Smoking prevention for ethnically diverse adolescents: 2-year outcomes of a multicultural, school-based smoking prevention curriculum in Southern California

Effectiveness of school-based interventions for preventing tobacco smoking initiation among young people in low- and middle-income countries: a systematic review protocol

BACKGROUND

Despite the commendable progress made globally in tobacco control, the world is falling short of achieving a 30% relative reduction in current tobacco use by 2025. The African region remains the least in the efforts in fighting the tobacco epidemic and is most exploited by the tobacco industry. Schools have been continuously used for over three decades as a setting for delivering youth smoking prevention programmes; however, the evidence of the effectiveness of those school-based interventions provides varying outcomes. Also, interventions that proved to be effective, in high-income countries (HICs), may not necessarily be effective in the African region as a result of cultural differences and other contrasting factors. An existing systematic review that explored school-based tobacco prevention programmes among the youth in African countries from 2000 to 2016 showed partial effectiveness. This review will address the gap by updating the 2016 review to examine studies in LMICs to generate findings to help target resources which have the potential to save lives by preventing smoking initiation among young people.

METHODS

The JBI methodology for systematic reviews of effectiveness will guide the conduct of this review. A comprehensive strategic search will be developed to retrieve both published and unpublished studies that evaluate school-based interventions to prevent tobacco smoking initiation among in-school young people in LMICs compared to non-intervention programmes. Published studies would be from databases such as MEDLINE via Ovid, CINAHL via EBSCO, Embase, PsycINFO, PsycEXTRA, and the Cochrane Central Register of Controlled Trials. Sources of grey literature would be ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove. The databases will be searched for published studies in the English language. The processes of study selection, critical appraisal, data extraction, and data synthesis will be in accordance with the JBI approach for reviews of effectiveness with a minimum of two reviewers at each stage. The primary outcome of the review will be the non-initiation of tobacco smoking by the youth.

DISCUSSION

The review will provide synthesized evidence on the effectiveness of school-based smoking initiation prevention among young people in LMICs. The findings of the review would support policymakers and programme implementers to develop targeted interventions for effective tobacco control initiatives.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021246206.

Effectiveness of a School Based Smokeless Tobacco Intervention: A Cluster Randomized Trial

To assess the effectiveness of intervention in improving knowledge, attitude and perception regarding smokeless tobacco (SLT) use and its harmful effects and intention to quit SLT among school going adolescents. A school-based cluster randomized control trial was carried out in 18 secondary schools targeting male and female students from grades 6 to 10 in Karachi. Primary outcome was knowledge about hazards of smokeless tobacco (SLT) and secondary outcomes were attitude and Perception about hazards of SLT, and intention to quit SLT. We enrolled 738 participants in intervention group and 589 in the control group. Mean score of knowledge significantly improved in intervention as compared to control group (P value < 0.01). Intention to quit was found to be proportionately higher (33%) in the intervention group as compared to control group. Generalized estimating equations were used to assess the association of factors with knowledge regarding harmful effects of SLT use. Significant predictors of increase in knowledge score were found in children: who had seen any anti SLT messages on social media in the past 30 days, who were getting information regarding harmful effects of SLT use in school or textbooks and who had friends using SLT. A school-based intervention was effective in increasing knowledge regarding the harmful effects of SLT use and intention to quit SLT use among school adolescents. Introduction of such educational programmes on a regular basis in schools or as part of school curriculum can have an impact on reducing prevalence of SLT use.Trial Registration NCT03418506. https://register.clinicaltrials.gov/NCT03418506 .

Designed Cultural Adaptation and Delivery Quality in Rural Substance Use Prevention: an Effectiveness Trial for the Keepin' it REAL Curriculum

This study examined how cultural adaptation and delivery quality of the school-based intervention keepin' it REAL (kiR) influenced adolescent substance use. The goal of the study was to compare the effectiveness of the multi-cultural, urban (non-adapted) kiR intervention, a re-grounded (adapted) rural version of the kiR intervention and control condition in a new, rural setting. A total of 39 middle schools in rural communities of two states in the USA were randomly assigned to one of three conditions (i.e., control, non-adapted urban kiR, and adapted rural kiR). Data included adolescent self-reported lifetime substance use and observers' ratings of delivery quality from video recordings of lessons. Ratings of delivery quality were used to create four comparison groups (i.e., low/high delivery quality in non-adapted/urban kiR condition and low/high quality in adapted/rural kiR condition). Controlling for substance use in the 7th grade, findings compared 9th graders' (N = 2781) lifetime alcohol, cigarette, marijuana, and chewing tobacco use. Mixed model analyses revealed that rural youth receiving the culturally adapted/rural curriculum reported significantly less cigarette use than rural youth in the control condition regardless of delivery quality. In the non-adapted/urban condition, youth receiving high delivery quality delivery reported less marijuana use than those receiving low delivery quality condition. However, substance use outcomes of youth receiving high and low delivery quality in the non-adapted intervention did not differ significantly from those the control group. Findings support the effectiveness of the culturally adapted/rural keepin' it REAL curriculum for rural youth.

