A Smoking Prevention Program Delivered by Medical Students to Secondary Schools in Brazil Called "Education Against Tobacco": Randomized Controlled Trial

Oscar Campos Lisboa, Breno Bernardes-Souza, Luiz Eduardo De Freitas Xavier, Matheus Rocha Almeida, Paulo César Rodrigues Pinto Corrêa, Titus Josef Brinker, Oscar Campos Lisboa, Breno Bernardes-Souza, Luiz Eduardo De Freitas Xavier, Matheus Rocha Almeida, Paulo César Rodrigues Pinto Corrêa, Titus Josef Brinker

Abstract

Background: Smoking is the largest preventable cause of mortality in Brazil. Education Against Tobacco (EAT) is a network of more than 3500 medical students and physicians across 14 countries who volunteer for school-based smoking prevention programs. EAT educates 50,000 adolescents per year in the classroom setting. A recent quasi-experimental study conducted in Germany showed that EAT had significant short-term smoking cessation effects among adolescents aged 11 to 15 years.

Objective: The aim is to measure the long-term effectiveness of the most recent version of the EAT curriculum in Brazil.

Methods: A randomized controlled trial was conducted among 2348 adolescents aged 12 to 21 years (grades 7-11) at public secondary schools in Brazil. The prospective experimental design included measurements at baseline and at 6 and 12 months postintervention. The study groups comprised randomized classes receiving the standardized EAT intervention (90 minutes of mentoring in a classroom setting) and control classes in the same schools (no intervention). Data were collected on smoking status, gender, social aspects, and predictors of smoking. The primary endpoint was the difference in the change in smoking prevalence between the intervention group and the control group at 12-month follow-up.

Results: From baseline to 12 months, the smoking prevalence increased from 11.0% to 20.9% in the control group and from 14.1% to 15.6% in the intervention group. This difference was statistically significant (P<.01). The effects were smaller for females (control 12.4% to 18.8% vs intervention 13.1% to 14.6%) than for males (control 9.1% to 23.6% vs intervention 15.3% to 16.8%). Increased quitting rates and prevented onset were responsible for the intervention effects. The differences in change in smoking prevalence from baseline to 12 months between the intervention and control groups were increased in students with low school performance.

Conclusions: To our knowledge, this is the first randomized trial on school-based tobacco prevention in Brazil that shows significant long-term favorable effects. The EAT program encourages quitting and prevents smoking onset, especially among males and students with low educational background.

Trial registration: ClinicalTrials.gov NCT02725021; https://ichgcp.net/clinical-trials-registry/NCT02725021.

International registered report identifier (irrid): RR2-10.2196/resprot.7134.

Keywords: medical students; prevention; schools; smoking; tobacco.

Conflict of interest statement

Conflicts of Interest: None declared.

©Oscar Campos Lisboa, Breno Bernardes-Souza, Luiz Eduardo De Freitas Xavier, Matheus Rocha Almeida, Paulo César Rodrigues Pinto Corrêa, Titus Josef Brinker. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.02.2019.

Figures

Figure 1
Figure 1
Study design and flow of participants.
Figure 2
Figure 2
Effects of the intervention on smoking status by gender.

