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REVIEW ARTICLE
Year : 2022 | Volume
: 59
| Issue : 3 | Page : 317-324
Systematic review of school-based tobacco prevention programs for the adolescents in India from 2000 to 2020
Pradnya V Kakodkar1, Sonal S Kale2, Ketaki B Bhor3, Anupreet K Sidhu4
1 Department of Research, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Public Health Dentistry, DR D Y Patil Vidyapeeth, DR D Y Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India
3 Department of Public Health Dentistry, Sinhagad Dental College, Pune, Maharashtra, India
4 Department of Psychiatry, Perelman School of Medicine University of Pennsylvania, USA
Correspondence Address:
Pradnya V Kakodkar
Department of Research, Dr D Y Patil Vidyapeeth, Pune, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijc.IJC_1206_20
In India, 14.6% of adolescents are currently using tobacco in any form and tobacco control is a major public health challenge. The objective of this systematic review is to analyze all the existing literature and evaluate the effectiveness of school-based tobacco use prevention programs for adolescents in India. The review protocol was registered in PROSPERO (CRD42020159535). Studies were selected using database search, manual search, gray literature, reference chasing, and contacting the authors. All randomized controlled trials, cluster-randomized trials, quasi-experimental, and non-randomized studies reporting school-based tobacco use preventive interventions for adolescents in India; articles published in English (other languages where it can be translated to English) published between January 2000 till May 2020 were included. Data was independently extracted by two reviewers. The Risk of bias (RoB) and quality of the study were assessed using appropriate tools. Among 7972 identified articles, only 13 studies met the inclusion criteria. Each study implemented a unique intervention and measured distinct outcomes. Postintervention, all the studies reported improvements in the study group with respect to the reduction of tobacco use and change in the knowledge, attitude, practices, and/or behavior outcome parameters. Twelve study results were based on short-term assessment. Overall, a 5.17–17.0% tobacco use reduction rate was noted. RoB was high for six studies. Key methodological problems related to study design, duration, outcome parameter, follow-up time, type of intervention, and attrition were identified. School-based tobacco use prevention programs for adolescents in India might have shown positive outcomes but are associated with significant limitations.
Keywords: Adolescent, India, schools, students, systematic review, tobacco use
Key Message: Significant risk factors of worse overall survival are: Higher age, male gender, presence of lymph node metastasis, presence of multivisceral resection, R1 surgical margin, tumor size >3 cm.
Addictions developed in adolescence are likely to persist into adult life, and tobacco use among adolescents is reaching pandemic levels.[1] The risk of addiction among adolescents increases with early uptake of tobacco use, potentially due to peer pressure, parental tobacco habits, and/or exposure to tobacco marketing and advertisements. More recently, WHO, through its World No Tobacco Day 2020 theme, highlighted this threat to the younger generation and sought to educate youth about deceptive tobacco industry tactics and empower them to resist tobacco use.
In India, every day more than 5,500 children under the age of 15 years try tobacco for the first time.[2] A systematic review of the strategies for tobacco control in India suggests that tobacco use outcomes could be improved by implementing school-based interventions.[3] Students who were educated in school about tobacco use and its effects were significantly more likely to have a negative attitude toward tobacco use and less likely to report the use of tobacco.[4]
The India Global Youth Tobacco Survey reported that 14.6% of adolescents are currently using tobacco in any form.[5] The Government of India has launched guidelines for Tobacco-Free Schools/Education Institutions (TFS/TFEI) in 2008, which has been revised and relaunched on May 31, 2019, to be implemented by schools and colleges as tobacco control initiatives among adolescents and young adults.[6]
It is evident that for the past two decades, there has been no systematic effort to compile and comprehensively analyze the effectiveness of school-based interventions for tobacco use prevention among adolescents. Hence, this present systematic review has been undertaken. The objective is to analyze all the existing literature and evaluate the effectiveness of school-based tobacco use preventive programs for adolescents in India.
Material and MethodsThis systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses[7] guidelines, and the protocol was registered in PROSPERO (CRD42020159535).
Inclusion criteria
All randomized controlled trials (RCT), cluster-randomized trials, quasi-experimental, and non-randomized studies reporting school-based interventions for tobacco use prevention among adolescents in India; articles published in English (also other languages where there was a possibility for translation to English) published between January 2000 till May 2020 were included.
Exclusion criteria
Any tobacco prevention interventions targeting adults and community or non-school-based programs for youth were excluded from this review. Also, cross-sectional studies, survey reports, literature reviews, case series, and letters to the editor were eliminated.
Information sources and search strategy
A comprehensive search strategy was developed to search articles in Medline using MeSH terms and free text terms (children, adolescence, school children, students, tobacco program, tobacco prevention, tobacco program, antitobacco, prevention, school, classroom, classroom-based intervention, school-based intervention, preventing tobacco use, and India). Other databases like Scopus, Google Scholar, EBSCOhost, and IndMED were also searched for the relevant articles. In addition, an extensive search for pertinent articles was carried out through the gray literature, reference list of the included articles and relevant systematic review (reference chasing), hand searching, using citation indices, and contacting the authors.