Cigarette Smoking Status Among Latino/Hispanic Middle and High School Students in the United States

Although Latino/Hispanic adolescent substance use is a growing research area in the United States, there is little research examining the prevalence and factors associated with adolescent cigarette smoking status in this population. A nationally representative sample of 5,929 middle and high Latino/Hispanic students in the 2009 US National Youth Tobacco Survey was selected to assess the prevalence and various risk and protective factors associated with cigarette smoking status. Results revealed one in five (20%) were experimental smokers, nearly one in eleven (8.5%) were occasional smokers, and 4% were regular smokers. Multinomial logistic regression analyses showed that, controlling for demographics, family members' smoking, refusal to smoke, school absence, and exposure to tobacco marketing were associated with experimental smoking; awareness of harmful effects of secondhand smoking, refusal to smoke, exposure to tobacco advertising, and receptivity to tobacco marketing were associated with occasional smoking; and refusal to smoke, school absence, and receptivity to tobacco marketing were associated with regular smoking. This study highlights the need to integrate various risk and proactive factors associated with different smoking status into practices and policies for Latino/Hispanic adolescent smokers.

Cultural adaptations to augment health and mental health services: a systematic review

BACKGROUND

Membership in diverse racial, ethnic, and cultural groups is often associated with inequitable health and mental health outcomes for diverse populations. Yet, little is known about how cultural adaptations of standard services affect health and mental health outcomes for service recipients. This systematic review identified extant themes in the research regarding cultural adaptations across a broad range of health and mental health services and synthesized the most rigorous experimental research available to isolate and evaluate potential efficacy gains of cultural adaptations to service delivery.

METHODS

MEDLINE, PsycINFO, CINAHL, EMBASE, and grey literature sources were searched for English-language studies published between January 1955 and January 2015. Cultural adaptations to any aspect of a service delivery were considered. Outcomes of interest included changes in service provider behavior or changes in the behavioral, medical, or self-reported experience of recipients.

RESULTS

Thirty-one studies met the inclusion criteria. The most frequently tested adaptation occurred in preventive services and consisted of modifying the content of materials or services delivered. None of the included studies focused on making changes in the provider's behavior. Many different populations were studied but most research was concerned with the experiences and outcomes of African Americans. Seventeen of the 31 retained studies observed at least one significant effect in favor of a culturally adapted service. However there were also findings that favored the control group or showed no difference. Researchers did not find consistent evidence supporting implementation of any specific type of adaptation nor increased efficacy with any particular cultural group.

CONCLUSIONS

Conceptual frameworks to classify cultural adaptations and their resultant health/mental health outcomes were developed and applied in a variety of ways. This review synthesizes the most rigorous research in the field and identifies implications for policy, practice, and research, including individualization, cost considerations, and patient or client satisfaction, among others.

Shisha Smoking Practices, Use Reasons, Attitudes, Health Effects and Intentions to Quit among Shisha Smokers in Malaysia

Despite its popularity, shisha smoking practices, reasons for its use, attitudes, detrimental health effects and intention to quit among shisha users in Malaysia have never been investigated. A total of 503 shisha users responded to a cross-sectional study conducted between July 2015 and March 2016. The majority of users were young people aged 21-30; a small minority were underage. The reasons for shisha use were its growing popularity as a favourite pastime activity and the perception of shisha use as cool and trendy. Just over half (57.3%) agree that shisha use exposes the smoker to large amounts of smoke and the majority were unsure about the health risks of shisha smoking compared to tobacco smoking. The three most common detrimental health effects reported by the study respondents were dry throat, headache and nausea. Regular shisha users have significantly higher detrimental health effects compared to no-regular shisha users. Shisha users with a duration of smoking of 6-12 months (odds ratio (OR) 3.212; 95% confidence interval (CI) 1.651-6.248) and 6 months and below (OR 2.601; 95% CI 1.475-4.584) were significantly more likely to have a higher proportion who intend quitting smoking than shisha users of more than 12 months duration.