References

    1. Pinto M, Bardach A, Palacios A, Biz A, Alcaraz A, Rodríguez B, Augustovski F, Pichon-Riviere A. Carga de doença atribuível ao uso do tabaco no Brasil e potencial impacto do aumento de preços por meio de impostos. Documento técnico IECS N° 21. Buenos Aires, Argentina: Instituto de Efectividad Clínica y Sanitaria; 2017.
    1. Barreto S, Giatti L, Oliveira-Campos M, Andreazzi M, Malta DC. Experimentation and use of cigarette and other tobacco products among adolescents in the Brazilian state capitals (PeNSE 2012) Rev Bras Epidemiol. 2014;17 Suppl 1:62–76.
    1. Thomas R, McLellan J, Perera R. Effectiveness of school-based smoking prevention curricula: systematic review and meta-analysis. BMJ Open. 2015 Mar 10;5(3):e006976. doi: 10.1136/bmjopen-2014-006976.
    1. Peirson L, Ali M, Kenny M, Raina P, Sherifali D. Interventions for prevention and treatment of tobacco smoking in school-aged children and adolescents: a systematic review and meta-analysis. Prev Med. 2016 Apr;85:20–31. doi: 10.1016/j.ypmed.2015.12.004.
    1. Hefler M, Liberato S, Thomas DP. Incentives for preventing smoking in children and adolescents. Cochrane Database Syst Rev. 2017 Dec 06;6:CD008645. doi: 10.1002/14651858.CD008645.pub3.
    1. Bast L, Due P, Ersbøll AK, Damsgaard M, Andersen A. Association of school characteristics and implementation in the X:IT Study-a school-randomized smoking prevention program. J Sch Health. 2017 Dec;87(5):329–337. doi: 10.1111/josh.12500.
    1. Midford R, Cahill H, Lester L, Foxcroft D, Ramsden R, Venning L. Smoking prevention for students: findings from a three-year program of integrated harm minimization school drug education. Subst Use Misuse. 2016;51(3):395–407. doi: 10.3109/10826084.2015.1110173.
    1. Garnham-Lee K, Trigwell J, McGee CE, Knowles Z, Foweather L. Impact and acceptability of the coach and teacher training within a school-based sport-for-health smoking prevention intervention: SmokeFree Sports. J Child Adoles Subst. 2016 Jun 17;25(6):606–612. doi: 10.1080/1067828X.2016.1175982.
    1. Brown N, Luckett T, Davidson P, DiGiacomo M. Family-focussed interventions to reduce harm from smoking in primary school-aged children: a systematic review of evaluative studies. Prev Med. 2017 Aug;101:117–125. doi: 10.1016/j.ypmed.2017.06.011.
    1. Chan S, Cheung Y, Fong D, Emmons K, Leung A, Leung D, Lam TH. Family-based smoking cessation intervention for smoking fathers and nonsmoking mothers with a child: a randomized controlled trial. J Pediatr. 2017 Dec;182:260.e4–266.e4. doi: 10.1016/j.jpeds.2016.11.021.
    1. do Nascimento MO, De Micheli D. Evaluation of different school-based preventive interventions for reducing the use of psychotropic substances among students: a randomized study. Cien Saude Colet. 2015 Aug;20(8):2499–2510. doi: 10.1590/1413-81232015208.15152014.
    1. Malcon M, Menezes A, Assunção M, Neutzling M, Challal P. Efetividade de uma intervenção educacional em tabagismo entre adolescentes escolares. Rev Bras Epidemiol. 2011 Mar;14(1):63–72. doi: 10.1590/S1415-790X2011000100006.
    1. Brinker T, Buslaff F, Haney C, Gaim B, Haney A, Schmidt S, Silchmüller MP, Taha L, Jakob L, Baumert HM, Hallmann M, Heckl M, Alfitian J, Brieske CM, Divizieva EP, Wilhelm J, Hillebrand G, Penka D, Raveendranathan S, Netzwerk Aufklärung gegen Tabak. Suhre JL. [The global medical network Education Against Tobacco-voluntary tobacco prevention made in Germany] Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2018 Nov;61(11):1453–1461. doi: 10.1007/s00103-018-2826-8.
    1. Brinker TJ, Seeger W. Photoaging mobile apps: a novel opportunity for smoking cessation? J Med Internet Res. 2015 Jul 27;17(7):e186. doi: 10.2196/jmir.4792.
    1. Education Against Tobacco. .
    1. Brinker T, Seeger W, Buslaff F. Photoaging mobile apps in school-based tobacco prevention: the mirroring approach. J Med Internet Res. 2016 Dec 28;18(6):e183. doi: 10.2196/jmir.6016.
    1. Brinker T, Stamm-Balderjahn S, Seeger W, Klingelhöfer D, Groneberg DA. Education Against Tobacco (EAT): a quasi-experimental prospective evaluation of a multinational medical-student-delivered smoking prevention programme for secondary schools in Germany. BMJ Open. 2015 Sep 18;5(9):e008093. doi: 10.1136/bmjopen-2015-008093.
