Welcome! Family-based

programmes for preventing smoking by

children and adolescents: 

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What’s the evidence?

Thomas, R.E., Baker, P.R.A., Thomas, B.C., & Lorenzetti, D. (2015). Family-based programmes for preventing smoking by children and adolescents. Cochrane Database of Systematic Reviews,2015(2), Art. No.: CD004493. 

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A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Stages in the process of Evidence-Informed Public Health

National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

Poll Question #1

Have you heard of PICO(S) before?

1.Yes2.No

Searchable Questions Think “PICOS”

1. Population (situation)

2. Intervention (exposure)

3. Comparison (other group)

4. Outcomes

5. Setting

How often do you use Systematic Reviews to inform a program/services?

A.AlwaysB.OftenC.SometimesD.NeverE.I don’t know what a systematic review is

Poll Question #2

Dr. Roger Thomas MD, Ph.D, CCFP, MRCGP is Professor in the Faculty of Medicine at the University of Calgary.

Cochrane Collaboration Coordinator, University of Calgary.

Roger Thomas

Review

Thomas, R.E., Baker, P.R.A., Thomas, B.C., & Lorenzetti, D. (2015). Family-based programmes for preventing smoking by children and adolescents. Cochrane Database of Systematic Reviews,2015(2), Art. No.: CD004493. 

Rationale

• Are interventions in families to prevent children smoking effective?

• Are combined family + school interventions more effective than only-family or only-school interventions?

• Are more intensive family interventions more effective than less intensive interventions?

Review Focus:

P Children (aged 5 to 12) and adolescents (aged 13 to 18) and family members

I Interventions with children and family members intended to deter starting to use tobacco

C No intervention or school intervention

O Smoking status of children who reported no use of tobacco at baseline

Family-based interventions prevent children and adolescents from starting to smokeA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

17

Poll Question #3

Outline1. Overview of included trials

2. Family interventions compared to no intervention, baseline never smokers

3. Family + school interventions compared to school interventions, baseline never smokers

4. Content of family interventions included in the systematic review:

a) high intensity

b) medium intensity

c) low intensity

Overview of Trials• 27 trials – 12 randomised controlled trials (RCTs)

– 15 cluster RCTs (C-RCTs) all of which controlled for clustering

• 23 trials in the USA, one each in Australia, India, the Netherlands, and Norway

• Variation in follow-up from 6 months to 29 years

Overview of Trials• 20 interventions each tested by only one

RCT

• 3 trials tested Strengthening Families Program (SFP 10-14) in (Spoth 2001, Spoth 2002, and a short version by Riesch 2012).

• 2 trials tested Family Resource Center intervention (Connell 2007, Fosco 2013)

• 2 trials tested Smoke-Free Kids programme (Hiemstra 2014, Jackson 2006)

Risk of Bias

Risk of bias graph.svg

Adherence to Training and Intervention• 10 studies reported good adherence

to training (where relevant) and adherence to intervention

• 13 reported intermediate levels

• 4 no evidence about adherence, or evidence of minimal adherence

EXAMPLE: High Intensity Intervention Fosco (2013) Family Resource Center in schools 1. Parent consultant trained in the Family Check-Up

model to facilitate collaboration with parents, identify youth at risk, and refer at-risk students for counselling

2. At risk adolescents and families participated in 3 motivational interviewing sessions to identify family strengths and weaknesses, motivate parents to improve parenting, and to engage in intervention services

3. Feedback about assessment results provided opportunity to select interventions tailored to unique needs of each family.

EXAMPLE: Medium Intensity Intervention Bauman (2001) Family Matters

• 4 booklets mailed to participants• 2 weeks after each booklet was

posted a health educator telephoned a parent, encouraged the participation of all family members in the programme and answered questions.

EXAMPLE: Low Intensity InterventionHiemstra 2014, Jackson 2006 Smoke-Free Kids • 6 printed activity modules• general communication about smoking• influence of smoking messages• rule setting and non-smoking

agreement• creating a smoke-free house and

environment• peer influences

High Intensity Family Interventions vs. No InterventionAuthor and Date N OR and 95%CI

Haggerty 2007 236 0.84 [0.43, 1.63]

Prado 2007 148 0.44 [0.21, 0.96]

Fosco 2013 592 0.55 [0.29, 1.07]

Cullen 1996 209 0.68 [0.44, 1.06]

Spoth 2001 (1) 199 0.79 [0.58, 1.09]

Spoth 2001 (2) 212 0.66 [0.47, 0.92]

Storr 2002 374 0.78 [0.61, 0.99]

Total 1970 0.71 [0.61, 0.82]

Heterogeneity: I² = 0%

Test for overall effect: Z = 4.52 (P < 0.00001)

Medium Intensity Family Interventions vs. No Intervention

Author and Date N OR and 95%CI

Bauman 2001 826 0.83 [0.67, 1.03]

Author and Date N OR and 95%CI

Jackson 2006 776 0.64 [0.45, 0.90]

Hiemstra 2014 1238 0.91 [0.66, 1.24]

Heterogeneity I² = 55%; test for overall effect Z = 2.21, p = 0.03) 2014

0.77 [0.61, 0.97]