The Smoking Outcome Expectation Scale and Anti-Smoking Self-Efficacy Scale for Early Adolescents: Instrument Development and Validation

Smoking-related outcome expectation and self-efficacy have been found to be associated with adolescent smoking initiation. There is, however, a lack of appropriate instruments to investigate early adolescents' smoking outcome expectations and antismoking self-efficacy. The purpose of this study was to develop and validate the Smoking Outcome Expectation Scale (SOES) and Anti-Smoking Self-Efficacy Scale (ASSES). A total of 232 fifth and sixth graders from four elementary schools in Taiwan participated in the study. Both scales had good content validity, internal consistency, and test-retest reliability. On the basis of exploratory factor analysis, the 6-item SOES with two factors accounted for 54.72% of total variance and the 15-item ASSES with three factors accounted for 56.49% of total variance. The SOES had convergent and discriminant validity and ASSES had convergent validity. The two scales could help school nurses to understand early adolescents' smoking outcome expectation and antismoking self-efficacy and to develop more appropriate antismoking curricula.

Mediation effects of a culturally generic substance use prevention program for Asian American adolescents

In this paper, we examined the mediation effects of a family-based substance use prevention program on a sample of Asian American families. These families were randomized into an intervention arm or a non-intervention control arm. Using path models, we assessed the effect of the intervention on adolescent girls' substance use outcomes at 2-year follow-up through family relationships and adolescent self-efficacy pathways. Bias-corrected bootstrapping strategy was employed to assess the significance of the mediation effect by evaluating the 95% confidence interval of the standardized coefficient. The results show that receiving the intervention exerted a positive effect on girls' family relationships at 1-year follow-up. Such an improvement was associated with girls' increased self-efficacy, which in turn led to girls' decreased alcohol use, marijuana use, and future intention to use substances at 2-year follow-up. Considering the diverse cultural backgrounds, as well as languages, nationalities, and acculturation levels under the umbrella term "Asian Americans", we demonstrate that a universal web-based intervention that tackles the theoretical- and empirical-based risk and protective factors can be effective for Asian Americans. Despite its generic nature, our program may provide relevant tools for Asian American parents in assisting their adolescent children to navigate through the developmental stage and ultimately, resist substance use.

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.

The role of ethnic pride and parental disapproval of smoking on smoking behaviors among minority and white adolescents in a suburban high school

BACKGROUND

Adolescence is a critical developmental period when tobacco use is initiated and progression to regular smoking occurs. Another growing concern is the mounting evidence of ethnic/racial disparities in the smoking rates and adverse health consequences related to smoking. To reduce ethnic/racial disparities in smoking behaviors, understanding the protective influences against smoking behaviors among minority adolescents is important. Therefore, we examined the role of ethnic pride and parental disapproval of smoking on a wide range of smoking behaviors in ethnic/racial minority and White adolescents attending a suburban high school in Connecticut.

METHODS

A total of 870 adolescents (ethnic/racial minority: n= 202) completed questions on susceptibility to smoking, ever trying a cigarette, smoking at least one cigarette daily in the past 30 days, as well as parental disapproval of smoking and ethnic pride in a school-wide survey.

RESULTS

Logistic regression analyses indicated that perceived parental disapproval of adolescent smoking and ethnic pride were associated with susceptibility to smoking, ever trying a cigarette, and daily smoking differently for minority and White adolescents. For White youth, high parental disapproval of smoking was protective against all three smoking behaviors whereas ethnic pride was not. For minority youth, the combined protective effect of higher ethnic pride and higher parental disapproval of smoking was protective against all smoking behaviors.

CONCLUSION

The protective role of parental disapproval of smoking and ethnic pride on smoking behaviors may inform culturally sensitive smoking interventions aimed at diverse, multi-ethnic youth, and future studies are needed to examine this.

A review of culturally targeted/tailored tobacco prevention and cessation interventions for minority adolescents

AIM

Emerging racial/ethnic disparities in tobacco use behaviors and resulting long-term health outcomes highlight the importance of developing culturally tailored/targeted tobacco prevention and cessation interventions. This manuscript describes the efficacy and the components of prevention and cessation interventions developed for minority adolescents.

METHODS

Thirteen studies focused on culturally tailoring and targeting tobacco prevention/cessation interventions were selected and information on intervention design (type, number of sessions), setting (school or community), theoretical constructs, culture-specific components (surface/deep structures), and treatment outcomes were extracted.

RESULTS

Of the 13 studies, 5 focused on prevention, 4 on cessation, and 4 combined prevention and cessation, and most of the studies were primarily school-based, while a few used community locations. Although diverse minority groups were targeted, a majority of the studies (n = 6) worked with Hispanic adolescents. The most common theoretical construct examined was the Social Influence Model (n = 5). The overall findings indicated that culturally tailoring cessation interventions did not appear to improve tobacco quit rates among minority adolescents, but culturally tailored prevention interventions appeared to produce lower tobacco initiation rates among minority adolescents than control conditions.

