It may take more than anti-smoking lessons in the classroom to keep school-age children and teens from lighting up, according to a recent review of studies.
There is little strong evidence that school-based programs are effective in the long term in preventing kids from taking up smoking, said Dr. Roger Thomas, lead reviewer and a professor in the family medicine department at the University of Calgary in Alberta, Canada.
The review appears in the July issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Thomas and colleagues identified 23 high-quality randomized controlled trials that examined the effectiveness of school-based smoking prevention programs taught to school children ages 5 to 18. The majority of these studies took place in the United States, the rest in Canada, the Netherlands and the United Kingdom.
Each study measured whether the students were nonsmokers before and immediately after the intervention program, as well as six months and two years later. Five types of tobacco-education programs were evaluated.
In information-giving education programs, students learned about smoking and its risks. Only one information-giving intervention met high-quality standards, but it did show a positive effect on students' smoking.
Social competence programs taught students behavioral skills, such as goal-setting, to help them learn to avoid smoking. When researchers pooled the results of the two best-quality social competence trials, they found a positive, but not statistically significant effect on student smoking.
Thirteen studies evaluated the effectiveness of social influence interventions, which helped students discuss ways to say no to smoking and make public commitments to not smoke. Of these, nine showed some positive effect on students' smoking prevalence.
"There is some evidence that school programs incorporating social influence models can affect smoking behavior in the short term," the reviewers wrote. But when they pooled the results of the social influence interventions, they were not statistically significant.
Combined programs used both social competence and influence methods in their anti-smoking interventions. One study found significantly decreased the prevalence of student smoking; another study indicated that the smoking intervention decreased student smoking, but only when health educators provided the smoking education, as opposed to students receiving information via self-instruction.
Of the four studies that evaluated multi-modal programs, which combined school-based programs with parent and community initiatives, three showed that the programs effectively reduced the prevalence of smoking in students.
The Cochrane review also mentioned the largest and most rigorous tobacco education study, the Hutchinson Smoking Prevention Project, which took place in 40 school districts in Washington state. The study found that an intensive eight-year program had no long-term effect on student smoking behavior when students were reassessed two years after high school.
The reviewers said that over the past three decades, efforts to influence youth smoking have focused on schools. Today, about 70 percent of U.S. middle school students and 50 percent of U.S. high school students receive tobacco prevention education in the classroom, according to the background information.
"The key problem for future research is whether more of the social influences programs can be improved so that they are effective," Thomas said.
The reviewers also concluded that when educators and parents examine smoking education programs, effectiveness is not the only issue. The cost of teacher training and extra classroom time spent are important factors to consider as well. "Those planning services will need to determine whether these costs are justified in the light of the existing evidence," Thomas said.
But David Schonfeld, M.D., director of the Division of Developmental and Behavioral Pediatrics at Cincinnati Children's Hospital Medical Center, said that the results of this review do not necessarily point to the ineffectiveness of school anti-smoking programs.
"The lack of rigorous evidence is not the same as rigorous evidence that something is ineffective," Schonfeld said. He also suggested that the positive effects on students' smoking behavior found in some of the trials may have been deemphasized in this review.
Tobacco use is responsible for an exceptional amount of social, personal and economic cost to our society, Schonfeld said. "If you take into account lost productivity and health costs, in the United States alone, it exceeds $167 billion dollars. Even a small impact — even a 1 percent drop in smoking interest in kids — that would be a savings," he said.
"What I would take from [this study] is that this is an important problem. We would like to see even more research in this area," Schonfeld said.