Background: Interventions to prevent smoking uptake or encourage cessation among children or adolescents may help slow or halt increased tobacco-related illness.
Purpose: To systematically review evidence for the efficacy and harms of primary care interventions to prevent tobacco initiation and encourage tobacco cessation among children and adolescents.
Methods: We identified three good-quality systematic reviews published since the previous USPSTF recommendation was released; two systematic reviews addressed smoking prevention that collectively covered the relevant literature through July 2002, and one Cochrane review addressed smoking cessation that included trials through August 2009. We examined the included and excluded studies of these reviews and then searched MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects to identify literature that was published after the search dates of the three prior systematic reviews. We also examined the references from 20 other good-quality systematic reviews and other relevant publications, searched Web sites of government agencies for grey literature (February to September 2011), and monitored health news Web sites and journal tables of contents (beginning in January 2011) to identify potentially eligible trials. Two investigators independently reviewed identified abstracts and full-text articles against a set of a priori inclusion and quality criteria. Discrepancies were resolved by consensus. One investigator abstracted data into an evidence table and a second investigator checked these data. We conducted random effects meta-analyses to estimate the effect size of smoking prevention or cessation interventions on self-reported smoking status. We grouped trials based on the focus of the trial—combined prevention and cessation, prevention, or cessation.
Results: We included 24 articles representing 19 unique studies. None of the studies examined childhood or longer-term health outcomes (e.g., respiratory health or adult smoking). Seven trials evaluating combined prevention and cessation interventions were mainly rated as fair quality and included a diverse mix of intervention components and approaches. Pooled analyses of six of the combined trials (n=8,749) resulted in a nonstatistically significant difference in the smoking prevalence among the intervention group compared with the control group at 6- to 12-months followup. Pooled analyses across all of the prevention trials suggested a small reduction in smoking initiation at 6- to 12-months followup among intervention participants compared with control group participants (risk ratio, 0.81 [95% confidence interval, 0.70 to 0.93]; k=9; n=26,624). Meta-analyses of the behavior-based cessation trials (k=7; n=2,328) and the medication (bupropion) cessation trials (k=2; n=256) did not show a statistically significant effect on self-reported smoking status among baseline smokers at 6- to 12-months followup. No trials evaluating behavior-based interventions (both prevention and cessation) reported possible harms from interventions. Some trials, however, reported a higher absolute prevalence of smoking in the intervention groups compared with the control groups, although none were statistically significant. Three studies were included that examined adverse effects related to bupropion use, and findings were mixed.
Conclusions: Interventions designed to reduce the prevalence of tobacco use among children and adolescents represent a clinically and methodologically heterogeneous body of literature. Overall, methodological differences between the included trials limits our ability to determine if the relatively small effect found on smoking initiation in this subset of trials represents true benefit across this body of literature. In particular, the measurement of smoking status, including what constituted smoking initiation and cessation, varied across all studies. In addition, the diversity of both the components and the intensity of the interventions limit our ability to draw conclusions about common efficacious elements.