School-based Smoking Prevention Intervention Research Articles

The Impact of Implementation Fidelity of a School-Based Multi-Component Smoking Prevention Intervention on Vocational Students’ Smoking Behavior: A Cluster-Randomized Controlled Trial

Preventing young people’s cigarette smoking is a major public health priority, and smoking is especially prevalent in vocational schools. Well-enforced comprehensive school tobacco policies accompanied by preventive efforts show potential to reduce smoking, but the implementation process is crucial to achieve the intended effect. We investigate whether and how implementation fidelity of a multi-component smoking prevention intervention impacted student smoking outcomes after 4–5 months among students in Danish vocational education and training (national age range 15–65 years, mean 25.6) and preparatory basic education (national age range 15–25 years, mean 17.6) institutions using questionnaire data from a cluster-RCT. The intervention included a smoke-free school hours policy, educational curriculum, and class competition. We calculated an overall implementation fidelity measure combining staff-reported school-level delivery (fidelity) and student-reported receipt (participation, responsiveness), and used multilevel regression models to analyze associations with smoking outcomes (smoking daily, regularly, and during school hours). We supplemented the analysis with restricted cubic spline regression. Additionally, we stratified the analyses by school types and analyzed associations between implementation fidelity of the separate intervention components and smoking outcomes. High implementation was associated with lower odds of regular smoking (OR: 0.37, 95% CI: 0.18–0.78) and smoking during school hours, but not daily smoking, and these associations varied between the school settings. When analyzed separately, implementation fidelity of the components did not affect the outcomes significantly. Our findings underline the need to support the implementation process of school tobacco policy interventions to ensure the intended effects of reducing students’ smoking.

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

ObjectiveTo 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...

Cultural adaptation of two school-based smoking prevention programs in Bogotá, Colombia

Smoking prevention among adolescents is a public health challenge that is even more significant in low- and middle-income countries where local evidence is limited and smoking rates remain high. Evidence-based interventions could be transferred to low- and middle-income country settings but only after appropriate cultural adaptation. This paper aims to describe the process of the cultural adaptation of two school-based smoking prevention interventions, A Stop Smoking in Schools Trial and Dead Cool, to be implemented in Bogotá, Colombia. A recognized heuristic framework guided the cultural adaptation through five stages. We conducted a concurrent nested mixed-methods study consisting of a qualitative descriptive case study and a quantitative pre- and post quasi-experiment without a control. Contextual, content, training, and implementation modifications were made to the programs to address cultural factors, to maintain the fidelity of implementation, and to increase the pupils’ engagement with the programs. Modifications incorporated the suggestions of stakeholders, the original developers, and local community members, whilst considering the feasibility of delivering the programs. Involving stakeholders, original program developers, and community members in the cultural adaptation of evidence-based interventions is essential to properly adapt them to the local context, and to maintain the fidelity of program implementation.

Gender differences in attitudes towards a school-based smoking prevention intervention.

There are well-known gender differences in smoking, including the pattern of use and the effectiveness of smoking prevention programs. However, little is known about the differences between boys and girls in their attitudes towards smoking prevention interventions. This study explores gender differences in attitudes towards a school-based intervention to prevent smoking. We used data from the X:IT II intervention study conducted in 46 Danish elementary schools. Compared to boys, girls were more positive towards smoke-free school time, both concerning rules for teachers smoking (odds ratio (OR) = 1.69, 95% confidence interval (CI): 1.35-2.12) and for students smoking (OR = 1.41, 95% CI: 1.13-1.76). No difference was observed in students signing the smoke-free agreement. However, a larger proportion of girls reported that the agreement was a good occasion to talk about smoking with their parents (OR = 1.36, 95% CI: 1.13-1.76). Girls were also more positive towards the smoke-free curriculum (OR = 1.52, 95% CI: 1.19-1.94). This study showed that girls were, overall, more positive towards the components of the smoking preventive intervention. Our findings highlight the importance of considering differences in intervention preferences for boys and girls in future health prevention initiatives.

