Family-based programmes for preventing smoking by children and adolescents

BACKGROUND: There is evidence that children's decisions to smoke are influenced by family and friends. OBJECTIVES: To assess the effectiveness of interventions to help family members to strengthen non-smoking attitudes and promote non-smoking by children and other family members. SEARCH STRATEGY: We searched 14 electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and CINAHL. We also searched unpublished material, and the reference lists of key articles. We performed both free-text Internet searches and targeted searches of appropriate websites, and we hand-searched key journals not available electronically. We also consulted authors and experts in the field. The most recent search was performed in July 2006. SELECTION CRITERIA: Randomized controlled trials (RCTs) of interventions with children (aged 5-12) or adolescents (aged 13-18) and family members to deter the use of tobacco. The primary outcome was the effect of the intervention on the smoking status of children who reported no use of tobacco at baseline. Included trials had to report outcomes measured at least six months from the start of the intervention. DATA COLLECTION AND ANALYSIS: We reviewed all potentially relevant citations and retrieved the full text to determine whether the study was an RCT and matched our inclusion criteria. Two authors independently extracted study data and assessed them for methodological quality. The studies were too limited in number and quality to undertake a formal meta-analysis, and we present a narrative synthesis. MAIN RESULTS: We identified 19 RCTs of family interventions to prevent smoking. We identified five RCTs in Category 1 (minimal risk of bias on all counts); nine in Category 2 (a risk of bias in one or more areas); and five in Category 3 (risks of bias in design and execution such that reliable conclusions cannot be drawn from the study).Considering the fourteen Category 1 and 2 studies together: (1) four of the nine that tested a family intervention against a control group had significant positive effects, but one showed significant negative effects; (2) one of the five RCTs that tested a family intervention against a school intervention had significant positive effects; (3) none of the six that compared the incremental effects of a family plus a school programme to a school programme alone had significant positive effects; (4) the one RCT that tested a family tobacco intervention against a family non-tobacco safety intervention showed no effects; and (5) the one trial that used general risk reduction interventions found the group which received the parent and teen interventions had less smoking than the one that received only the teen intervention (there was no tobacco intervention but tobacco outcomes were measured). For the included trials the amount of implementer training and the fidelity of implementation are related to positive outcomes, but the number of sessions is not. AUTHORS' CONCLUSIONS: Some well-executed RCTs show family interventions may prevent adolescent smoking, but RCTs which were less well executed had mostly neutral or negative results. There is thus a need for well-designed and executed RCTs in this area.

Family-based interventions in preventing children and adolescents from using tobacco: A systematic review and meta-analysis

- Background Tobacco is the main preventable cause of death and disease worldwide. Adolescent smoking is increasing in many countries with poorer countries following the earlier experiences of affluent countries. Preventing adolescents starting smoking is crucial to decreasing tobacco-related illness. - Objective To assess effectiveness of family-based interventions alone and combined with school-based interventions to prevent children and adolescents from initiating tobacco use. - Data Sources 14 bibliographic databases and the Internet, journals hand-searched, experts consulted. - Study Eligibility Criteria, Participants, and Interventions Randomised controlled trials (RCTs) with children or adolescents and families, interventions to prevent starting tobacco use, follow-up ≥ 6 months. - Study Appraisal/Synthesis methods Abstracts/titles independently assessed and data independently entered by two authors. Risk-of-bias assessed with the Cochrane Risk-of-Bias tool. - Results Twenty-seven RCTs were included. Nine trials of never-smokers compared to a control provided data for meta-analysis. Family intervention trials had significantly fewer students who started smoking. Meta-analysis of twoRCTs of combined family and school interventions compared to school only, showed additional significant benefit. The common feature of effective high intensity interventions was encouraging authoritative parenting. - Limitations Only 14 RCTs provided data for meta-analysis (about 1/3 of participants). Of the 13 RCTs which did not provide data for meta-analysis eight compared a family intervention to no intervention and one found significant effects, and five compared a family + school intervention to a school intervention and none found additional significant effects. - Conclusions and Implications of Key Findings There is moderate quality evidence that family-based interventions prevent children and adolescents starting to smoke.

