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Prevention of Smoking in adolescents with Lower Education

Evidence level:
Best PracticePromising PracticeEmergent Practice
 
Evidence of Effectiveness:
?-0+++
Transferability:
?-0+
Enduring Impact:
?-0+
Review criteria and process

Policy category

Helping Vulnerable Children

Recommendation Pillars

Improve education systems’ impact on equal opportunities, Put in place mechanisms that promote children’s participation in decision making that affect their lives

Countries that have implemented practice

Netherlands

Age Groups

Teenagers (age 13 to 19)

Target Groups

Children

Years in Operation

2012  - still operating

Type of Organization Implementing Practice

National Government

Practice Overview

This intervention was based on peer group pressure and social influence to prevent smoking.  The intervention focused on students in junior secondary education (this is what is meant by ‘lower education’ in the title) and was implemented in twenty six schools throughout the Netherlands. It consisted of three lessons on knowledge, attitudes, and social influence, followed by a class agreement not to start or to stop smoking for five months and a class based competition. Admission to the competition was dependent on having a class with less than 10% smokers after five months. The intervention is similar to the Smokefree Class Competition programme implemented across 22 European countries. The authors added some lessons on attitude and social influence. Two extra video lessons on smoking and social influence were available as an optional extra during these five months. Researchers approached these schools directly and gave them a brief explanation about the intervention in order to motivate them to participate. Eighteen schools agreed to do so. The other eight schools (26 in total) were recruited through four other community health services that approached the schools themselves. Baseline data was obtained through questionnaires administered directly to the students. Data for background characteristics was also obtained through these questionnaires. The Dutch National Institute against Smoking (Stivoro) and The Dutch National Institute on mental Health and Addiction (Trimbos Institute) developed and conducted the intervention together with the schools. Stivoro looked at the adherence of schools to the intervention protocol, and collected the registration forms and other documents.  Evaluation was conducted by the authors of this paper.

 

Last updated 
March, 2014

Sustainability

Transferability

There is no evidence of the program being evaluated in other schools beyond the original study population. Furthermore, the study does not describe in detail the contents of the lessons imparted during the intervention or the contents of the videos on smoking, making it more difficult to replicate. However, the intervention is similar to the Smokefree Class Competition programme implemented across 22 European countries. The authors added some lessons on attitude and social influence. This is something that has been done in several Smokefree Class Competitions in Europe. Please see the EPIC-SmokeFree Class Competition for more information.

Evidence of Effectiveness

Evaluation 1  

Crone, M. R., Reijneveld, S. A., Willemsen, M. C., Van Leerdam, F. J. M., Spruijt, R. D., & Sing, R. H. (2003). Prevention of smoking in adolescents with lower education: a school based intervention study. Journal of epidemiology and community health, 57(9), 675-680.

A clustered randomized control trial (Cluster RCT) was conducted among first grade students in the lower secondary in the Netherlands selected to participate in the study. The main outcome measure was the smoking status of students (before and after, as well as a year after the intervention). “Smoking” was defined as ‘all students who experiment with smoking or who smoke weekly or daily’. The questionnaires were administered immediately before and after the intervention, as well as a follow up a year after the intervention ended. These took place in October 1998, June 1999, and June 2000, respectively. The intervention and control groups were compared in terms of the change of the proportion of smokers before and immediately after the intervention and in terms of the proportion of students who took up smoking.  The analysis used multilevel techniques to account for clustering effects among students in classes and schools.

Summary of Results for Evaluation 1

 

 

Outcome

Results

Outcomes improved (statistically significant)

 

 

Odds ratio of smoking in the intervention group compared to the control group at the first follow up measurement

The odds that a student in the treatment group would be a smoker was .62 lower than a student in the control group

Odds ratio of students taking up smoking in the intervention group compared to the control group at the first follow up measurement

The odds that a student in the treatment group would be take up smoking was .61 lower than a student in the control group

Outcomes with no effect

 

 

Odds ratio of smoking in the intervention group compared to the control group one year after the intervention

The difference between students who smoked in the treatment and control groups ceased to be significant at the .05 level.

 

 

 

 

Issue to consider

 

This programme received an “Emerging” rating. Schools were successfully randomized to treatment and control groups. Differences in baseline characteristics between groups, although statistically significantly different from zero, are a concern. However, these could not be attributed to self-selection due to the experimental nature of the study. The study acknowledges this and states that chance confounding because of the randomization at school level may explain these differences. The authors adjusted for this difference in their analysis. Measurements were self-reported, so the possibility of information bias exists, especially within the intervention group. The study prevented this bias by conducting a registration for the competition that was independent from the evaluation. Smoking and taking up smoking were directly related to outcomes identified in the beginning of the study. Outcomes were measured at the baseline and both follow ups, with characteristics and sample sizes for both intervention and control groups, as well as characteristics at baseline for non-response group. The Dutch National Institute against Smoking (Stivoro) and The Dutch National Institute on mental Health and Addiction (Trimbos Institute) developed and conducted the intervention together with the schools.

Contact Information

Name

 

M. R. Crone

Title

 Dr.

Organization

 TNO Prevention and Health

Address

 

PO Box 2215, Leiden, Netherlands

Phone

 

Email

 mrcrone@pg.tno.nl

Website

http://stivoro.nl/

Available Resources

 

http://stivoro.nl/

Evaluation Details

 

Recruitment for schools and students was made step by step. First, all community health services in the country, except for three that were participating in another study, were asked to join the study and to provide the names of the schools that were probably prepared to participate. Fourteen community health services provided names for 48 schools. Researchers approached these schools directly and gave them a brief explanation about the intervention in order to try and motivate them to participate. Eighteen schools agreed to do so. The other eight schools (26 in total) were recruited through four other community health services that approached the schools themselves. The intervention lasted five months because it had to fit in one school year. Admission to the final competition, meaning groups that were eligible to participate in the study and win prizes, as well as agreeing as a class to not start smoking or to stop smoking for the next five months, was restricted to classes that filled out three registration forms on smoking status at the beginning of, halfway through, and at the end of the agreement period. In order to win competition prizes (ranging from 220 to 450 Euro) the classes had to have less than 10% smokers after five months. This cutoff point was established because <10% of class smokers is less than the mean percentage of smokers among Dutch students in the first grade of secondary education.   

Immediately after the intervention, the study found that the odds that students in the treatment group would smoke or take up smoking were lower than for those in the control groups. For the second follow up, the effects of the intervention ceased to be significant due to the high attrition rate for both groups.

Bibliography

Crone, M. R., Reijneveld, S. A., Willemsen, M. C., Van Leerdam, F. J. M., Spruijt, R. D., & Sing, R. H. (2003). Prevention of smoking in adolescents with lower education: a school based intervention study. Journal of epidemiology and community health, 57(9), 675-680.

Date

Cost information

Scale of Implementation

Enduring Impact

 

Even though a one-year follow up was conducted after the intervention took place, no significant effects were found. It is not clear whether this was due to attrition or other factors. A 2-year follow up was not conducted on this programme.

Years in Operation

 Data was first obtained in October, 1998 (the beginning of the school year). First and second follow ups took place in June, 1999 and June, 2000, respectively. The first follow up took place immediately after the intervention, while the second one was taken a year after the intervention. The programme ran from 1999 until about 2009/2010 and is no longer in operation.

 

Last updated
March, 2014