Low Intensity Family Interventions vs. No Intervention

High, Medium and Low Intensity Family Interventions vs. No Intervention

N OR and 95%CI

Heterogeneity: I² = 0%Test for overall effect z = 5.04, p < 0.00001)

4810 0.76 [0.68, 0.84]

Family + School Interventions vs. School Interventions

Author and date N OR and 95%CI

Spoth 2002 (High Intensity)

6000.86 [0.57, 1.30]

Jøsendal 1998 (Low intensity

17010.85 [0.74, 0.97]

Total 2301 0.85 [0.75, 0.96]

OVERALL SUMMARYBaseline never smokers, prevention of new smokers

Intervention Comparison No of studies

N OR and 95%CI

Family No intervention

9 4810 0.85 [0.75, 0.96]

Family + school

School 2 2301 0.85 [0.75, 0.96]

Family-based interventions prevent children and adolescents from starting to smokeA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Poll Question #4

Poll Question #5

Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Questions?

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Appendix

What were the included

high intensity family interventions?

Cullen 1996GP interviews

• 20-30 minute interviews with new mothers (4 in 1st year, 2 annually for next 4 years)

• To enhance self-worth, self-acceptance, foster gentle physical interaction with her child, and adopt a positive attitude to modifying her child's behaviour

• Children followed up as adolescents or young adults

Fosco 2013 Family Resource Center in schools

• Parent consultant trained in Family Check-Up model to facilitate collaboration with parents, identify at-risk youth and for counselling

• At-risk adolescents and families: 3 motivational interviewing sessions to identify family strengths and weaknesses, motivate parents to improve parenting, and engage in intervention services

• Feedback about assessment results provided opportunity to select interventions tailored to unique needs of each family

Haggerty 2007Parents Who Care workbook: 7 chapters in 7 sessions 2 formats: •self-administered with telephone facilitator support•parent and adolescent met weekly in groups in schools

1.Relating to your teen2.Risks: Identifying and reducing them 3.Protection: Bonding with your teen to strengthen resilience4.Tools: Working with your family to solve problems5.Involvement: Allowing everyone to contribute6.Policies: Setting family policies on health and safety issues7.Supervision: Supervising without invading

In each session parents and adolescents watched a video, practised skills separately and then as families, and were asked to continue practice at home.

Prado 2007Substance, sexual behaviour and HIV risk intervention

2 interventions:

1.Familias Unidas to focus on and strengthen Hispanic family-centred values, increase parental involvement, positive parenting and family support 2.PATH (Parent pre-adolescent training for HIV prevention)

Spoth 2001Strengthening Families Program compared to Preparing for Drug-Free Years Program

1. Full length SFP 10-14, now renamed ISF (6 two-hour, + 1 one-hour sessions)

2. Preparing for the Drug-Free Years Program (five two-hour sessions)

3. Control group received mailed information

Storr 2002Classroom-Centered (CC) Intervention

• Language and mathematics curricula enhanced to encourage skills in critical thinking, composition, listening and comprehension

• Whole-class strategies to encourage problem solving by children in group contexts, decrease aggressive behaviour, and encourage time on task

• Strategies for children not performing adequately

Storr 2002Classroom-Centered (CC) Intervention compared to Family School Partnership (FSP)

Classroom-Centered (CC) Intervention•Teams of children received points for good behaviour and lost points for behaviours such as starting fights - the points could be exchanged for classroom activities, game periods and stickers)

Storr 2002Family-School Partnership (FSP) intervention

1. 'Parents on Your Side Program' trained teachers to communicate with parents and build partnerships (3 day workshop, training manual, follow-up supervisory visits)

2. Home-school learning and communicating activities weekly

3. 9 workshops for parents

Storr 2002Family-School Partnership (FSP) intervention • 2 workshops to establish effective and

enduring parent-staff relationship and facilitate children's learning and behaviour

• 5 workshops focused on effective disciplinary strategies

• No description of the amount of tobacco-focused content

High Intensity Interventions,which could not be included in the meta-analysisAuthor and Date

Intervention How Data were Reported

Results

Connell 2007

Family Check Up

Complier Average Causal Effect Analysis. Data from model presented as slope and intercept, no N’s

No effect ages 11-17, large effect size for engagers age 22

Dishion 1995

4 family therapy treatment groups

Frequency (Log + 1), probabilities. Non-random control group

Parent-only baseline 0.91, 1 year follow-up 0.63Teen only Baseline 0.81, 1 year follow-up 1.66Parent and teen baseline 0.95, 1 year follow-up 2.09 (p < .05)Self-directed baseline 0.75, 1 year follow-up 1.16.

Author and Date

Intervention How Data were Reported Results

Olds 1998

400 pregnant women randomised to different types of antenatal & postnatal support until child's 2nd birthday. Follow-up at 15 years

Mean differences, no Ns No differences in amount of cigarette use in past 6 months between any group

Riesch 2012

Strengthening Families Program

No baseline smoking data. Attrition in intervention group 87 to 63 and control from 81 to 66. Post program data for "smoked a cigarette, even a puff" are incomplete

"Youth participation in alcohol, tobacco, and other drugs was very low and did not differ post program."

High Intensity Interventions,which could not be included in the meta-analysis

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