MECHANISMS Study: Using Game Theory to Assess the Effects of Social Norms and Social Networks on Adolescent Smoking in Schools-Study Protocol.

This proof of concept study harnesses novel transdisciplinary insights to contrast two school-based smoking prevention interventions among adolescents in the UK and Colombia. We compare schools in these locations because smoking rates and norms are different, in order to better understand social norms based mechanisms of action related to smoking. We aim to: (1) improve the measurement of social norms for smoking behaviors in adolescents and reveal how they spread in schools; (2) to better characterize the mechanisms of action of smoking prevention interventions in schools, learning lessons for future intervention research. The A Stop Smoking in Schools Trial (ASSIST) intervention harnesses peer influence, while the Dead Cool intervention uses classroom pedagogy. Both interventions were originally developed in the UK but culturally adapted for a Colombian setting. In a before and after design, we will obtain psychosocial, friendship, and behavioral data (e.g., attitudes and intentions toward smoking and vaping) from ~300 students in three schools for each intervention in the UK and the same number in Colombia (i.e., ~1,200 participants in total). Pre-intervention, participants take part in a Rule Following task, and in Coordination Games that allow us to assess their judgments about the social appropriateness of a range of smoking-related and unrelated behaviors, and elicit individual sensitivity to social norms. After the interventions, these behavioral economic experiments are repeated, so we can assess how social norms related to smoking have changed, how sensitivity to classroom and school year group norms have changed and how individual changes are related to changes among friends. This Game Theoretic approach allows us to estimate proxies for norms and norm sensitivity parameters and to test for the influence of individual student attributes and their social networks within a Markov Chain Monte Carlo modeling framework. We identify hypothesized mechanisms by triangulating results with qualitative data from participants. The MECHANISMS study is innovative in the interplay of Game Theory and longitudinal social network analytical approaches, and in its transdisciplinary research approach. This study will help us to better understand the mechanisms of smoking prevention interventions in high and middle income settings.

Smoking initiation in Italian regions, 2014, and Regional Prevention Plans

to evaluate smoking prevalence in adolescents by Italian region from the Health Behaviour Study in School-aged Children (HBSC) of 2014 and to correlate it with the presence, in the 2014-2018 Regional Prevention Plans (PRPs), of school-based smoking prevention interventions. the 2014 HBSC surveillance system provided data on 48,000 adolescents aged 11, 13, and 15 years; Ministry of Health provided data for each PRP on interventions with a tobacco control component and, among them, school-based smoking prevention interventions. weekly smoking prevalence; proportion of school-based smoking prevention interventions out of prevention interventions with tobacco control measures. regions with the highest weekly smoking prevalence were Sardinia and Apulia for all age groups, Abruzzo for 11- and 15-year-old children, Basilicata for 15-year-old children, Bolzano for girls aged 13 years old; Liguria for females, Molise, Calabria, and Veneto for males. In the regions with the highest prevalence of smoking in 2014, in girls aged 11 and 13 years (Sardinia, Apulia, Basilicata, Liguria, Bolzano), a greater proportion of school-based smoking prevention interventions to be developed in the period 2014-2018 have been recorded. smoking prevalence in Italian adolescents is high, especially in 15-year-old children. Implementing policies recommended by the World Health Organization - Framework Convention on Tobacco Control (higher tobacco taxes, anti-tobacco mass media campaigns, plain tobacco package) could work synergistically with school-based interventions in order to decrease tobacco initiation among adolescents in Italy.