A smoking cessation intervention for people with chronic Hepatitis C : a randomised controlled trial

Purpose The purpose of this study was to examine the validity of current practice in smoking cessation for the general population i.e., a telephone counselling and nicotine replacement therapy (NRT) intervention and its applicability to people with chronic hepatitis-C. Methods A randomised controlled trial was conducted over twelve weeks. Following consent, ninety-two smokers (outpatients) with chronic hepatitis-C were recruited by the Nurse Practitioner hepatology, randomly assigned and stratified by number of cigarettes smoked (i.e., 15 and greater; <15) into the intervention group (telephone counselling and NRT) and control group (telephone counselling). Outcomes measured included socio-demographics, nicotine dependence, depression, anxiety and stress and quality of life (QOL). All statistical data were analysed using SPSS. Results After 12 weeks, the intervention group showed a sustained reduction of smoking i.e., 5.8(CI: 2.4,9.3) cigarettes less per day, whereas the control group showed 1.6(CI:-1.9,5.2) cigarette reduction. Although not statistically significantly different (F=2.9, p=0.090) the intervention group on average smoked 4.2 fewer cigarettes compared to the control group. After twelve weeks, seven patients in the intervention group and three patients in the control group reported quitting. Whilst not statistically significant (Fisher’s Exact, p=0.311) this was a clinically significant result. No differences were found for nicotine dependence or depression, anxiety and stress. The intervention group experienced no change in QOL (-0.1,CI:-0.9, 0.6), however, the environmental score for the control group decreased by 1.8(CI:1.0, 2.6,p= 0.001). This was statistically significant. Conclusion A telephone counselling and nicotine replacement therapy intervention from the nurse practitioner, hepatology reduced smoking in patients with chronic hepatitis-C. The intervention group showed a sustained reduction over the 12 weeks. A total of 10 patients quit smoking at the end of the study. QOL deteriorated in the environmental subscale for the control group. These results informed a nurse practitioner model of care for approaches to smoking cessation.

A randomized controlled trial of a program to reduce adolescent road-related medically-treated injuries

Background Injury is the leading cause of adolescent death and injury around the road is a common source of adolescent injuries. Skills for Preventing Injury in Youth (SPIY) is a comprehensive program developed in Australia for early adolescents (term-long curriculum, including looking out for friends, first-aid training coupled with teacher school-connectedness professional development). Jessors’ Protection-Risk Framework guided the program approach focusing on building protective relationships. Method A randomized controlled trial with 35 schools was undertaken. Students completed surveys at baseline, six-months post-intervention and twelve-months post intervention. There were 1686 students (56% female) who completed the twelve-month survey, including the Extended-Adolescent Injury Checklist whereby students self-report on medically-treated injuries over the previous three-months (only road-related items are reported in this study; cycling, motorcycle riding, pedestrian, and riding as a passenger). Randomly selected SPIY classes also participated in focus groups and reported on perceptions of SPIY and injury risk behavior. Results As a check of randomization baseline differences of the variables were examined, with no significant differences between intervention and control groups. At the 12-month follow-up, there were fewer medically-treated injuries among the intervention students compared with the control group, particularly associated with being a passenger. The process evaluation revealed students perceived change in injury risk and risk behaviors. Conclusions While data analyses are continuing, the results indicate that the program seeking to encourage adolescents to look out for their friends, build connections to school and provide first aid skills training goes some way to reducing self-reported medically-treated injuries around the road.

