control group and one a trend in favour of the control group.Hard drug use at < 12 months: we found no difference (RR 0.69; 95% CI 0.40 to 1.18, one study, 2090 participants, moderate quality evidence). Two studies assessed this outcome (no data for meta-analysis): one showed comparable results for the intervention and control group; one found a statistically non-significant trend in favour of the social competence approach.Hard drug use at 12+ months: we found no difference (mean difference (MD) -0.01; 95% CI -0.06 to 0.04), one study, 1075 participants, high quality evidence). One study with no data for meta-analysis showed comparable results for the intervention and control group.Any drug use at < 12 months: the results favoured social competence interventions (RR 0.27; 95% CI 0.14 to 0.51, two studies, 2512 participants, moderate quality evidence). One study with 1566 participants provided continuous data showing no difference (MD 0.02; 95% CI -0.05 to 0.09, moderate quality evidence). Social influence approach versus usual curricula or no intervention Marijuana use at < 12 months: we found a nearly statistically significant effect in favour of the social influence approach (RR 0.88; 95% CI 0.72 to 1.07, three studies, 10,716 participants, moderate quality evidence). One study with 764 participants provided continuous data showing results that favoured the social influence intervention (MD -0.26; 95% CI -0.48 to -0.04).Marijuana use at 12+ months: we found no difference (RR 0.95; 95% CI 0.81 to 1.13, one study, 5862 participants, moderate quality evidence). One study with 764 participants provided continuous data and showed nearly statistically significant results in favour of the social influence intervention (MD -0.22; 95% CI -0.46 to 0.02). Of the four studies not providing data for meta-analysis a statistically significant protective effect was only found by one study.Hard drug use at 12+ months: one study not providing data for meta-analysis found a significant protective effect of the social influence approach.Any drug use: no studies assessed this outcome. Combined approach versus usual curricula or no intervention Marijuana use at < 12 months: there was a trend in favour of intervention (RR 0.79; 95% CI 0.59 to 1.05, three studies, 8701 participants, moderate quality evidence). One study with 693 participants provided continuous data and showed no difference (MD -1.90; 95% CI -5.83 to 2.03).Marijuana use at 12+ months: the results favoured combined intervention (RR 0.83; 95% CI 0.69 to 0.99, six studies, 26,910 participants, moderate quality evidence). One study with 690 participants provided continuous data and showed no difference (MD -0.80; 95% CI -4.39 to 2.79). Two studies not providing data for meta-analysis did not find a significant effect.Hard drug use at < 12 months: one study with 693 participants provided both dichotomous and continuous data and showed conflicting results: no difference for dichotomous outcomes (RR 0.85; 95% CI 0.63 to 1.14), but results in favour of the combined intervention for the continuous outcome (MD -3.10; 95% CI -5.90 to -0.30). The quality of evidence was high.Hard drug use at 12+ months: we found no difference (RR 0.86; 95% CI 0.39 to 1.90, two studies, 1066 participants, high quality evidence). One study with 690 participants provided continuous data and showed no difference (MD 0.30; 95% CI -1.36 to 1.96). Two studies not providing data for meta-analysis showed a significant effect of treatment.Any drug use at < 12 months: the results favoured combined intervention (RR 0.76; 95% CI 0.64 to 0.89, one study, 6362 participants).Only one study assessed the effect of a knowledge-focused intervention on drug use and found no effect. The types of comparisons and the programmes assessed in the other two groups of studies were very heterogeneous and difficult to synthesise.

AUTHORS' CONCLUSIONS

School programmes based on a combination of social competence and social influence approaches showed, on average, small but consistent protective effects in preventing drug use, even if some outcomes did not show statistical significance. Some programmes based on the social competence approach also showed protective effects for some outcomes.Since the effects of school-based programmes are small, they should form part of more comprehensive strategies for drug use prevention in order to achieve a population-level impact.

Prevalence and correlates of smokeless tobacco use among grade 8-11 school students in South Africa: a nationwide study

INTRODUCTION

Smokeless tobacco in South Africa is commonly used in the form of snuff or chewing tobacco. This paper reports its use among secondary school students and provides evidence of its association with demographic characteristics, tobacco smoking, and socioeconomic status.

