Health Evidence hosted a 60 minute webinar examining the effectiveness of school-based smoking prevention curricula in keeping children and adolescents never-smokers. Dr. Roger Thomas, Professor, Faculty of Medicine, University of Calgary, presented findings from his latest systematic reviews on school-based smoking prevention: Thomas, R., McLellan, J., & Perera, R. (2013). School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews, 2013 (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). Evidence Summary:Thomas, R.E., McLellan, J., Perera, R., Sully, E.P. & Dobbins, M. (2015). School-based smoking prevention curricula: Evidence and implications for public health. Hamilton, ON: McMaster University. Over the past three decades, the school environment has been a particular focus of efforts to influence youth smoking behaviour. This review examines the effectiveness of school-based smoking prevention curricula in keeping children never-smokers. 50 RCTs (74 different intervention arms, n=143 495) are included in this review. For baseline child and adolescent never-smokers, a significant effect in preventing starting smoking (12%) was found at the longest follow up. However, there was no effect of school-based smoking prevention curricula at ≤1 year except for social competence and combined social competence + social skills curricula. This webinar will highlight which curricula types are most effective, as well as the gaps in knowledge that remain with regard to smoking prevention curricula in youth.

1. Welcome!
School-based programmes
for preventing smoking in
children and adolescents:
What's the Evidence?
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2. 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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1. Saves you time
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7. 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]

8. 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]

9. Poll Question #1
Have you heard of PICO(S) before?
1.Yes
2.No

10. Searchable Questions
Think “PICOS”
1. Population (situation)
2. Intervention (exposure)
3. Comparison (other group)
4. Outcomes
5. Setting

11. How often do you use Systematic Reviews
to inform a program/services?
A.Always
B.Often
C.Sometimes
D.Never
E.I don’t know what a systematic review is
Poll Question #2

12. 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

13. Review
Thomas, 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).

14. 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?

15. 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

16. Review Focus
P 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

17. School-based interventions prevent
children and adolescents from starting to
smoke
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree
17
Poll Question #3

18. Outline
1. Overview of included trials
2. School interventions compared to no
intervention, baseline never smokers
3. Examples of social skills and social
competence interventions
4. Conclusions for practice
5. Conclusions for research

19. 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

20. Overview of Trials
Pure 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

21. 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

22. 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

23. Risk of Bias
Risk of bias graph schools.svg

24. Results: Pure prevention cohort (49 C-
RCTs, 73 arms): Follow-up < 1 year
Curriculum 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

25. Results: Pure prevention cohort (49 C-
RCTs, 73 arms): Follow-up ≥ 1 year
Curriculum 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

26. Data by Gender:
Follow-up < 1 year (7 studies)
OR 95%CI p
Females 0.69 0.49, 0.96 0.04
Males 0.66 0.44, 0.98 0.04
No effect for follow-up ≥ 1 year

27. Adult-led curricula (56 studies)
OR 95%CI p
All curricula 0.88 0.81, 0.96 0.002
Social competence 0.52 0.30, 0.88 0.02
Social 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

28. 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)

29. Effect of booster sessions
after the curriculum
OR 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

30. Spoth (2002): Example of combined social
influences + social competence intervention
Social 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

31. Spoth (2002): Example of combined social
influences + social competence intervention
Social 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

32. Resnicow (2008): Example of combined social
influences + social competence intervention
Life 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

33. Resnicow (2008): Example of combined social
influences + social competence intervention
Social 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

34. 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

35. 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

36. 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

37. School-based interventions prevent
children and adolescents from starting to
smoke
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree
Poll Question #4

38. Poll Question #5
Do you agree with the findings of this
review?
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree

39. Questions?

40. 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]

41. Thank you!
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