Effectiveness of School-based Interventions for Preventing Tobacco Smoking Initiation Among Young People in Low-and-middle-income Countries: a Systematic Review Protocol.

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Effectiveness of School-based Interventions for Preventing Tobacco Smoking Initiation Among Young People in Low-and-middle-income Countries: a Systematic Review Protocol.

https://doi.org/10.21203/rs.3.rs-697306/v1

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Background: In-school young people in Low- and Middle-Income Countries (LMICs) are more likely to initiate tobacco use, sustain its use, and are at a higher risk of tobacco related-harms compared to their counterparts in High-Income Countries. Synthesized evidence however on the effectiveness of school-based tobacco prevention interventions for preventing tobacco initiation among young people in LMICs are not documented. We aim to evaluate the effectiveness of school-based interventions compared to non-intervention school programmes in preventing tobacco smoking initiation among young people in LMICs, including Ghana.

Methods: The JBI methodology for systematic reviews of effectiveness will guide the conduct of this review. A comprehensive strategic search will be developed to retrieve both published and unpublished studies. Studies published in the English language from the year 2000 will be considered for the review. The processes of study selection, critical appraisal, data extraction, and data synthesis will be in accordance with the JBI approach for reviews of effectiveness. The primary outcome for the review will be the non-initiation of tobacco smoking by the youth.

Discussion: We anticipate providing synthesized evidence on the effectiveness of school-based smoking initiation prevention among young people in LMICs. The findings could also support policymakers in regulating and implementing smoke-free laws.

Systematic review registration: PROSPERO CRD42021246206

Health Economics & Outcomes Research

Smoking

School-based intervention

education

smoking initiation prevention

Randomised

Youth

students

Tobacco use may be defined as any habitual use of the tobacco plant leaf and its products (1). The use of tobacco products by children and adolescents has become a global phenomenon, with increasing rates in low- and middle-income countries (LMICs)(2). The global prevalence of tobacco use among young people (persons aged 10–24 years) is on the rise as a result of an early child or adolescent (persons aged 10–19 years) smoking initiation (3). Smoking initiation refers to a person having “ever tried cigarette smoking, be it one or two puffs?” – Initiation is defined as a transition from being a never smoker to an ever smoker (4). Early initiation of cigarette smoking is associated with greater health risks including coronary heart diseases, stroke, and multiple cancers (5). As per the United States (US) Surgeon General’s report, more than 80% of adult smokers initiated the practice before age 18 (6). The same report hints that individuals will likely never smoke or use tobacco if they remain non-smokers throughout adolescence (6). These findings emphasize the importance of preventive efforts, especially among young people.

Results of the Global Youth Tobacco Survey (GYTS) indicate that nearly 25 million and 13 million youth (persons aged 13–15 years) worldwide are currently smoking cigarettes or using smokeless tobacco products, respectively. The survey further emphasizes that the prevalence of tobacco use among the youth in High-Income countries (HICs) is on the decline, as compared to that of LMICs (7).

The prevalence of tobacco use among the youth globally ranges from around 2% to over 30% depending on the region and on the form of tobacco (cigarette or other) (7). Among the HICs, data from the 2013 and 2016 Australian National Drug Strategy Household Survey depicts a reduction in smoking prevalence from 7.0–3.0% among those aged 14–19 years (8). The United States of America recorded a lower rate of 8% among high-school students in 2017 (9), whiles the United Kingdom 3% of 11–15 years old in 2015(8). On the contrary, the smoking prevalence among persons 12–15 years of age in 68 LMICs was averaged at 13.6% ranging from 2.8–44.7% between the years 2006 and 2013 (10).

The increase in the prevalence of tobacco use in LMICs could be attributed to factors such as the lack of political will for the enforcement of smoke-free laws and policies(11). Secondly, due to the lack of enforcement of smoke-free laws, young people and the vulnerable, have easy access to cheap and/or illicit cigarettes, mostly sold as single sticks ¹³. The selling of single-stick cigarettes mostly promotes tobacco use among these groups, thwarts control efforts such as graphic health warnings(13), and undermines public health gains realized from tobacco taxation through its pricing strategies (14).

Assisting young people to avoid tobacco use is universally endorsed as an effective public health strategy. This is because tobacco use is usually initiated and established in this age group (6). Also, adult smoking rates today represent a true reflection of young people’s smoking rates (6), who might not receive any knowledge on the harmful effects of tobacco use. Furthermore, young people in LMICs are more likely to initiate tobacco use and are more at-risk of tobacco-related harms compared to their colleagues in HICs. This is a result of population growth, income growth, increased tobacco affordability, and aggressive marketing and political lobbying in those countries(15).

Given the prevalence of young people’s tobacco use and related harms, there has been a series of interventions developed globally to reduce youth tobacco consumption and the associated negative consequences. These interventions include school-based tobacco smoking prevention programmes, mass media campaigns, tobacco cessation and treatment, smoke-free laws, price and tax measures, and minimum age restriction(16).

