Welcome! School-based

programmes for preventing smoking in

children and adolescents: 

What's the Evidence?You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the

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What’s the evidence? Thomas, R., McLellan, J., & Perera, R. (2013). School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews, 2013 (4) Art. No.: CD001293. http://www.healthevidence.org/view-article.aspx?a=15727

Thomas, R. E., McLellan, J., & Perera, R. (2015). Effectiveness of school-based smoking prevention curricula: Systematic review and meta-analysis. BMJ Open, 5(3). http://www.healthevidence.org/view-article.aspx?a=28703

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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

ReviewThomas, R.E., McLellan, J., & Perera, R. (2013) School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001293.

Thomas, R. E., McLellan, J., & Perera, R. (2015). Effectiveness of school-based smoking prevention curricula: Systematic review and meta-analysis. BMJ Open, 5(3). 

Rationale • Are interventions in schools to prevent

children who have never smoked from starting to smoke effective?

• Which interventions are effective: Information? Social skills to refuse tobacco offers? Interventions to become socially more

competent?Social skills + Social competence?Multimodal programmes?

Rationale Which methods of programme delivery are more

effective? • Gender-specific• Peer-led programmes vs. those taught by

researchers or teachers• Booster sessions after programme

completion vs. no booster• Tobacco-focused interventions vs.

interventions focused on tobacco, alcohol, drugs and risky behaviours

Review FocusP Children (aged 5 to 12) and adolescents

(aged 13 to 18)I Interventions in schools 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

School-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 trials2. School interventions compared to no

intervention, baseline never smokers3. Examples of social skills and social

competence interventions 4. Conclusions for practice5. Conclusions for research

Overview of Trials• 133 C-RCTs, 1 RCT• 200 intervention arms• 428,293 participants from 25

countries• Pure Prevention cohorts (Group 1): – 56 trials, 184,467 participants  – Of these, 49 trials (73 arms) with

142,447 participants from 19 different countries provided analysable data

Overview of TrialsPure Prevention cohorts

• 26 USA• 4 each Netherlands, UK• 3 each from Canada, Germany, Italy.• 2 each China, Spain• 1 each Austria, Australia, Belgium, Czech

Republic, Denmark, Finland, Greece, Portugal, South Africa, Sweden and Thailand

• This 4 continents, mostly USA and Europe

Overview of Trials• Change in Smoking Behaviour over

time (Group 2): Studies provided change data

• 16 trials, 57,577 participants, of which 15 trials (27 arms) with 45,555 participants provided analysable data

• 3 countries: 12 from USA, 2 India, 1 Canada

Overview of Trials• Point Prevalence of Smoking (Group 3): Studies

provided point prevalence data.• 1 RCT and 65 C-RCTs, 208,518 participants, of

which one RCT and 24 C-RCTs (39 arms) with 110,016 participants from 11 different countries provided usable data.

• 12 USA, 2 each Australia, Netherlands, UK• 1 each France, Germany, India, Mexico, Norway,

Romania and Sweden• The problem is: for baseline and follow-ups we

don’t know the percentages of never-smokers, smokers, quitters and triers

Risk of Bias

Risk of bias graph schools.svg

Results: Pure prevention cohort (49 C-RCTs, 73 arms): Follow-up <

1 yearCurriculum OR 95%CI p

All curricula 0.94 0.85, 1.05

Combined social competence & social influences

0.49 0.28, 0.87 0.01

Social influences 1.00 0.88, 1.13

Multimodal 0.89 0.73, 1.08

Results: Pure prevention cohort (49 C-RCTs, 73 arms): Follow-up ≥

1 yearCurriculum OR 95%CI p

All curricula 0.88 0.82, 0.96 0.002

Combined social competence & social influences

0.50 0.28, 0.87 0.01

Social competence 0.52 0.30, 0.88 0.002

Social influences 1.00 0.88, 1.13

Multimodal 0.89 0.73, 1.08

Data by Gender: Follow-up < 1 year (7 studies)

OR 95%CI pFemales 0.69 0.49, 0.96 0.04

Males 0.66 0.44, 0.98 0.04

No effect for follow-up ≥ 1 year

Adult-led curricula (56 studies)

OR 95%CI pAll curricula 0.88 0.81, 0.96 0.002Social competence 0.52 0.30, 0.88 0.02Social competence + social influences

0.47 0.26, 0.84 0.001

No effects for social influences or multimodal curricula

No effects for peer-led curricula

Curricula focussed on tobacco

OR 95%CI p

< 1 year (26 studies) 0.93 0.83, 1.04

≥ 1 year (42 studies) 0.88 0.80, 0.97 0.01

No effect of multi-focal curricula (tobacco, drugs, alcohol, other risky behaviours)

Effect of booster sessions after the

curriculumOR 95%CI p

< 1 year (36 studies) 0.94 0.85, 1.05

≥ 1 year (66 studies) 0.90 0.83, 0.97 0.10

Social competence & social influences < 1 year (2 studies)

0.50 0.26, 0.96 0.04

Social competence & social influences ≥ 1 year (3 studies)

0.51 0.27, 0.96 0.04

Spoth (2002): Example of combined social influences + social competence

interventionSocial competence intervention:

The Strengthening Families Program for Parents and Youth 10-14

•7 one-hour sessions for parents and children: – those for parents strengthened parental skills

in nurturing, setting limits and communication about substances;

– those for children strengthened prosocial and peer resistance skills

– 1 year later families were invited to participate in 4 x 1 hour booster sessions

Spoth (2002): Example of combined social influences + social competence

interventionSocial Influences Intervention:

Life Skills Training

•Homework and 15 x 45-min classes to – provide knowledge about substance abuse– promote youth skills in social resistance, self

management and general social skills – used coaching, facilitating, role modelling,

feedback and reinforcement

Resnicow (2008): Example of combined social influences + social competence

interventionLife Skills training ‘LST’

8 units in 8th and 8 in 9th grade

•Programme deliverer: Life orientation teachers, who teach mandatory LO health education course in schools

– general and substance-specific life skills, decision making

– stress management, affect management – assertive communication, resisting peer pressure– role plays, group activities, skills practice;

individual workbooks; educator’s manual

Resnicow (2008): Example of combined social influences + social competence

interventionSocial Competence "KEEP LEFT" Harm

Minimisation 8 units in 8th and 8 in 9th grade

•Decision-making for reducing physical, social and psychologic harms from tobacco and drug use– analysing context and cues for smoking, for

users, additional focus on addiction prevention, reducing intake and quitting

– individual workbooks, educator's manual

Implications for Practice Significant effects preventing smoking uptake compared with

controls •Pure Prevention cohorts studies which followed participants for more than one year, but not for shorter-term outcomes•Combined social competence and social influences interventions at all time points•Social competence interventions at longest follow-up

Implications for Research

• Further studies of social competence and combined social competence and social influences programmes to explore potential of these interventions

• Further research to design and test programmes that will be optimally effective for both genders

• Further research to identify factors that can be tailored to the requirements of different ethnic groups

• Studies need to follow-up participants > one year

Implications for Research

• Studies should clearly identify and follow separately students in different stages of their smoking career (never-smokers, experimenters, quitters, smokers of different frequencies and intensities), as composite change rates and point prevalence scores at baseline and follow-up make findings difficult to interpret

• Outcome measures should be standardised at trial design stage

• Studies are needed across all cultural areas of the world

• There is minimal information on the costs of designing and implementing these programmes. Economic evaluation is important, in view of the fact that many interventions have not proven their effectiveness

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

Poll Question #4

Poll Question #5Do 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]

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