    1. Brinker T, Stamm-Balderjahn S, Seeger W, Groneberg DA. Education Against Tobacco (EAT): a quasi-experimental prospective evaluation of a programme for preventing smoking in secondary schools delivered by medical students: a study protocol. BMJ Open. 2014 Jul 24;4(7):e004909. doi: 10.1136/bmjopen-2014-004909.
    1. Brinker T, Owczarek A, Seeger W, Groneberg D, Brieske C, Jansen P, Klode J, Stoffels I, Schadendorf D, Izar B, Fries FN, Hofmann FJ. A medical student-delivered smoking prevention program, Education Against Tobacco, for secondary schools in Germany: randomized controlled trial. J Med Internet Res. 2017 Dec 06;19(6):e199. doi: 10.2196/jmir.7906.
    1. Bernstein S, Yu S, Post L, Dziura J, Rigotti NA. Undertreatment of tobacco use relative to other chronic conditions. Am J Public Health. 2013 Aug;103(8):e59–e65. doi: 10.2105/AJPH.2012.301112.
    1. Raupach T, Falk J, Vangeli E, Schiekirka S, Rustler C, Grassi M, Pipe A, West R. Structured smoking cessation training for health professionals on cardiology wards: a prospective study. Eur J Prev Cardiol. 2014 Jul;21(7):915–922. doi: 10.1177/2047487312462803.
    1. Anders S, Strobel L, Krampe H, Raupach T. [Do final-year medical students know enough about the treatment of alcohol use disorders and smoking?] Dtsch Med Wochenschr. 2013 Jan;138(1-2):23–27. doi: 10.1055/s-0032-1327367.
    1. Flett K, Grogan S, Clark-Carter D, Gough B, Conner M. Male smokers' experiences of an appearance-focused facial-ageing intervention. J Health Psychol. 2017 Dec;22(4):422–433. doi: 10.1177/1359105315603477.
    1. Jiwa M, Burford O, Parsons R. Preliminary findings of how visual demonstrations of changes to physical appearance may enhance weight loss attempts. Eur J Public Health. 2015 Apr;25(2):283–285. doi: 10.1093/eurpub/cku249.
    1. Mahler H, Kulik J, Butler H, Gerrard M, Gibbons FX. Social norms information enhances the efficacy of an appearance-based sun protection intervention. Soc Sci Med. 2008 Jul;67(2):321–329. doi: 10.1016/j.socscimed.2008.03.037.
    1. Olson A, Gaffney C, Starr P, Dietrich AJ. The impact of an appearance-based educational intervention on adolescent intention to use sunscreen. Health Educ Res. 2008 Oct;23(5):763–769. doi: 10.1093/her/cym005.
    1. Owen A, Grogan S, Clark-Carter D. Effects of an appearance-focussed versus a health-focussed intervention on men's attitudes towards UV exposure. Int J Men Health. 2016;15(1):12–26. doi: 10.3149/jmh.1501.34.
    1. Stapleton J, Turrisi R, Hillhouse J, Robinson J, Abar B. A comparison of the efficacy of an appearance-focused skin cancer intervention within indoor tanner subgroups identified by latent profile analysis. J Behav Med. 2010 Jun;33(3):181–190. doi: 10.1007/s10865-009-9246-z.
    1. Tuong W, Armstrong AW. Effect of appearance-based education compared with health-based education on sunscreen use and knowledge: a randomized controlled trial. J Am Acad Dermatol. 2014 Apr;70(4):665–669. doi: 10.1016/j.jaad.2013.12.007.
    1. Brinker T, Holzapfel J, Baudson T, Sies K, Jakob L, Baumert H, Heckl M, Cirac A, Suhre J, Mathes V, Fries FN, Spielmann H, Rigotti N, Seeger W, Herth F, Groneberg DA, Raupach T, Gall H, Bauer C, Marek P, Batra A, Harrison CH, Taha L, Owczarek A, Hofmann FJ, Thomas R, Mons U, Kreuter M. Photoaging smartphone app promoting poster campaign to reduce smoking prevalence in secondary schools: the Smokerface Randomized Trial: design and baseline characteristics. BMJ Open. 2016 Dec 07;6(11):e014288. doi: 10.1136/bmjopen-2016-014288.
    1. Brinker T, Schadendorf D, Klode J, Cosgarea I, Rösch A, Jansen P, Stoffels I, Izar B. Photoaging mobile apps as a novel opportunity for melanoma prevention: pilot study. JMIR Mhealth Uhealth. 2017 Jul 26;5(7):e101. doi: 10.2196/mhealth.8231.
    1. Burford O, Smith M, Jiwa M, Carter O. Photoageing Intervention (PAINT): a proposal for a randomised controlled trial in Australian primary care. AMJ. 2008 Nov 31;1(7):8–12. doi: 10.4066/AMJ.2009.108.
    1. Eastabrook S, Chang P, Taylor MF. Melanoma risk: adolescent females' perspectives on skin protection pre/post-viewing a ultraviolet photoaged photograph of their own facial sun damage. Glob Health Promot. 2018 Mar;25(1):23–32. doi: 10.1177/1757975916639871.