Smoking Habit Prevention in Schools: Report of a Pediatric Educational Intervention Held in Pisa

Introduction: Smoking is the leading preventable cause of death in the world and the detrimental effects of tobacco on health have been described across the full life span. There is no safe level of tobacco exposure and childhood is the more vulnerable period of life. Current estimates show that 10% of children aged 13-15 years are active smokers and most of them started smoking at >11 years of age, due to peer and/or family influence. Moreover, recently, e-cigarette use has spread, particularly among youth. Many school-based smoking prevention interventions have been carried out around the world, the efficacy of which has yet to be established. Materials and methods: In February 2018 we planned an educational program on smoking habit within the Italian Society of Pediatric Respiratory Diseases (SIMRI) (“Dai un calcio al fumo” program). In May 2018 we held 8 interventions at the Fibonacci School (Pisa, Italy), meeting 365 children aged 9 to 13 years and involving a pediatrician and a pediatric resident in a 2-hour lesson focusing on the importance of a healthy lifestyle and smoking habit effects. The children were invited to ask questions and talk about their experiences, with a subsequent 30-minutes collegial discussion. The most frequent questions were collected, as well as students’, physicians’ and teachers’ opinions on each meeting. Results: During our educational interventions the most frequently asked questions were about the discrepancy related to the fact that a dangerous product is legally sold and the potential harmful effects of e-cigarettes. All the children stated that they knew that combustible cigarette smoking was dangerous. Most of them admitted that they feel that smoking habits start from emulating friends and relatives. Almost 70% of the children reported to have at least one smoker relative. Teachers, physicians and students proposed to replicate the meetings the following year. Conclusions: The considerable interest shown by the students, together with the low cost and potential effectiveness of school-based educational measures, suggest that in our country a national educational program should be introduced in schools. Too many children are still exposed to tobacco smoke in the household environment.

School-based Smoking Prevention in Adolescents in Developing Countries: A Literature Review

BACKGROUND: The incidence of diseases due to tobacco consumption has increased, especially in developing countries, where around 90% of smokers start consuming tobacco before the age of 18 years. School-based smoking prevention programs can prevent smoking among adolescents. This program is often implemented in developing countries because it is considered cost-effective, and the results are promising. At present, the school-based smoking prevention program is expanding with many methods.
 AIM: This study aims to describe the various types of school-based smoking prevention interventions in developing countries.
 METHODS: This research applied a literature review approach with the process of collecting data through the Science Direct, ProQuest, EBSCO, and NCBI databases. Search literature was by keyword “smoking AND prevention AND school-based AND adolescent AND randomized controlled trials or randomized controlled trials.” Inclusion criteria used for data collection were studies on school-based smoking prevention interventions, full text, and journal publishing from 2015 to 2019, using English. The research conducted in developing countries and prevention interventions was not only for smoking in the traditional way but also in the form of other than the consumption of tobacco such as cigars, smokeless tobacco, and hookah or shisha. Exclusion criteria in this review were publication articles not in the form of original publications such as letters to editors, only abstracts, and books.
 RESULTS: The literature search results found 594 journals with details of 99 Science direct journals, ProQuest 385 journals, NCBI 85 journals, and 25 EBSCO journals. The entire database belongs to the inclusion criteria and only seven articles meet the requirements. The results of the analysis revealed that interventions conducted in school-based smoking prevention programs for adolescents in developing countries included the application of the anti-smoking curriculum, behavior change intervention (BCI), and peer education.
 CONCLUSION: Interventions considered useful for preventing smoking in adolescents are the anti-smoking curriculum, BCI, and peer education.

Diffusion of effects of the ASSIST school-based smoking prevention intervention to non-participating family members: a secondary analysis of a randomized controlled trial.