The importance of school connectedness in adolescent risk taking and injury prevention

Background: Injury is the leading cause of mortality for young people in Australia (AIHW, 2008). Adolescent injury mortality is consistently associated with risk taking behaviour, including transport and interpersonal violence (AIHW, 2003), which often occurs in the context of alcohol and other substance use. A rapid increase in risk taking and injury through early to late adolescence highlights the need for effective school based interventions. Aim: The aim of the current research was to examine the relationship between school connectedness and adolescent risk and injury, in order to inform effective prevention approaches. School connectedness, or students’ feelings of belongingness to school, has been shown to be a critical protective factor in adolescence which can be targeted effectively through teacher interventions. Despite evidence linking low school connectedness with increased health risk behaviour, including substance use and violence, research has not yet addressed possible links between connectedness and a broader range of risk taking behaviours (e.g. transport risks) or injury. Method: This study involved background data collection to inform the development of an intervention. A total of 595 Year 9 students (aged 13-14 years) from 5 Southeast Queensland high schools completed questionnaires that included measures of school connectedness, risk taking behaviour, alcohol and other substance use, and injuries. Results: Increased school connectedness was found to be associated with fewer transport risk behaviours and with decreased alcohol and other substance use for both males and females. Similarly, increased school connectedness was associated with fewer passenger and motorcycle injuries for male participants. Both males and females with increased school connectedness reported fewer alcohol related injuries. Implications: These results indicate that school connectedness appears to have protective effects for early adolescence. These findings may also hold for older adolescents and indicate that it may be an important factor to target in school based risk and injury prevention programs. A school connectedness intervention is currently being designed, focusing on teacher professional development. The intervention will be implemented in conjunction with a curriculum based injury prevention program for Year 9 students and will be evaluated through a large scale cluster randomised trial involving 26 schools.

Self-efficacy and social support as predictors of smoking after a quit attempt

Examined findings (e.g., A. J. Yates and J. Thain [see PA, Vol 73:28269]) that suggest that perceived social support for attempts to quit smoking is a determinant of self-efficacy (SE). 102 adults (aged 18–71 yrs) who participated in a trial of 4 smoking interventions were studied over a 10-mo follow-up period. The study attested to the validity of SE as a predictor of sustained success from an attempt to stop smoking. The tendency for SE theory to be more strongly supported in the longer term was highly consistent with the proposed mechanism for SE effects. The absence of a relationship with perceived social support might be an advantage for SE, since support was a poor predictor of outcomes during follow-up. Results suggest that perceived social influences had less utility than personal skills and SE in predicting sustained non-smoking outcomes.

A randomised controlled trial of a tele-based lifestyle intervention for colorectal cancer survivors ('CanChange') : Study protocol

Background Colorectal cancer survivors may suffer from a range of ongoing psychosocial and physical problems that negatively impact on quality of life. This paper presents the study protocol for a novel telephone-delivered intervention to improve lifestyle factors and health outcomes for colorectal cancer survivors. Methods/Design Approximately 350 recently diagnosed colorectal cancer survivors will be recruited through the Queensland Cancer Registry and randomised to the intervention or control condition. The intervention focuses on symptom management, lifestyle and psychosocial support to assist participants to make improvements in lifestyle factors (physical activity, healthy diet, weight management, and smoking cessation) and health outcomes. Participants will receive up to 11 telephone-delivered sessions over a 6 month period from a qualified health professional or 'health coach'. Data collection will occur at baseline (Time 1), post-intervention or six months follow-up (Time 2), and at 12 months follow-up for longer term effects (Time 3). Primary outcome measures will include physical activity, cancer-related fatigue and quality of life. A cost-effective analysis of the costs and outcomes for survivors in the intervention and control conditions will be conducted from the perspective of health care costs to the government. Discussion The study will provide valuable information about an innovative intervention to improve lifestyle factors and health outcomes for colorectal cancer survivors.

