Incentives for preventing smoking in children and adolescents

Marita Hefler; Selma C Liberato; David P Thomas

doi:10.1002/14651858.CD008645.pub3

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Figure 1

PRISMA study flow diagram of search results

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1 Incentive versus control. Randomized and non‐randomized controlled studies (adjusted for clustering), Outcome 1 Smoking uptake at longest follow‐up (RR).

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Study	Number of non‐smokers at baseline	Number of smokers at endpoint who reported not smoking at baseline	Time point	Outcome	Biological criterion	Results	Secondary outcomes (dose response, cost, harms)
Crone 2003	556 intervention; 420 control (data from authors)	112 intervention; 88 control	19 months	Smoking = current smoking, including daily/weekly/experimental	Not biochemically verified	Not reported at 19 months in published paper. Our reanalysis: RR 0.92 (95% CI 0.53 to 1.61)	Not reported
Isensee 2012a	430 never‐ smokers in intervention; 610 never‐smokers in control (data from authors)	136 intervention; 184 control	19 months	Smoking = ever smoking, even just a puff	Not biochemically verified	From published paper: Authors reported that no group differences were found in the frequency of smoking initiation but data not presented in paper. Our reanalysis: RR 1.05 (95% CI 0.80 to 1.38)	Bullying (Hanewinkel 2010): "When compared with control classrooms on all three dependent variables – being victimised, active bullying or being isolated – the adjusted ORs indicated no significant differences at post‐test for any of the IGs [Intervention Groups]".
Schulze 2006	591 never‐smokers in intervention; 449 never‐smokers in control	224 intervention; 173 control	24 months	Smoking = current smoking, including irregular (less than weekly) smoking	Not biochemically verified	From published paper: 62.1% remained ‘never smoker’ in intervention group at follow‐up versus 61.4% in control group: OR 1.02 (0.83 to 1.24) adjusted for age, sex and school type. Our reanalysis: RR 0.98 (95% CI 0.77 to 1.24)	Not reported

Analysis 2.1

Comparison 2 Results of included studies, Outcome 1 Results table: RCTs.

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Study	Number of non‐smokers at baseline	Number of smokers at endpoint who reported not smoking at baseline	Time point	Outcome	Biological criterion	Results	Secondary outcomes (dose response, cost, harms)	Comment
Burke 1992	Not reported	Not reported	18 months	Mean (SD) score of 5‐category self‐definition of smoking and 10‐category self‐reported frequency	Salivary thiocyanate (TCN)	From published paper: Mean TCN at follow‐up of pre‐intervention never‐smokers higher (560 mcg/mL, SD 403) versus control (514 mcg/mL, SD 424). Primary outcome for this review not available.	Not reported
Kairouz 2009	664 intervention; 915 control	93 intervention; 165 control	10 ‐ 18 months	Smoking = ever smoking, even just a puff	Not biochemically verified	From published paper: OR 0.8 (0.5 to 1.1), adjusted for age, gender, school location, social deprivation index. Our reanalysis: RR 0.81 (95% CI 0.55 to1.20)	Intervention participants more likely than control participants to report that people “should not hang out with smokers” (14% versus 11%) and that they, themselves would “not want to be friends with a classmate who smokes” (28% versus 25%)	Concerns about misreporting of smoking status. Note large numbers of ever‐smokers at baseline then denying ever smoking at follow‐up. Stat sig more in intervention vs control (24% vs 16%)
Stucki 2014	544 intervention, 378 control	39 intervention, 24 control	About 7 months	Smoking = any smoking in last 6 months, even just a puff and smoking during the previous month	Not biochemically verified	From published and additional data from authors. OR for decreased smoking prevalence 0.7, CI 0.5 to 1.0	Increased smoking‐related knowledge b ‐1.0, P < 0.01
Vartiainen 1996	Not reported and not available from authors	Not reported and not available from authors	18 months	Smoking = daily smoking	Not biochemically verified	Reports only on the increase in prevalence of smoking from baseline to follow‐up. From baseline to longest follow‐up, increase by 10.8% points in Intervention group vs 11.2% points in control group: OR 1.25 (P = 0.15). Primary outcome for this review not available.	Not reported. Except in discussion – authors report "The social pressure created by the competition process was not greatly criticised in the pupils’ answers."
Wiborg 2002	1215 intervention group; 502 control (data from authors)	207 intervention; 107 control	12 months	Smoking = 4 week prevalence of smoking	Not biochemically verified	From published paper: OR 1.36 (1.04 to 1.76), adjusted for age, sex, smoking status at baseline Our reanalysis: RR 0.81 (95% CI 0.53 to 1.23)	Cost benefit (Hoeflymayr 2008). Cost benefit ratio: economic modelling based on estimates of reduced smoking prevalence in Intervention group and models of assumed future smoking behaviour and cessation. Not based on prevention of initiation

Analysis 2.2

Comparison 2 Results of included studies, Outcome 2 Results table: non‐randomized CTs.

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Smokefree Class Competitions (SFC) for preventing smoking uptake
Patient or population: Children and adolescents aged 5 ‐ 18 years who were non‐smokers at baseline Settings: Schools in Germany, the Netherlands, Finland, Switzerland, Canada and the United States Intervention: Participation in SFC Comparison: No participation in SFC
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants Actual number/ effective number² (studies)	Quality of the evidence (GRADE)
	Assumed risk¹	Corresponding risk
Smoking uptake at longest follow‐up (RCTS)	317 per 1000	320 per 1000	RR 1.00 (0.84 to 1.19)	3056/1108 (3)	Low^{3, 4}
Smoking uptake at longest follow‐up (Non‐RCTs)	158 per 1000	132 per 1000	RR 0.82 (0.63 to 1.08)	4219/1377 (3)	Very low^{3, 5, 6}
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; RCT: Randomised Controlled Trial
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹'Assumed risk' calculated as risk in control groups. ²Adjusted for clustering. ³Downgraded one level due to imprecision. All studies included had a wide confidence interval. ⁴Downgraded one level due to risk of bias. 2/3 studies judged to be at high risk of attrition bias. ⁵Downgraded one level due to observational (non‐RCT) study type. ⁶Downgraded one level due to risk of bias. 2/3 studies judged to be at high risk of selection bias, most other bias risks unclear.

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Comparison 1. Incentive versus control. Randomized and non‐randomized controlled studies (adjusted for clustering)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Smoking uptake at longest follow‐up (RR) Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 RCTs	3	1108	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.84, 1.19]
1.2 Non‐randomized CTs	3	1377	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.63, 1.08]

Comparison 1. Incentive versus control. Randomized and non‐randomized controlled studies (adjusted for clustering)

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Comparison 2. Results of included studies

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Results table: RCTs Show forest plot			Other data	No numeric data

2 Results table: non‐randomized CTs Show forest plot			Other data	No numeric data

Comparison 2. Results of included studies

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