AimsTo investigate whether effects of the ASSIST (A Stop Smoking In Schools Trial) school‐based smoking prevention intervention diffused from students to the people they lived with.DesignSecondary analysis of a cluster‐randomized control trial (cRCT).SettingEngland and Wales.ParticipantsA total of 10 730 students aged 12–13 years in 59 schools assigned using stratified block randomization to the control (29 schools, 5372 students) or intervention (30 schools, 5358 students) condition.Intervention and comparatorThe ASSIST intervention involves 2 days of off‐site training of influential students to encourage their peers not to smoke during a 10‐week period. The control group continued with their usual education.MeasurementsThe outcomes were the proportion of students who self‐reported living with a smoker and the smoking status of each resident family member/caregiver. Follow‐up assessments were immediately after the intervention and at 1 and 2 years post‐intervention.FindingsThe odds ratio (OR) for living with a smoker in the intervention compared with the control groups was 0.86 [95% confidence interval (CI) = 0.72, 1.03] immediately after the intervention, OR = 0.84 (95% CI = 0.72, 0.97) at a 1‐year follow‐up and OR = 0.86 (95% CI = 0.75, 0.99) at 2‐year follow‐up. In a three‐tier multi‐level model with data from all three follow‐ups, student‐reported smoking by fathers (OR = 0.90, 95% CI = 0.80, 1.00), brothers (OR = 0.78, 95% CI = 0.67, 0.92) and sisters (OR = 0.80, 95% CI = 0.69, 0.92) was lower in the intervention compared with control group. Subgroup analyses by baseline smoking status suggested that these effects were more consistent with prevention of uptake than prompting cessation.ConclusionsA Stop Smoking In Schools Trial (ASSIST) school‐based smoking prevention intervention may have reduced the prevalence of smoking in people who lived with ASSIST‐trained students. This indirect transmission is consistent with the predictions of diffusion of innovations theory which underpins the design of ASSIST.

Sex differences in the attitudes towards a school-based smoking prevention intervention

Sex differences in the attitudes towards a school-based smoking prevention intervention

The importance of social environment in preventing smoking: an analysis of the Dead Cool intervention

BackgroundAn adolescent’s perceptions of their family’s and friends’ smoking attitudes and behaviour can influence their own uptake of smoking. There are two broad sources of such social influence: observing the behaviour directly, and assimilating attitudes.MethodsWe analysed data collected for the evaluation of Dead Cool, a school based smoking prevention intervention in Northern Ireland (n=480 in 20 clusters). The main analysis fits three nested logistic regression models predicting pre-intervention susceptibility to taking up smoking, as reflected in responses to three attitudinal questions. Model 1 includes only personal characteristics as explanatory factors. Model 2 adds the behaviour of friends and family that would provide an opportunity for social influence through observational learning. Model 3 adds the susceptibility of friends.ResultsEach additional group of variables improved the model fit (with reduced AIC and BIC). However, in the final model, only three variables were found to be statistically significant (p<0.05) in predicting susceptibility to smoking initiation: rebelliousness (OR [1.1,1.3]) from the personal characteristics group; and, in the observational learning group, being friends with a smoker (OR [1.0,2.9]) and frequency of being in the same room or car with someone smoking (OR [2.0,9.0] for most frequent). Adding the two measures of diffusion of susceptibility through the friendship network improved the model fit, but neither was found to be statistically significant.ConclusionsThe analysis provides additional evidence to support policies that could reduce children’s exposure to smoking behaviour, and potential subsequent smoking initiation. No conclusions could be drawn about the diffusion of smoking attitudes through the school friendship networks of children.

Bayesian evaluation of informative hypotheses in cluster-randomized trials

Researchers often have informative hypotheses in mind when comparing means across treatment groups, such as H1 : μA < μB < μC and H2 : μB < μA < μC, and want to compare these hypotheses to each other directly. This can be done by means of Bayesian inference. This article discusses the disadvantages of the frequentist approach to null hypothesis testing and the advantages of the Bayesian approach. It demonstrates how to use the Bayesian approach to hypothesis testing in the setting of cluster-randomized trials. The data from a school-based smoking prevention intervention with four treatment groups are used to illustrate the Bayesian approach. The main advantage of the Bayesian approach is that it provides a degree of evidence from the collected data in favor of an informative hypothesis. Furthermore, a simulation study was conducted to investigate how Bayes factors behave with cluster-randomized trials. The results from the simulation study showed that the Bayes factor increases with increasing number of clusters, cluster size, and effect size, and decreases with increasing intraclass correlation coefficient. The effect of the number of clusters is stronger than the effect of cluster size. With a small number of clusters, the effect of increasing cluster size may be weak, especially when the intraclass correlation coefficient is large. In conclusion, the study showed that the Bayes factor is affected by sample size and intraclass correlation similarly to how these parameters affect statistical power in the frequentist approach of null hypothesis significance testing. Bayesian evaluation may be used as an alternative to null hypotheses testing.

