A review of research on smoking prevention programs has turned up several family-based initiatives that helped keep children from becoming smokers.

Successful approaches included an Iowa program that educated parents on substance abuse risks and encouraged adults to establish clear family rules about cigarette smoking and a program in Norway that emphasized each child's freedom to choose. "I'd say that well-tested programs with enthusiastic counselors work," said lead review author Roger Thomas, M.D. But "these programs are not surefire," he added. The reviewers identified 19 trials that tested the effectiveness of prevention strategies centered on family and parent involvement, then drew their conclusions from 14 studies they determined were sufficiently reliable. The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic. "You are going to put more trust in the studies that try to figure out the trajectory and underlying causes of why children smoke, versus just taking a snapshot," Thomas said. "The Cochrane approach is very cautious; if we are going to spend millions of dollars we need to make sure it really works. So the essence of the review is deciding what quality of data we have." Nine better-quality studies identified by the review authors tested family-based programs against no intervention. In four of these studies, the family intervention significantly reduced the risk that a child would become a smoker. Some of the successful programs were short interventions, while others were multilayered approaches that extended for seven or eight sessions. "The programs that worked were quite different," said Thomas, a professor of family medicine at the University of Calgary in Canada. Asked if parents and policy-makers should have confidence in family-based smoking prevention programs, Thomas said: "It really depends on whether you are a glass-half-full or glass-half-empty person. An optimist would say 'Oh, four worked, great, we'll go ahead.' A pessimist who controls the budget might say, 'There were five programs that didn't work. So I'm not going to bother.'" Of the studies that compared a family and a school program, only one found the family program reduced smoking more than the school program. Six studies compared a combined family-plus-school program to a school program and none found a difference. Two family programs were unusual: One aimed to reduce alcohol use, the other targeted a variety of risk behaviors including HIV. Although neither study intervened against smoking, in both programs smoking decreased compared to the control group. All 14 studies measured effectiveness somewhat differently, but in general the researchers documented the number of children who remained nonsmokers, the number of new smokers in each study group and whether the children had ever tried cigarettes. Public health researcher Christine Jackson, Ph.D., said early research on smoking prevention programs for children clearly shows that school-based programs are not adequate to keep kids from smoking. So researchers, looking for more effective approaches, turned to family-based programs. Jackson, a senior research scientist with the Pacific Institute for Research and Evaluation in Chapel Hill, N.C., was not involved in the Cochrane review. But she led research on an effective smoking prevention program in North Carolina that was built around mail-home activity guides, newsletters for children and giveaways like wristbands and yo-yos. "You have to make it fun for the kids. It's like joining a club from the kids' perspective," she said. Jackson said she believes that prevention programs that reach children well before middle school have the most promise. "Early onset of smoking is a known predictor of becoming a habitual smoker by late adolescence," she said. "That's the problem we are up against. The highest-risk kids are the early starters." Thomas says the Cochrane review does not point to one definite plan for families or communities to keep children from smoking, but the analysis does highlight several potential strategies. "I'd focus on these four effective programs, decide on the needs of your particular location and then get some local experts to improve it," he said. Thomas, RE et al. Family-based programmes for preventing smoking by children and adolescents. The Cochrane Library 2007, Issue 1. The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit

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