METHODS

Data were derived from a nationally representative study conducted in 2008 among 10,270 grade 8-11 students from 192 schools in South Africa. Data were collected with self-administered questionnaires. Multiple logistic regression analyses were used to examine correlates of past-month smokeless tobacco use.

RESULTS

Nationally, 12.4% of students used smokeless tobacco such as chewing tobacco or snuff in the month preceding the survey, with significantly higher rates among males (13.6%) than females (10.6%). Smokeless tobacco use differed between racial groups, with African (12.8%) and colored (11.7%) students having the highest rates of past-month use. Grade 8 students (15.3%) reported significantly higher rates of use than grade 11 students (9.1%). Current cigarette smokers (21.3%) reported a higher prevalence of smokeless tobacco use than noncurrent smokers (10.1%). Logistic regression of past-month smokeless tobacco use showed significant associations with race, grade, school socioeconomic level, urbanicity, current cigarette smoking, and having first smoked a cigarette before the age of 10 years.

CONCLUSIONS

These findings provide evidence for policy makers and program developers to develop targeted and tailored interventions for young people regarding smokeless tobacco use.

Evaluation of the effectiveness of a smoking prevention program based on the 'Life Skills Training' approach

Our objective was to verify the effectiveness of a program based on the Life Skills Training approach with a greater extent than usual, not applied by teachers and a very high degree of reliability regarding the implementation of the expected content. Twenty-eight secondary schools in Granada (Spain) were randomly assigned to the intervention or control group. The students in the intervention group received 21 one-hour sessions in the first year and 12 one-hour sessions in the second year, whereas those in the control group received no health education or preventive sessions. Students completed questionnaires before and after the first year of sessions, before and after the second year, and at 1 year after the program. All five questionnaires were completed by 77% of the 1048 students initially enrolled in the study. The results suggest that the program had no preventive effects either immediately or at 1 year after its application. Application of the Life Skills Training approach does not appear to prevent the onset of smoking but may prove effective for avoiding escalation of the consumption levels of tobacco or other problematic drugs.

School-based programmes for preventing smoking

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The impact of education programs on smoking prevention: a randomized controlled trial among 11 to 14 year olds in Aceh, Indonesia

BACKGROUND

School-based smoking prevention programs have been shown to increase knowledge of the negative effects of smoking and prevent tobacco smoking. The majority of evidence on effectiveness comes from Western countries. This study investigated the impact of school-based smoking prevention programs on adolescents' smoking knowledge, attitude, intentions and behaviors (KAIB) in Aceh, Indonesia.

METHODS

We conducted a 2 × 2 factorial randomized controlled trial among 7(th) and 8(th) grade students aged 11 to 14 years. Eight schools were randomly assigned to a control group or one of three school-based programs: health-based, Islamic-based, or a combined program. Students in the intervention groups received eight classroom sessions on smoking prevention education over two months. The KAIB impact of the program was measured by questionnaires administered one week before and one week after the intervention.

RESULTS

A total of 477 students participated (58% female, 51% eighth graders). Following the intervention, there was a significant main effect of the Health based intervention for health knowledge scores (β = 3.9 ± 0.6, p < 0.001). There were significant main effects of the Islamic-based intervention in both health knowledge (β = 3.8 ± 0.6, p < 0.001) and Islamic knowledge (β = 3.5 ± 0.5, p < 0.001); an improvement in smoking attitude (β = -7.1 ± 1.5, p < 0.001). The effects of Health and Islam were less than additive for the health and Islamic factors for health knowledge (β = -3.5 ± 0.9, p < 0.01 for interaction) and Islamic knowledge (β = -2.0 ± 0.8, p = 0.02 for interaction). There were no significant effects on the odds of intention to smoke or smoking behaviors.

CONCLUSIONS

Both Health and Islamic school-based smoking prevention programs provided positive effects on health and Islamic related knowledge respectively among adolescents in Indonesia. Tailoring program interventions with participants' religion background information may provide additional benefits to health only focused interventions.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register, ACTRN12612001070820.