Facilitators and barriers to the delivery of school-based smoking prevention interventions for children and young people: a protocol for a systematic review of qualitative studies

BackgroundDespite a decline in child and adult smoking prevalence, young people who smoke (even occasionally) can rapidly become addicted to nicotine, with most adult smokers initiating smoking before they are 18. Schools have long been a popular setting to deliver youth smoking prevention interventions, but evidence of the effectiveness of school-based prevention programmes is mixed, and outcomes vary by the type of programme delivered. Existing systematic reviews that explore the factors contributing to the success or failure of school-based smoking prevention programmes often exclude qualitative studies, due to a focus on intervention effectiveness which qualitative research cannot answer. Instead, qualitative research is focussed on the experiences and perceptions of those involved in the programmes. This systematic review will address this gap by updating a 2009 review to examine qualitative studies. The aim is to generate deeper insight to help target resources which have the potential to save lives by preventing smoking initiation among children and young people.MethodsThis systematic review will be searching the following databases: the Cochrane Library, MEDLINE, EMBASE, PsycINFO, HMIC, ERIC, ASSIA, Web of Science and CINAHL. In order to identify additional references, we will consult the reference lists of a sample of systematic reviews and search relevant organizational websites in order to identify appropriate grey literature. The search strategy will include key words and database-specific subject headings relating to smoking, children and young people, health promotion and school. Authors will independently screen, assess data quality and extract data for synthesis. Study findings will be synthesised thematically using ‘best-fit framework syntheses’. This allows for an existing set of themes to be used as a starting point to map or code included studies. These themes are then adapted as coding takes place to accommodate new emerging themes.DiscussionThis review will focus on qualitative studies that seek to examine the barriers and facilitators to the delivery of school-based smoking prevention programmes in order to inform the design of future theory-based interventions in schools to prevent children and young people from smoking.Systematic review registrationPROSPERO CRD42014015483

A school-based peer-led smoking prevention intervention with extracurricular activities: the LILT-LdP cluster randomized controlled trial design and study population.

Few school programs are effective in preventing adolescents' tobacco smoking initiation. The "Lega contro i Tumori - Luoghi di Prevenzione" is a cluster randomized controlled trial designed to evaluate a school-based peer-led smoking prevention intervention with extracurricular activities for students aged 14-15 years. This paper presents the study design and the baseline characteristics of the study population. Twenty secondary schools located in the Reggio Emilia province took part in the study. Five schools were excluded because they already participated in smoking prevention interventions. The schools were randomized to control or intervention arms. The study population consisted of students attending the first grade. Components of the intervention included 1) the out-of-school "Smoking Prevention Tour" (SPT) at the "Luoghi di Prevenzione" Center, a 4-hour (4 sessions) extracurricular activity; 2) the "Smoke-free Schools" intervention, combining a life-skills-based peer-led intervention at school, an in-depth lesson on one of the SPT sessions, and enforcement surveillance of the school antismoking policy. Tobacco use was studied through a questionnaire administered before and 6 months after the intervention. Eleven high schools and 9 vocational secondary schools took part in the study for a total of 2,476 out of 3,050 eligible students (81.2%). The proportions of respondents in high schools and vocational secondary schools were 90.9% and 64.5%, respectively (P <0.001). Intervention and control arms showed a different distribution of gender and school type, whereas no difference was observed in any tobacco-use characteristic. This study is one of the few Italian trials to evaluate the effectiveness of a school-based program for preventing smoking initiation.