The Eat Smart Study : a randomised controlled trial of a reduced carbohydrate versus a low fat diet for weight loss in obese adolescents

Background Despite the recognition of obesity in young people as a key health issue, there is limited evidence to inform health professionals regarding the most appropriate treatment options. The Eat Smart study aims to contribute to the knowledge base of effective dietary strategies for the clinical management of the obese adolescent and examine the cardiometablic effects of a reduced carbohydrate diet versus a low fat diet. Methods and design Eat Smart is a randomised controlled trial and aims to recruit 100 adolescents over a 2½ year period. Families will be invited to participate following referral by their health professional who has recommended weight management. Participants will be overweight as defined by a body mass index (BMI) greater than the 90th percentile, using CDC 2000 growth charts. An accredited 6-week psychological life skills program ‘FRIENDS for Life’, which is designed to provide behaviour change and coping skills will be undertaken prior to volunteers being randomised to group. The intervention arms include a structured reduced carbohydrate or a structured low fat dietary program based on an individualised energy prescription. The intervention will involve a series of dietetic appointments over 24 weeks. The control group will commence the dietary program of their choice after a 12 week period. Outcome measures will be assessed at baseline, week 12 and week 24. The primary outcome measure will be change in BMI z-score. A range of secondary outcome measures including body composition, lipid fractions, inflammatory markers, social and psychological measures will be measured. Discussion The chronic and difficult nature of treating the obese adolescent is increasingly recognised by clinicians and has highlighted the need for research aimed at providing effective intervention strategies, particularly for use in the tertiary setting. A structured reduced carbohydrate approach may provide a dietary pattern that some families will find more sustainable and effective than the conventional low fat dietary approach currently advocated. This study aims to investigate the acceptability and effectiveness of a structured reduced dietary carbohydrate intervention and will compare the outcomes of this approach with a structured low fat eating plan. Trial Registration: The protocol for this study is registered with the International Clinical Trials Registry (ISRCTN49438757).

Determinants of rapid weight gain during infancy: Baseline results from the NOURISH randomised controlled trial.

Background: Rapid weight gain in infancy is an important predictor of obesity in later childhood. Our aim was to determine which modifiable variables are associated with rapid weight gain in early life. Methods: Subjects were healthy infants enrolled in NOURISH, a randomised, controlled trial evaluating an intervention to promote positive early feeding practices. This analysis used the birth and baseline data for NOURISH. Birthweight was collected from hospital records and infants were also weighed at baseline assessment when they were aged 4-7 months and before randomisation. Infant feeding practices and demographic variables were collected from the mother using a self administered questionnaire. Rapid weight gain was defined as an increase in weight-for-age Z-score (using WHO standards) above 0.67 SD from birth to baseline assessment, which is interpreted clinically as crossing centile lines on a growth chart. Variables associated with rapid weight gain were evaluated using a multivariable logistic regression model. Results: Complete data were available for 612 infants (88% of the total sample recruited) with a mean (SD) age of 4.3 (1.0) months at baseline assessment. After adjusting for mother's age, smoking in pregnancy, BMI, and education and infant birthweight, age, gender and introduction of solid foods, the only two modifiable factors associated with rapid weight gain to attain statistical significance were formula feeding [OR=1.72 (95%CI 1.01-2.94), P= 0.047] and feeding on schedule [OR=2.29 (95%CI 1.14-4.61), P=0.020]. Male gender and lower birthweight were non-modifiable factors associated with rapid weight gain. Conclusions: This analysis supports the contention that there is an association between formula feeding, feeding to schedule and weight gain in the first months of life. Mechanisms may include the actual content of formula milk (e.g. higher protein intake) or differences in feeding styles, such as feeding to schedule, which increase the risk of overfeeding. Trial Registration: Australian Clinical Trials Registry ACTRN12608000056392

A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare')