School-based programmes are considered as one of the most effective strategies available for reducing smoking prevalence among young people in general(17). School-based tobacco prevention programmes facilitate skill-building, educate students on personal and social skills to help them stay away from tobacco use. Skills provided by such programmes include problem-solving, decision making, and coping methods for stress; techniques to improve self-esteem, self-control, and assertiveness; and also methods to resist personal, tobacco industry marketing strategies and media influences (18). These interventions are classified based on the theoretical approaches guiding them. These include interventions being based on only information of harmful effects of tobacco use, social influence, social competence, a combination of social influence and social competence or multimodal i.e., a combination of information, social influence, and competence (18). Approaches to the administration of these interventions include teacher-led, peer-led, or researcher-led (18, 19). For some interventions, booster sessions are provided to sustain their effect (18, 19). Control programmes that would compare with the interventions include the routine health education programmes that are components of the School Health and Health Education Programmes (SHEP) in Ghana (20). The SHEP consists of other health programmes with a component on the harmful effects of tobacco use.

These interventions have been shown to improve young people’s knowledge, attitude, and behavior towards smoking ²⁴ and reduce smoking initiation (23). The school-based programme in preventing smoking initiation has been proven to have a greater advantage over other approaches because most children can be reached through schools, where the focus of the intervention can be naturally achieved as it falls within the school activities (24). However, reviews addressing the prevention of smoking initiation mostly rely on evidence from interventions implemented in HICs. Since this review is a crucial step towards implementing and further developing effective tobacco initiation prevention interventions among young people in LMICs, it will be inappropriate to rely only on evidence from HICs. It has been observed that effective health interventions based in the context of HICs, are not necessarily effective in LMICs(25, 26). It is imperative, therefore, to conduct this review to identify interventions that are from LMICs, which have led to a reduction in tobacco initiation among young people.

Our initial search conducted in PROSPERO, MEDLINE, PUBMED, the Cochrane Database of Systematic Reviews, and the JBI Evidence Synthesis shows no current or underway systematic reviews on the topic to be studied. The objective of this review is to evaluate the effectiveness of school-based interventions compared to non-intervention programmes in preventing tobacco smoking initiation among young people in LMICs.

The proposed systematic review will be conducted in line with the JBI methodology for systematic reviews of effectiveness (27). We will also use the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines and its extension for protocols (PRISMA-P) (28) [see Additional file 1: PRISMA-P checklist].

Research Objective

This systematic review aims to evaluate the effectiveness of school-based interventions compared to non-intervention programmes in preventing tobacco smoking initiation among young people in LMICs.

Specifically, we will

Assess the effect of a school-based intervention in preventing smoking initiation among young ones
Assess the effects of the school-based intervention in reducing the smoking rate (reduction in the number of cigarettes smoke) Determine the effectiveness of the interventions based on their theoretical concepts.
Determine effectiveness based on the mode of implementation (teacher-led or peer-led)

Review question

What is the effectiveness of school-based programmes classified by intervention type compared to no intervention in preventing tobacco smoking initiation among young people living in LMICs?

Inclusion criteria

The systematic review will consider studies that evaluate school-based interventions that prevent tobacco smoking initiation among in-school young people in LMICs compared to other non-intervention programmes. The primary outcome will be the non-initiation of tobacco smoking by the youth. Studies published in the English language from the year 2000 will be considered for the review to align with current trends of tobacco intervention programmes.

Participants

This review will consider studies that include in-school persons aged 10 – 24 years in LMICs.

Interventions

The review will consider studies that evaluate school-based interventions that aim at preventing tobacco smoking initiation, or tobacco use among young people who reside in LMICs. The types of interventions based on theoretical approaches such as only information of harmful effects of tobacco use, social influence, social competence, a combination of social influence and social competence or multimodal i.e., a combination of information, social influence, and competence will be considered. Furthermore, the approach to the administration of the intervention i.e. teacher-led, or peer-led, or researcher-led will be considered. Finally, the presence or absence of booster sessions will be considered.

Comparator

The review will consider studies that compare the intervention with non-intervention such as normal school education or the standard health education programmes taught in schools.

Outcomes

The review will consider studies whose outcome evaluates the smoking status of individuals or groups who reported tobacco non-use at baseline. The theoretical approach, mode of administration of interventions, and the presence or absence of booster sessions will be considered.

Effect sizes of the outcome would be measured by the rate/risk difference, rate/risk/odds ratio for categorical data and weighted/standardized mean difference for continuous data together with their 95% confidence intervals.

Type of studies:

This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, and before and after studies. Furthermore, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. Studies published in peer-reviewed journals in the English language from 2000 will be included in the review to align with current trends of tobacco intervention programmes.

Search Strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (PUBMED see Appendix #). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.

Information Sources

The databases to be searched include MEDLINE via Ovid, CINAHL via EBSCO, Embase, PsycINFO, PsycEXTRA, and the Cochrane Central Register of Controlled Trials. Sources of gray literature to be searched include ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove.

Study selection

Following the search, all identified citations will be ordered and uploaded into Mendeley (cite), and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Relevant studies will be retrieved and saved in full and their citation details imported into the JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI; JBI, Adelaide, Australia)(29). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (30)^.