Adaptation of the ASSIST peer-led smoking intervention to deliver information from the Talk to FRANK drug education website (ASSIST+FRANK): a pilot cluster-randomised controlled trial

BackgroundIllicit drug use increases the risk of poor physical and mental health. Few effective school-based drug prevention interventions are available. We adapted an effective school-based peer-led smoking prevention intervention (ASSIST) to deliver information from the UK national drug education website, FRANK MethodsWe conducted a four-arm pilot cluster-randomised control trial of 1567 students aged 12–13 years in 12 schools in Wales. Three schools each (mean number students per year 131) were randomly allocated to: ASSIST+FRANK, FRANK friends, ASSIST, or usual practice which may or may not include drug eduation. ASSIST+FRANK is a peer-led smoking prevention intervention in UK Year 8 (ASSIST) followed by a drug prevention adjunct in Year 9 (+FRANK). FRANK friends is a stand-alone peer-led drug prevention intervention in Year 9. ASSIST involves 2 days off-site training, plus four follow-up sessions. +FRANK involves 1 day off-site training plus 3 follow-ups. FRANK friends involves 2 days off-site training and four follow-ups. Influential students were trained to disseminate information on the risks of drug use and minimising harms. Primary outcome was the acceptability of the +FRANK and FRANK friends, which was assessed through interviews with students, staff, parents, and intervention staff (n=66), structured observations of delivery (195), exploratory effectiveness analysis (multilevel logistic models), and estimated costs. Secondary outcome was the lifetime use of any illicit drugs at 18 months. Intention-to-treat analyses were conducted unmasked to the intervention allocation. This trial was approved by Cardiff University School of Social Sciences Research Ethics Committee (SREC/ 1103; ISRCTN 14415936). FindingsAll 12 schools were recruited, randomised, and retained (ASSIST+FRANK 419 students, FRANK friends 440, ASSIST 347, usual practice 361). At the 18 month follow-up the student retention rate was 93% (1460/1567). +FRANK and FRANK friends were acceptable to students, teachers, and parents, and delivered as intended, but FRANK friends was preferred over +FRANK. Some staff felt pressured to meet all the learning objectives for +FRANK in 1 day training versus 2 days in FRANK friends. There could also have been a lack of novelty for +FRANK peer supporters since they had previously experienced the ASSIST intervention. The odds of lifetime drug use at 18 months was marginally lower in both the +FRANK arm and the FRANK friends arm than in the usual practice arm (38 [12·4%] of 307 vs 34 [13·4%] of 254 [odds ratio 0·96, 95% CI 0·58–1·59] and 30 [9·3%] vs 34 [13·4%] [0·70, 0·39–1·24], respectively). The estimated cost per school was £1942 for +FRANK and £3041 for FRANK friends. All progression criteria were met. InterpretationAlthough both interventions were acceptable to students, teachers, and parents, FRANK friends was preferred over +FRANK. There is, therefore, sufficient evidence to warrant a full-scale cluster-randomised controlled trial of FRANK friends. FundingNational Institute for Health Research Public Health Research programme (for the research), Public Health Wales (for the intervention delivery).

Mediating factors of a school-based multi-component smoking prevention intervention: the LdP cluster randomized controlled trial.