Background Coronary heart disease (CHD) and depression are leading causes of disease burden globally and the two often co-exist. Depression is common after Myocardial Infarction (MI) and it has been estimated that 15-35% of patients experience depressive symptoms. Co-morbid depression can impair health related quality of life (HRQOL), decrease medication adherence and appropriate utilisation of health services, lead to increased morbidity and suicide risk, and is associated with poorer CHD risk factor profiles and reduced survival. We aim to determine the feasibility of conducting a randomised, multi-centre trial designed to compare a tele-health program (MoodCare) for depression and CHD secondary prevention, with Usual Care (UC). Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome (ACS) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensland. Consenting participants are then contacted at two weeks post-discharge for baseline assessment. One hundred eligible participants are to be randomised to an intervention or a usual medical care control group (50 per group). The intervention consists of up to 10 × 30-40 minute structured telephone sessions, delivered by registered psychologists, commencing within two weeks of baseline screening. The intervention focuses on depression management, lifestyle factors (physical activity, healthy eating, smoking cessation, alcohol intake), medication adherence and managing co-morbidities. Data collection occurs at baseline (Time 1), 6 months (post-intervention) (Time 2), 12 months (Time 3) and 24 months follow-up for longer term effects (Time 4). We are comparing depression (Cardiac Depression Scale [CDS]) and HRQOL (Short Form-12 [SF-12]) scores between treatment and UC groups, assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects. A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government. Discussion This manuscript presents the protocol for a randomised, multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients. The results of this trial will provide valuable new information about potential psychological and wellbeing benefits, cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression.

A randomised controlled trial of a theory-based intervention to improve sun protective behaviour in adolescents ('you can still be HOT in the shade') : study protocol

Background: Most skin cancers are preventable by encouraging consistent use of sun protective behaviour. In Australia, adolescents have high levels of knowledge and awareness of the risks of skin cancer but exhibit significantly lower sun protection behaviours than adults. There is limited research aimed at understanding why people do or do not engage in sun protective behaviour, and an associated absence of theory-based interventions to improve sun safe behaviour. This paper presents the study protocol for a school-based intervention which aims to improve the sun safe behaviour of adolescents. Methods/design: Approximately 400 adolescents (aged 12-17 years) will be recruited through Queensland, Australia public and private schools and randomized to the intervention (n = 200) or 'wait-list' control group (n = 200). The intervention focuses on encouraging supportive sun protective attitudes and beliefs, fostering perceptions of normative support for sun protection behaviour, and increasing perceptions of control/self-efficacy over using sun protection. It will be delivered during three × one hour sessions over a three week period from a trained facilitator during class time. Data will be collected one week pre-intervention (Time 1), and at one week (Time 2) and four weeks (Time 3) post-intervention. Primary outcomes are intentions to sun protect and sun protection behaviour. Secondary outcomes include attitudes toward performing sun protective behaviours (i.e., attitudes), perceptions of normative support to sun protect (i.e., subjective norms, group norms, and image norms), and perceived control over performing sun protective behaviours (i.e., perceived behavioural control). Discussion: The study will provide valuable information about the effectiveness of the intervention in improving the sun protective behaviour of adolescents.

Ask : a health advocacy program for adolescents with an intellectual disability : a cluster randomised controlled trial

Background Adolescents with intellectual disability often have poor health and healthcare. This is partly as a consequence of poor communication and recall difficulties, and the possible loss of specialised paediatric services. Methods/Design A cluster randomised trial was conducted with adolescents with intellectual disability to investigate a health intervention package to enhance interactions among adolescents with intellectual disability, their parents/carers, and general practitioners (GPs). The trial took place in Queensland, Australia, between February 2007 and September 2010. The intervention package was designed to improve communication with health professionals and families’ organisation of health information, and to increase clinical activities beneficial to improved health outcomes. It consisted of the Comprehensive Health Assessment Program (CHAP), a one-off health check, and the Ask Health Diary, designed for on-going use. Participants were drawn from Special Education Schools and Special Education Units. The education component of the intervention was delivered as part of the school curriculum. Educators were surveyed at baseline and followed-up four months later. Carers were surveyed at baseline and after 26 months. Evidence of health promotion, disease prevention and case-finding activities were extracted from GPs clinical records. Qualitative interviews of educators occurred after completion of the educational component of the intervention and with adolescents and carers after the CHAP. Discussion Adolescents with intellectual disability have difficulty obtaining many health services and often find it difficult to become empowered to improve and protect their health. The health intervention package proposed may aid them by augmenting communication, improving documentation of health encounters, and improving access to, and quality of, GP care. Recruitment strategies to consider for future studies in this population include ensuring potential participants can identify themselves with the individuals used in promotional study material, making direct contact with their families at the start of the study, and closely monitoring the implementation of the educational intervention.