Assessment of Methodological Quality

Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using standardized critical appraisal instruments from the JBI for experimental, quasi-experimental, and analytical observational studies. Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise will be resolved through discussion, or with a third reviewer. The results of the critical appraisal will be reported in narrative form and a table. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible).

Data Extraction:

Data will be extracted from studies included in the review by two independent reviewers using the standardized data extraction tool within the JBI SUMARI (27). The data extracted will include specific details about the populations, study methods, interventions, intervention, and control/comparison groups and outcomes (incidence/rate/odds ratios, incidence/rate difference, weighted/standardized mean differences, etc.) of significance to the review objective. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data Synthesis:

Studies will, where possible be pooled in a statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds/rate/risk ratios or incidence/rate differences (for dichotomous data) and weighted (or standardized) final post-intervention mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared (Cochran’s Q test) and I squared tests. Statistical analyses will be performed using a random-effects model (31). Sensitivity and subgroup analyses will be conducted for 10 or more studies to assess the robustness of the methods used. Where statistical pooling is not possible the findings will be presented in the narrative form including tables and figures to aid in data presentation where appropriate. A funnel plot will be generated using RevMan V5 (Copenhagen: The Nordic Cochrane Centre, Cochrane) to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed where appropriate.

Assessing certainty in findings

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed (32) and a Summary of Findings (SoF) will be created using GRADEPro GDT Version XX/updated in 2014McMaster University, ON, Canada) (33). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcomes to be reported in the SoF will be non-initiation of tobacco smoking, the theoretical approaches employed in the intervention, the mode of administration of interventions, and the presence or absence of booster sessions.

This systematic review will provide evidence to support the effectiveness of school-based intervention in terms of smoking initiation and quit rates. We will also have evidence on the effective methods of implementation and effective mode of programme delivery. Findings will therefore help policymakers to develop targeted interventions as an effective tobacco control initiative.

JBI: Joanna Briggs Institute; SUMARI: System for the Unified Management, Assessment, and Review of Information; GRADE: The Grading of Recommendations, Assessment, Development, and Evaluation; SoF: Summary of Findings; LMICs: Low and Middle-Income Countries; HICs: High-Income Countries; GYTS: Global Youth Tobacco Survey; SHEP: School and Education Programme; PROSPERO: International Prospective Register of Systematic Reviews; PRISMA: Preferred Reporting Items for Systematic review and Meta-Analyses; PRISMA-P: Cochrane RevMan: Cochrane Review Manager; GRADEpro GDT: The Grading of Recommendations, Assessment, Development, and Evaluation Guideline Development Tool

Acknowledgments

The authors would like to thank the School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana for funding this review.

Amendments

We do not anticipate any amendment however, should it be required, we will provide a revised date of the amendment with a description of the change and reasons.

Authors’ contributions

DDL, YE, and GA conceptualized the study. The protocol was drafted DDL, YE, GA, and AS and was reviewed by all. FBO and EN will independently screen the potential studies. DDL. YE and ED will extract data from the included studies FBO ED, and EN will assess the risk of bias and finish data synthesis. EOD will work on any discrepancies and ensure that no errors occur during the review. All authors read, provided feedback, and approved the final manuscript.

Funding

No funding was received for this work.

Availability of data and materials

Not applicable

Ethics approval and consent to participate

This systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42021246206). Any amendments to the protocol will be documented on the PROSPERO site.

There is no ethical approval for this study as it is a systematic review. The results will be submitted to peer-reviewed journals for publication and also presented at conferences.

Consent for publication

Not Applicable

Competing interests

The authors declare no competing interests.

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Appendix I: Search strategy in Pubmed; Search conducted on June 2021.

Search number	Query	Results
7	(((adolescen* OR youth OR young adult OR young people OR child) AND (school-based tobacco prevention program* OR in-school tobacco prevention program* OR routine tobacco prevention program* OR standard tobacco control program* OR school health promotion)) AND (smok* OR tobacco use)) AND (low-middle income countr* OR LMIC* OR developing countr*)	380
6	school-based tobacco prevention program* OR in-school tobacco prevention program* OR routine tobacco prevention program* OR standard tobacco control program* OR school health promotion OR school health education	238,059
5	(((adolescen* OR youth OR young adult OR young people OR child) AND (school-based tobacco prevention program* OR in-school tobacco prevention program* OR routine tobacco prevention program* OR standard tobacco control program)) AND (smok OR tobacco use)) AND (low-middle income countr* OR LMIC* OR developing countr*)	77
4	low-middle income countr* OR LMIC* OR developing countr*	272,348
3	smok* OR tobacco use	405,000
1	adolescen* OR youth OR young adult OR young people OR child	4,350,683

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Reviewer #1 agreed at journal
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Submission checks completed at journal
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Effectiveness of School-based Interventions for Preventing Tobacco Smoking Initiation Among Young People in Low-and-middle-income Countries: a Systematic Review Protocol.

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