CONCLUSIONS

The results of review suggest that there is a critical need to develop better interventions to reduce tobacco use among minority adolescents and that developing a better understanding of cultural issues related to both cessation and initiation of tobacco use among minority populations is a key component of this endeavor.

Substance use among Asian-American adolescents: perceptions of use and preferences for prevention programming

Rarely has substance use prevention programming targeted Asian-American adolescents. Using a focus group methodology, we explored perceptions of substance use and preferences for prevention programming among 31 Asian-American adolescents in New York City. Participants considered substance use common in the community. Factors contributing to substance use among Asian-American adolescents (e.g., peer pressure, pressure to achieve, family factors, and community influence) were identified, and the need for prevention programs tailored for the Asian-American community was highlighted. Participants discussed preferred program content, delivery settings, and recruitment and retention strategies. Despite the favorable attitude for family-based prevention programming, participants raised potential issues concerning the feasibility of such a program. Study findings facilitate understanding of Asian-American adolescents' substance use behavior and shed light on prevention program development for this underserved population.

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.

Overweight, body image, and depression in Asian and Hispanic adolescents

OBJECTIVES

To prospectively investigate associations between overweight and depressive symptoms in Asian and Hispanic adolescents.

METHODS

Data included 780 Hispanic and 375 Asian students. Structural equation model was used to prospectively explore moderation effects of gender, ethnicity, and acculturation on associations of overweight, body image dissatisfaction, and depressive symptoms.

RESULTS

Significant mediation effect was found only in Asian girls (mediation effect = 0.16, P < 0.05) and girls with high acculturation (mediation effect = 0.17, P < 0.05). Overweight significantly predicted higher body image dissatisfaction, which in turn was significantly related to depressive symptoms.

CONCLUSIONS

Our findings help understanding the association of overweight and experience of depressive symptoms.

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

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

Psychographic segments based on attitudes about smoking and lifestyle among Vietnamese-American adolescents

PURPOSE

Tobacco marketing campaigns target distinct psychographic segments of the population. We describe psychographic segments among Vietnamese-American youth and their relationship to smoking behavior.

METHODS

This was a cross-sectional survey of 411 Vietnamese-American young people (aged 14-24 years). Cluster analysis was performed to describe different population segments.

RESULTS

We identified four segments, categorized as follows: risk seekers, stressed pessimists, optimistic achievers, and sedentary well-behaved individuals. The risk seekers and stressed pessimists reported that they had tried smoking at some time (60% and 53%, respectively) in greater proportions than the other two segments (25% and 24%); and 20% of risk seekers and 22% of stressed pessimists were current smokers compared with 2% of the other clusters. In comparison to the other groups, the risk seekers more frequently went to bars and clubs, and their friends engaged in risky behavior. They agreed that secondhand smoke was dangerous, but accepted ventilation as an alternative to smoke-free policies more frequently than the other groups. The stressed pessimists had negative views of the future, did not value physical fitness, and doubted the dangers of secondhand smoke. Optimistic achievers were active in sports and student activities, were optimistic about future achievements, prioritized good nutrition, and supported smoke-free policies. The sedentary well-behaved group had well-behaved friends, did not value physical fitness, strongly opposed smoking, and supported smoke-free policies.

CONCLUSION

Different segments of the Vietnamese-American population have different attitudes and smoking risk, which may facilitate targeted tobacco control message development. Future research should address whether similar psychographic segments exist in other ethnic populations.

Why Smoking Prevention Programs Sometimes Fail. Does Effectiveness Depend on Sociocultural Context and Individual Characteristics?

BACKGROUND

School-based smoking prevention programs sometimes fail in unexpected ways. This study tests the hypotheses that both social/cultural contexts and individual dispositional characteristics may interact with program content to produce effects that are variable in potentially predictable ways.

METHODS

Students in 24 culturally heterogeneous or primarily Hispanic/Latino middle schools (N = 3,157 6th graders) received a multicultural collectivist-framed social influences (SI) program, an individualist-framed SI program, or a control condition. Three-way linear and nonlinear interactions, program frame x social context x dispositional phenotype, were tested.

RESULTS

Three-way interactions were found for the dispositional phenotypes of depression and hostility with social context and program content/frame. In predominantly Hispanic/Latino schools, larger program effects were observed for high depressed and high hostile youth in both the collectivist and individualist framed programs. In culturally mixed schools, prevention effects were greatest for low depressed and low hostile youth, especially in the individualist framed program. In culturally mixed schools, there may have been a negative treatment effect for both programs among adolescents scoring high on depression and hostility.