Pilot evaluation of an adolescent risk and injury prevention programme incorporating curriculum and school connectedness components

School connectedness is an important protective factor for adolescent risk-taking behaviour. This study examined a pilot version of the Skills for Preventing Injury in Youth (SPIY) programme, combining teacher professional development for increasing school connectedness (connectedness component) with a risk and injury prevention curriculum for early adolescents (curriculum component). A process evaluation was conducted on the connectedness component, involving assessments of programme reach, participant receptiveness and initial use, and a preliminary impact evaluation was conducted on the combined connectedness and curriculum programme. The connectedness component was well received by teacher participants, who saw benefits for both themselves and their students. Classroom observation also showed that teachers who received professional development made use of the programme strategies. Grade 8 students who participated in the SPIY programme were less likely to report violent behaviour at six-month follow-up than were control students, and trends also suggested reduced transport injuries. The results of this research support the use of the combined SPIY connectedness and curriculum components in a large-scale effectiveness trial to assess the impact of the programme on students’ connectedness, risk-taking and associated injuries.

School-based first aid training and the implications for traffic injury prevention : a randomised controlled trial

Adolescent injury remains a significant public health concern and is often the result of at-risk transport related behaviours. When a person is injured actions taken by bystanders are of crucial importance and timely first aid appears to reduce the severity of some injuries (Hussain & Redmond, 1994). Accordingly, researchers have suggested that first aid training should be more widely available as a potential strategy to reduce injury (Lynch et al., 2006). Further research has identified schools as an ideal setting for learning first aid skills as a means of injury prevention (Maitra, 1997). The current research examines the implications of school based first aid training for young adolescents on injury prevention, particularly relating to transport injuries. First aid training was integrated with peer protection and school connectedness within the Skills for Preventing Injury in Youth (SPIY) program (Buckley & Sheehan, 2009) and evaluated to determine if there was a reduction in the likelihood of transport related injuries at six months post-intervention. In Queensland, Australia, 35 high schools were recruited and randomly assigned to intervention and control conditions in early April 2012. A total of 2,000 Year nine students (mean age 13.5 years, 39% male) completed surveys six months post-intervention in November 2012. Analyses will compare the intervention students with control group students who self-reported i) first aid training with a teacher, professional or other adult and ii) no first aid in the preceding six months. Using the Extended Adolescent Injury Checklist (E-AIC) (Chapman, Buckley & Sheehan, 2011) the transport related injury experiences included being injured while “riding as a passenger in a car”, “driving a car off road” and “riding a bicycle”. It is expected that students taught first aid within SPIY will report significantly fewer transport related injuries in the previous three months, compared to the control groups described above. Analyses will be conducted separately for sex and socio-economic class of schools. Findings from this study will provide insight into the value of first aid in adolescent injury prevention and provide evidence as to whether teaching first aid skills within a school based health education curriculum has traffic safety implications.

The HealthyTexts study : A randomized controlled trial to improve skin cancer prevention behaviors among young people

Several randomized trials have found behavior change programs delivered via text messaging to be efficacious to improve preventive health behaviors such as physical activity and stopping smoking; however few have assessed its value in skin cancer prevention or early detection. The HealthyTexts study enrolled 678 participants 18–42 years, and assigned them to receive 21 text messages about skin cancer prevention, skin self-examination or physical activity(attention control) over the course of one year. Baseline data have been collected and outcomes will be assessed at three months and twelve months post intervention. The trial aims to increase the mean overall sun protection habits index score from 2.3 to 2.7 with a standard deviation of 0.5 (effect size of 0.5) and the proportion of people who conduct a whole-body skin self-examination by an absolute 10%. This paper describes the study design and participants' baseline characteristics. In addition, participants' goals for their health, and strategies they apply to achieve those goals are summarized.