Study selection and data extraction
After the initial search, three reviewers (PK, KB, SK) screened titles and abstracts to identify potentially eligible studies. Full texts of selected articles were reviewed independently by two reviewers (PK, KB) for eligibility based on predefined inclusion criteria, with discrepancies resolved by discussion. Two reviewers (PK, KB) performed data extraction independently using pre-piloted forms for all the studies that met the inclusion criteria. In case of disagreement, the opinion of the third reviewer (SK) was obtained. Data items extracted were: author names, publication year, location, study design, sample description, sample size at baseline and follow-up, dropout percentage, intervention group details, follow-up details (time and tool), outcome parameters, and results of the study. The outcome parameters extracted were reduction/cessation of tobacco use and change in the knowledge, attitude, practices, and/or behavior (KAPB).
Risk of bias (RoB) judgment and quality assessment
The level of evidence for every included study was assessed using the Joanna Briggs Institute (JBI).[8] RoB for cluster randomized trials were assessed using revised cochrane RoB tool for randomized trials (RoB 2.0).[9] Robin-1 tool was used for quasi-experimental studies[10], and quality assessment of non-randomized studies was done using Minor's checklist.[11]
ResultsResults of literature search
The online database search yielded 7937 articles, and 35 articles were retrieved from other sources. Overall, 13 studies met the inclusion criteria. The entire article selection process is detailed in [Figure 1].
Characteristics of included studies
The data was extracted from the 13 included studies.[2],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] Four studies were cluster randomized trials,[12],[13],[14],[15] two were quasi experimental[2],[16], and the remaining seven were non-randomized studies.[17],[18],[19],[20],[21],[22],[23] The study participation was mixed ranging from 5th grade to 12 grade, aged 10–17 years. The sample size ranged from 60 at minimum to more than 12,000 school students at maximum. The dropouts observed at follow-up ranged from 1.17 to 29% overall. Different types of school-based tobacco use preventive interventions were carried out in each of the 13 studies. Multi approach activities were carried out in eight schools,[2],[12],[13],[14],[15],[16],[17],[20] which included classroom-based events,[2],[12],[13],[14],[15],[16],[17],[20] peer-led events,[2],[13],[14],[15],[20] use of booklets,[12],[20] family involvement,[12],[13],[14],[20] prevention and cessation sessions,[16] school policy,[14] and working with civic authorities.[2],[12] Single-approach activity in the form of health education program was reported in five schools.[18],[19],[21],[22],[23] Manpower utilized for the interventions were trained staff[2],[18],[19],[21],[22],[23] and teachers.[12],[13],[14] Only three out of the 13 studies had some activities for the control group, namely: in the study by Perry et al.[13], the control group was given non-tobacco-themed booklets during the study period, but intervention resource materials were also shared after the study was completed (delayed intervention); in the study by Sidhu et al.[16], standard care was provided to the control group and an educative non-tobacco-promoting booklet was given to each student, and in the study by Matapati et al.[22], the control group received a general health education lecture.
The postintervention, follow-up ranged from an immediate assessment to about 2 years after the program implementation. All the studies used self-administered questionnaires to collect follow-up data, and in addition, only one study used focus group discussion with teachers and students.[12] Outcome parameter assessment varied across the studies. Seven studies[2],[13],[15],[16],[17],[20],[21] assessed the reduction of tobacco use, eight studies[2],[12],[14],[18],[19],[21],[22],[23] assessed change in the KAPB, one study[16] assessed prevention and cessation of tobacco use, one study[13] assessed the psychosocial factors, and two studies[19],[20] assessed family-related parameters.
Postintervention, all the studies reported positive effects in the study group with regards to the outcome parameters [Table 1]. There was a significant improvement in KAPB regarding tobacco use as compared to baseline; the tobacco use reduction rate in the study group[13],[14],[15],[17],[20] was in the range of 5.17–17.0%, while no cessation effect was noted.[16]
Level of evidence/RoB/quality assessment
According to the JBI level of evidence,[8] three studies[12],[13],[14] were ranked at 1c, one study[15] as 1d, two studies[2],[16] as 2c, and the remaining seven studies[17],[18],[19],[20],[21],[22],[23] as 2d. Among the four cluster randomized trials,[12],[13],[14],[15] one study was a high risk[15][Table 2], both the quasi-experimental trials[2],[16] were low risk [Table 3], and among the seven non-randomized studies, only two studies[17],[18] were free of bias [Table 4].