    1. Faria B, Brieske C, Cosgarea I, Omlor A, Fries F, de Faria CO, Lino H, Oliveira A, Lisboa O, Klode J, Schadendorf D, Bernardes-Souza B, Brinker TJ. A smoking prevention photoageing intervention for secondary schools in Brazil delivered by medical students: protocol for a randomised trial. BMJ Open. 2017 Dec 10;7(12):e018589. doi: 10.1136/bmjopen-2017-018589.
    1. Mahler H, Kulik J, Gerrard M, Gibbons FX. Effects of photoaging information and UV photo on sun protection intentions and behaviours: a cross-regional comparison. Psychol Health. 2013;28(9):1009–1031. doi: 10.1080/08870446.2013.777966.
    1. Lo Presti L, Chang P, Taylor MF. Young Australian adults' reactions to viewing personalised UV photoaged photographs. Australas Med J. 2014;7(11):454–461. doi: 10.4066/AMJ.2014.2253.
    1. Brinker T, Heckl M, Gatzka M, Heppt M, Resende Rodrigues H, Schneider S, Sondermann W, de Almeida E Silva C, Kirchberger M, Klode J, Enk AH, Knispel S, von Kalle C, Stoffels I, Schadendorf D, Nakamura Y, Esser S, Assis A, Bernardes-Souza B. A skin cancer prevention facial-aging mobile app for secondary schools in Brazil: appearance-focused interventional study. JMIR Mhealth Uhealth. 2018 Mar 09;6(3):e60. doi: 10.2196/mhealth.9794.
    1. Brinker T, Brieske C, Esser S, Klode J, Mons U, Batra A, Rüther T, Seeger W, Enk A, von Kalle C, Berking C, Heppt MV, Gatzka MV, Bernardes-Souza B, Schlenk RF, Schadendorf D. A face-aging app for smoking cessation in a waiting room setting: pilot study in an HIV outpatient clinic. J Med Internet Res. 2018 Aug 15;20(8):e10976. doi: 10.2196/10976.
    1. Brinker T, Klode J, Esser S, Schadendorf D. Facial-aging app availability in waiting rooms as a potential opportunity for skin cancer prevention. JAMA Dermatol. 2018 Sep 01;154(9):1085–1086. doi: 10.1001/jamadermatol.2018.1907.
    1. Baudson T, Weber K, Freund PA. More than only skin deep: appearance self-concept predicts most of secondary school students' self-esteem. Front Psychol. 2016;7:1568. doi: 10.3389/fpsyg.2016.01568. doi: 10.3389/fpsyg.2016.01568.
    1. Burford O, Jiwa M, Carter O, Parsons R, Hendrie D. Internet-based photoaging within Australian pharmacies to promote smoking cessation: randomized controlled trial. J Med Internet Res. 2013 Mar 26;15(3):e64. doi: 10.2196/jmir.2337.
    1. Xavier L, Bernardes-Souza B, Lisboa O, Seeger W, Groneberg D, Tran T, Fries F, Corrêa PC, Brinker TJ. A medical student-delivered smoking prevention program, Education Against Tobacco, for secondary schools in Brazil: study protocol for a randomized trial. JMIR Res Protoc. 2017 Jan 30;6(1):e16. doi: 10.2196/resprot.7134.
    1. BMBF Gesundheitsforschung Deutsche Arbeitsgemeinschaft fuer Epidemiologie. 2004. Leitlinien und Empfehlungen zur Sicherung von Guter Epidemiologischer Praxis (GEP) .
    1. Kuntz B, Waldhauer J, Moor I, Rathmann K, Richter M, Orth B, Piontek D, Kraus L, Zeiher J, Lampert T. [Trends in educational inequalities in smoking among adolescents in Germany: evidence from four population-based studies] Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2018 Jan;61(1):7–19. doi: 10.1007/s00103-017-2636-4.
    1. Hoebel J, Kuntz B, Kroll L, Finger J, Zeiher J, Lange C, Lampert T. Trends in absolute and relative educational inequalities in adult smoking since the early 2000s: the case of Germany. Nicotine Tob Res. 2018 Feb 07;20(3):295–302. doi: 10.1093/ntr/ntx087.
    1. Kuntz B, Zeiher J, Hoebel J, Lampert T. Soziale Ungleichheit, Rauchen und Gesundheit. Suchttherapie. 2016 Aug 16;17(03):115–123. doi: 10.1055/s-0042-109372.
    1. Kuntz B, Lampert T. Smoking and passive smoke exposure among adolescents in Germany. Dtsch Arztebl Int. 2016 Jan 22;113(3):23–30. doi: 10.3238/arztebl.2016.0023. doi: 10.3238/arztebl.2016.0023.
    1. Kuntz B, Hoebel J, Lampert T. [Educational differences in smoking and smoking cessation among young adults. Results from the "German Health Update" (GEDA) Study 2009 and 2010] Gesundheitswesen. 2014 Oct;76(10):647–654. doi: 10.1055/s-0033-1364017.
    1. Corrêa PCRP, Pereira RMOS, Temporao JG, Cavalcante TM, Lisboa OC, Azevedo LG, Brinker TJ, Bernardes-Souza B. EAT-Brazil Award for Tobacco Control: a brief description of the profile of the proposals submitted in the 1st edition of the award. Revista da Associação Médica Brasileira. 2019 (forthcoming)

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