DISCUSSION

Prevention program effects can vary by combination of program content, social setting, and individual dispositional characteristics. The results suggest that prevention program design and implementation should be sensitive to population characteristics at both the individual and sociocultural levels.

Socioeconomic correlates of smoking among an ethnically diverse sample of 8th grade adolescents in Southern California

OBJECTIVE

Socioeconomic status (SES) has been associated with smoking among adolescents, but it is not known which attributes of SES are responsible for the added risk, or whether these associations are consistent in ethnically diverse samples.

METHODS

This study investigated the associations between SES variables and smoking behavior among an ethnically diverse sample of 1847 8th grade adolescents in Southern California in 2002. Several aspects of SES were examined: an objective composite measure of family and neighborhood SES, the adolescent's spending money, and the adolescent's perception of SES (family's ability to afford basic necessities, wealth relative to others, and wealth relative to last year).

RESULTS

After controlling for demographic characteristics, smoking behavior of parents and friends, and parental monitoring, low scores on the objective SES index and large amounts of pocket money were associated with an increased risk of smoking. The subjective measures of perceived SES were not associated with smoking.

CONCLUSIONS

Results indicate that increased smoking prevention efforts are needed in low-SES areas, and that limiting adolescents' pocket money may be an effective strategy for preventing smoking.

Tobacco use among youth and adults in Mainland China: the China Seven Cities Study

OBJECTIVE

The China Seven Cities Study (CSCS) monitors geographic and temporal trends in tobacco use among adolescents and adults in seven cities throughout Mainland China: Harbin, Shenyang, Wuhan, Chengdu, Kunming, Hangzhou, and Qingdao. This article presents the methodology and prevalence data from the baseline survey of the CSCS, conducted in 2002.

METHODS

Stratified random samples of middle schools, high schools, and colleges were selected within each city. Students and their parents completed self-report surveys of their tobacco use. Data were obtained from 6138 middle school students, 5848 academic high school students, 2448 vocational high school students, 2556 college students, and 25 697 parents.

RESULTS

Smoking prevalence varied across age groups, school types, genders, and cities. Past-month smoking prevalence was 9% among middle school students, 8% among academic high school students, 26% among vocational high school students, 21% among college students, and 40% among parents. Smoking prevalence was higher among males than among females, with larger gender disparities among adults than among youth. Smoking also varied across cities, with higher smoking prevalence in southwestern cities and lower prevalence in coastal cities. Intraclass correlations of students within schools are presented to inform statistical power estimates for further research in China.

CONCLUSIONS

These results provide a baseline for future longitudinal studies of smoking in these cities and identify demographic groups at risk for tobacco-related disease. Effective smoking prevention programmes for youth and smoking cessation programmes for adults are needed in China, especially in the lower-income southwestern cities and in vocational high schools throughout the country.

Socio-demographic and cultural comparison of overweight and obesity risk and prevalence in adolescents in Southern California and Wuhan, China

PURPOSE

This study performed parallel analyses on two large samples of seventh graders living in Los Angeles, California and in Wuhan, China to make direct comparisons of overweight and obesity risks in Western and Eastern cultural environments.

METHODS

Two representative samples of 1772 and 1896 seventh grade students were randomly selected from the public or parochial middle schools in the greater Los Angeles area of Southern California in the United States, and public schools in Wuhan city of China. Two body mass index (BMI) references recently established by the U.S. National Center for Health Statistics (NCHS) and the International Obesity Task Force (IOTF), respectively, were used to define overweight (85th < or = BMI < 95th percentile) and obesity (BMI > or = 95th percentile). Logistic regressions were conducted to examine relationships between socioeconomic status (SES) and obesity risk.

RESULTS

The prevalence rates of combined overweight and obesity in Los Angeles and in Wuhan were 43.1% and 12.1%, respectively, by the US-NCHS reference, and 45.8% and 11.9%, respectively, by the IOTF reference. Chinese-American adolescents had higher prevalence rates for overweight and obesity than those from China. SES was positively related to the risk of overweight and obesity in the Chinese sample, whereas a negative association was found in Southern California adolescents. Urbanicity was significantly positively related to higher overweight and obesity prevalence.

CONCLUSION

Different overweight and obesity prevalence estimates and SES effects were observed for American and Chinese adolescent samples. Research on the underlying mechanisms is needed to help us to set up a tailored program for obesity prevention in Eastern and Western cultural environments.

School-based programmes for preventing smoking

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

TYPES OF PARTICIPANTS

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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