Table 3: Risk of bias judgment for quasi-experimental trials (ROBIN-1 tool)
Table 4: Quality assessment of non-randomized studies (Minor's checklist) Discussion Smoking and smokeless tobacco use are almost always initiated and established during adolescence.[20] Therefore, education regarding the harms of tobacco use should start early in schools.[12] School-based tobacco use prevention programs targeted at adolescents can potentially serve two purposes: first, prevent them from falling prey to tobacco company advertisements and marketing, and second, to equip them with skills to resist peer pressure and influence their friends and family members to quit.[25]
Unfortunately, this review reveals a dismaying fact that over the past 20 years, effectively there are only 13 school-based tobacco use preventive intervention programs conducted, which are collectively reaching only a meager adolescent population of 29,699, as compared to the 14.6% of adolescents in India who are reported to use tobacco.[5]
Undoubtedly, the Government of India has implemented key tobacco control measures. In its revised TFEI guidelines,[6] a strategic framework is provided as a fresh momentum to implement tobacco control initiatives among adolescents and young adults at educational institutions. Eventually, it aims at promoting more awareness about harmful effects and long-term health impact of tobacco use among the students, teachers, workers, and officials in educational institutions; awareness about various avenues available for tobacco cessation and a healthy and tobacco-free environment in educational institutions. TFEI guidelines[6] have integrated some of the unique strategies from the school tobacco prevention program considered in this systematic review, namely: 1. Designation of “tobacco monitor” which is similar to the identifying peer leaders and “peer-led” activities reported in three studies[13],[15],[20]; 2. Conducting poster/slogan/essay/quiz/debate competitions and street plays at the institution to increase awareness of tobacco harms, as recommended by four studies[12],[13],[14],[20]; 3. Encouraging the students to avail Quitline services and mCessation services which are proposed by Mall and Bhagyalaxmi,[15] and 4. Taking a pledge against tobacco in the school assembly, which will reinforce the commitment among students to never use tobacco in the future as suggested in two studies.[19],[23] In the coming years, it will be important to evaluate the adherence of TFEI guidelines by the schools and educational institutions and the success achieved.
In this review, every included school-based program had a unique preventive approach and measured distinct outcomes. The strength of these programs is that each one has shown positive improvements in the intervention group as compared to the control with regards the measured outcomes [Table 1], but then again, it is associated with limitations.
Foremost, the high level of heterogeneity among the included studies poses a great limitation to comparatively evaluate the effectiveness of these programs. Heterogeneity is evident with respect to study design, study period, intervention, follow-up period, and outcome parameters. With respect to the outcome parameter, a noteworthy discrepancy is in its definition. For example, two studies[2],[13] defined a current smoker as a person who used tobacco in the past 30 days, while for one of the studies,[17] it was in the past 3 months. Such variations prevent comparison between studies, making it critical to use some measures consistently across studies. The most important shortcoming in all the programs is the use of participants' self-reported data for outcome measurement. Self-reporting is susceptible to social desirability bias[14] and may lead to under or overreporting of key outcome measures. Loss to follow-up is the second major lacunae observed in most studies except for the three studies[17],[18],[23] in the review. Also, it was the reason for reporting high risk in four non-randomized studies.[19],[20],[21],[22] Further, biochemical validation, which is an objective measure having higher reliability, has not been reported in any of the included studies[2],[13],[15],[16],[17],[20],[21] to confirm the tobacco use reduction rate. The study by Mall and Bhagyalaxmi[15] was reported as high risk because of a bias in randomization and recruitment [Table 2]. The other limitations peculiar to individual studies were cross-contamination between study and control group,[14] underpowered and small sample size,[16],[23] and inclusion of only male participants from government schools.[21]
This review highlights the research in the area of school-based tobacco use preventive programs in India and its limitations. The wide variety of intervention characteristics makes it challenging for comparison and to recommend any one specific intervention as effective for country-wide implementation. Comparably, a previous systematic review among school-aged adolescents worldwide has also reported a high level of variation within school-based tobacco programs.[26]
Although strict systematic review guidelines have been followed to conduct this study, there may have been some limitations. First, despite an extensive search for school-based program studies in India, some nonindexed and unpublished data may have been missed. Second, considering a large degree of heterogeneity in relation to the study methods, the results could not be pooled using meta-analysis.
ConclusionSchool-based tobacco use preventive programs in India are showing positive outcomes in terms of tobacco use reduction and improving the knowledge, attitude, and practice/behavior toward tobacco use, but none of the programs are found significantly effective for India-wide implementation. These programs are very limited and do not reach the wider mass of adolescents in India. To improve the evidence base of effective school-based tobacco prevention programs, it is recommended that evaluation studies are conducted rigorously with the robust RCT design, using standardized measures and comparable assessment tools, using biochemical validation (if possible) when reporting tobacco use reduction, minimizing attrition rates, and gathering long-term follow-up data.
Acknowledgements
The authors wish to acknowledge the support of Dr Anju Sinha (Scientist F, ICMR), Dr Priti Dargad (Public Health Dentist), and Ms Neelima Chadha (Assistant Librarian at PGIMER, Chandigarh) for Library support and the authors who generously shared their articles for including in the review.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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