The aim of this study was to investigate factors mediating the effects of Luoghi di Prevenzione (LdP) smoking prevention intervention based on social competence and social influence approaches, and characterized by peer-led school-based interventions, out-of-school workshops, school lessons, and by enforcing the school anti-smoking policy. Students aged 14-15 years in 13 secondary schools in Reggio Emilia, Italy (989 students) were randomly assigned to the LdP intervention or a control condition. The baseline and follow-up surveys were carried out before and 18 months after the intervention, respectively.The outcomes were cigarette daily and frequent smoking and smoking at school. Multilevel multiple mediation analyses were carried out in order to study effect mediation. The mediators were normative perception, positive and negative beliefs, refusal skills for smoking, social acceptability perception, risk perception, smoking knowledge and awareness about dangers of second-hand smoking.The intervention effects were explained by the social influence component through the mediator refusal skills for smoking. The programme also showed to significantly increase risk perception and smoking knowledge, even though these mediators had no effect on smoking. Moreover, LdP intervention directly reduced smoking in school areas. Future interventions should maintain and strengthen the LdP social influence component and the part regarding the school anti-smoking policy.

Operation Smoke Storm: effectiveness of a school-based smoking prevention intervention providing insight into the tobacco industry

BackgroundAssessment of the US Truth campaign showed that mass media campaigns informing children about tobacco industry practices are effective in preventing smoking uptake. The aim of this study was to assess the potential effectiveness of a school-based intervention, based on the premise of Truth, in reducing ever smoking and susceptibility to smoking among children in the UK. MethodsData come from a pilot study intended to test the acceptability of the intervention and ease of delivery, and to provide preliminary evidence of effectiveness before further assessment in a randomised trial. 445 students in two schools in the East Midlands, UK, completed anonymous questionnaires in Year 7 (ie, aged 11–12 years) and Year 8 (12–13), before and after receiving the Operation Smoke Storm intervention. This intervention consisted of three teacher-led sessions that combined interactive paper-based and audio-visual components in Year 7 and one booster session in Year 8. We used multilevel logistic regression (students nested within schools), adjusted for confounders, to compare the odds of smoking and susceptibility at follow-up in students who received Operation Smoke Storm with 1692 students in eight local schools who were asked identical questions about smoking behaviour as part of another survey but who did not receive the intervention. The study was approved by the University of Nottingham Medical School Research Ethics Committee (reference C13122012 CHS EPH Smoking). FindingsPrevalence of ever smoking or susceptibility to smoking was similar in intervention and control schools in Year 7. In Year 8, 34 students (7·6%) who received Operation Smoke Storm reported ever smoking and 111 (24·9%) reported susceptibility to smoking; 175 students (10·3%) who did not receive Operation Smoke Storm reported ever smoking and 329 (19·4%) reported susceptibility. There was no significant difference in the odds of a combined outcome of ever smoking or susceptibility to smoking in students who received the intervention compared with controls (adjusted odds ratio 1·28, 95% CI 0·83–1·97; p=0·263), and no difference in odds of ever smoking (0·82, 0·42–1·58; p=0·549). InterpretationOperation Smoke Storm does not seem to have reduced smoking and susceptibility to smoking among students aged 12–13 years in two UK schools. Qualitative analysis is ongoing to explore students’ and teachers’ perceptions of Operation Smoke Storm and potential reasons to explain the apparent lack of effectiveness. FundingThe National Institute for Health Research Public Health Research Programme (NIHR PHRP) (project number 11/3010/02). The funder had no role in the writing of the abstract or the decision to submit.

Challenges to obtaining parental permission for child participation in a school-based waterpipe tobacco smoking prevention intervention in Qatar.