Promoting life skills and preventing tobacco use among low-income Mumbai youth: effects of Salaam Bombay Foundation intervention

Background

In response to India's growing tobacco epidemic, strategies are needed to decrease tobacco use among Indian youth, particularly among those who are economically disadvantaged. The objective of this study was to assess the effectiveness of a school-based life-skills tobacco control program for youth of low socio-economic status in Mumbai and the surrounding state of Maharashtra. We hypothesized that compared to youth in control schools, youth exposed to the program would have greater knowledge of effects of tobacco use; be more likely to take action to prevent others from using tobacco; demonstrate more positive life skills and attitudes; and be less likely to report tobacco use.

Methods/Findings

Using a quasi-experimental design, we assessed program effectiveness by comparing 8^th and 9^th grade students in intervention schools to 8^th grade students in comparable schools that did not receive the program. Across all schools, 1851 students completed a survey that assessed core program components in early 2010. The program consisted of activities focused on building awareness about the hazards of tobacco, developing life skills, and advocacy development. The primary outcome measure was self-reported tobacco use in the last 30 days.

Findings indicate that 4.1% of 8^th grade intervention students (OR = 0.51) and 3.6% of 9^th grade intervention students (OR = 0.33) reported using tobacco at least once in the last 30 days, compared to 8.7% of students in the control schools. Intervention group students were also significantly more knowledgeable about tobacco and related legislation, reported more efforts to prevent tobacco use among others, and reported stronger life skills and self-efficacy than students in control schools. Limitations to the study include schools not being randomly assigned to condition and tobacco use being measured by self-report.

Conclusions

This program represents an effective model of school-based tobacco use prevention that low-income schools in India and other low- and middle-income countries can replicate.

Transparency of outcome reporting and trial registration of randomized controlled trials in top psychosomatic and behavioral health journals: A systematic review

OBJECTIVE

The most reliable evidence for evaluating healthcare interventions comes from well-designed and conducted randomized controlled trials (RCTs). The extent to which published RCTs reflect the efficacy of interventions, however, depends on the completeness and accuracy of published results. The Consolidated Standards of Reporting Trials statement, initially developed in 1996, provides guidelines intended to improve the transparency of published RCT reports. A policy of the International Committee of Medical Journal Editors, initiated in 2005, requires clinical trials published in member journals to be registered in publicly accessible registries prior to patient enrollment. The objective of this study was to assess the clarity of outcome reporting, proportion of registered trials, and adequacy of outcome registration in RCTs published in top behavioral health journals.

METHODS

Eligible studies were primary or secondary reports of RCTs published in Annals of Behavioral Medicine, Health Psychology, Journal of Psychosomatic Research, and Psychosomatic Medicine from January 2008 to September 2009. Data were extracted for each study on adequacy of outcome reporting and registration.

RESULTS

Of 63 articles reviewed, only 25 (39.7%) had adequately declared primary or secondary outcomes, whereas 38 (60.3%) had multiple primary outcomes or did not define outcomes. Only 13 studies (20.6%) were registered. Only 1 study registered sufficiently precise outcome information to compare with published outcomes, and registered and published outcomes were discrepant in that study.

CONCLUSION

Greater attention to outcome reporting and trial registration by researchers, peer reviewers, and journal editors will increase the likelihood that effective behavioral health interventions are readily identified and made available to patients.

When intraclass correlation coefficients go awry: a case study from a school-based smoking prevention study in South Africa

OBJECTIVES

We conducted a group randomized trial of 2 South African school-based smoking prevention programs and examined possible sources and implications of why our actual intraclass correlation coefficients (ICCs) were significantly higher than the ICC of 0.02 used to compute initial sample size requirements.

METHODS

Thirty-six South African high schools were randomly assigned to 1 of 3 experimental groups. On 3 occasions, students completed questionnaires on tobacco and drug use attitudes and behaviors. We used mixed-effects models to partition individual and school-level variance components, with and without covariate adjustment.

RESULTS

For 30-day smoking, unadjusted ICCs ranged from 0.12 to 0.17 across the 3 time points. For lifetime smoking, ICCs ranged from 0.18 to 0.22; for other drug use variables, 0.02 to 0.10; and for psychosocial variables, 0.09 to 0.23. Covariate adjustment substantially reduced most ICCs.

CONCLUSIONS

The unadjusted ICCs we observed for smoking behaviors were considerably higher than those previously reported. This effectively reduced our sample size by a factor of 17. Future studies that anticipate significant cluster-level racial homogeneity may consider using higher-value ICCs in sample-size calculations to ensure adequate statistical power.