BackgroundInvolving children in research studies requires obtaining parental permission. A school-based intervention to delay/prevent waterpipe use for 7th and 8th graders in Qatar was developed, and parental permission requested. Fifty three percent (2308/4314) of the parents returned permission forms; of those 19.5% of the total (840/4314) granted permission. This paper describes the challenges to obtaining parental permission. No research to date has described such challenges in the Arab world.MethodsA random sample of 40 schools in Doha, Qatar was selected for inclusion in the original intervention. Permission forms were distributed to parents for approval of their child’s participation. The permission forms requested that parents indicate their reasons for non-permission if they declined. These were categorized into themes. In order to understand reasons for non-permission, interviews with parents were conducted. Phone numbers of parents were requested from the school administration; 12 of the 40 schools (30%) agreed to provide the contact information. A random sample of 28 parents from 12 schools was interviewed to reach data saturation. Thematic analysis was used to analyze their responses.ResultsReasons for non-permission documented in both the forms and interviews included: poor timing; lack of interest; the child not wanting to participate; and the child living in a smoke-free environment. Interviews provided information on important topics to include in the consent forms, parents’ decision-making processes regarding their child’s participation, and considerations for communicating with parents. Many parents also indicated that this was the first time they had been asked to give an informed consent for their child’s participation in a study.ConclusionsResults indicate that more attention needs to be given to the informed parental consent process. Researchers should consider enhancing both the methods of communicating information as well the specific information provided. Before embarking on recruitment of children for studies, formative research on the parental consent process is suggested.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6939-15-70) contains supplementary material, which is available to authorized users.

Effectiveness of a school-based multi-component smoking prevention intervention: The LdP cluster randomized controlled trial

ObjectiveWe assessed the effectiveness of the Luoghi di Prevenzione-Prevention Grounds school-based smoking prevention programme. MethodsWe undertook a cluster randomized controlled trial of 989 students aged 14–15years in 13 secondary schools located in Reggio Emilia, Italy. The intervention consisted of the “Smoking Prevention Tour” (SPT) out-of-school workshop, one in-depth lesson on one Smoking Prevention Tour topic, a life-skills peer-led intervention, and enforcement surveillance of school antismoking policy. Self-reported past 30-day smoking of ≥20 or 1–19days of cigarette smoking (daily or frequent smoking, respectively) was recorded in 2 surveys administered immediately before and 18months after the beginning of the programme. Analysis was by intention to treat. The effect of the intervention was evaluated using random effects logistic regression and propensity score-matching analyses. ResultsPast 30-day smoking and daily cigarette use at eighteen months follow-up were 31% and 46% lower, respectively, for intervention students compared to control students. Taking into account non-smokers at baseline only, daily smoking at eighteen months follow-up was 59% lower in intervention students than in controls. Past 30-day smoking in school areas was 62% lower in intervention students compared to controls. ConclusionsThe Luoghi di Prevenzione-Prevention Grounds programme was effective in reducing daily smokers and in reducing smoking in school areas.

A School-Based Peer-Led Smoking Prevention Intervention with Extracurricular Activities: The LILT-LdP Cluster Randomized Controlled Trial Design and Study Population

Few school programs are effective in preventing adolescents' tobacco smoking initiation. The "Lega contro i Tumori - Luoghi di Prevenzione" is a cluster randomized controlled trial designed to evaluate a school-based peer-led smoking prevention intervention with extracurricular activities for students aged 14-15 years. This paper presents the study design and the baseline characteristics of the study population. Twenty secondary schools located in the Reggio Emilia province took part in the study. Five schools were excluded because they already participated in smoking prevention interventions. The schools were randomized to control or intervention arms. The study population consisted of students attending the first grade. Components of the intervention included 1) the out-of-school "Smoking Prevention Tour" (SPT) at the "Luoghi di Prevenzione" Center, a 4-hour (4 sessions) extracurricular activity; 2) the "Smoke-free Schools" intervention, combining a life-skills-based peer-led intervention at school, an in-depth lesson on one of the SPT sessions, and enforcement surveillance of the school antismoking policy. Tobacco use was studied through a questionnaire administered before and 6 months after the intervention. Eleven high schools and 9 vocational secondary schools took part in the study for a total of 2,476 out of 3,050 eligible students (81.2%). The proportions of respondents in high schools and vocational secondary schools were 90.9% and 64.5%, respectively (P <0.001). Intervention and control arms showed a different distribution of gender and school type, whereas no difference was observed in any tobacco-use characteristic. This study is one of the few Italian trials to evaluate the effectiveness of a school-based program for preventing smoking initiation.