Process Evaluation of a Medical Student–Delivered Smoking Prevention Program for Secondary Schools: Protocol for the Education Against Tobacco Cluster Randomized Trial

Abstract

Background Most smokers start smoking during their early adolescence under the impression that smoking entails positive attributes. Given the addictive nature of cigarettes, however, many of them might end up as long-term smokers and suffering from tobacco-related diseases. To prevent tobacco use among adolescents, the large international medical students’ network Education Against Tobacco (EAT) educates more than 40,000 secondary school students per year in the classroom setting, using evidence-based self-developed apps and strategies. Objective This study aimed to evaluate the long-term effectiveness of the school-based EAT intervention in reducing smoking prevalence among seventh-grade students in Germany. Additionally, we aimed to improve the intervention by drawing conclusions from our process evaluation. Methods We conduct a cluster-randomized controlled trial with measurements at baseline and 9, 16, and 24 months postintervention via paper-and-pencil questionnaires administered by teachers. The study groups consist of randomized schools receiving the 2016 EAT curriculum and control schools with comparable baseline data (no intervention). The primary outcome is the difference of change in smoking prevalence between the intervention and control groups at the 24-month follow-up. Secondary outcomes are between-group differences of changes in smoking-related attitudes and the number of new smokers, quitters, and never-smokers. Results A total of 11,268 students of both sexes, with an average age of 12.32 years, in seventh grade of 144 secondary schools in Germany were included at baseline. The prevalence of cigarette smoking in our sample was 2.6%. The process evaluation surveys were filled out by 324 medical student volunteers, 63 medical student supervisors, 4896 students, and 141 teachers. Conclusions The EAT cluster randomized trial is the largest school-based tobacco-prevention study in Germany conducted to date. Its results will provide important insights with regards to the effectiveness of medical student–delivered smoking prevention programs at school. International Registered Report Identifier (IRRID) DERR1-10.2196/13508

Tobacco prevention education for middle school and high school educators

“…Moreover, those delivering a tobacco prevention programmes to educators and/or students are encouraged to use evidence-based educational resources, such as the Stanford Tobacco Prevention Toolkit (Stanford Medicine, 2020), a resource not used for the present study. In prior studies, medical students have delivered tobacco prevention educational classes to middle and high school students (Brinker et al, 2019), but this may not be feasible for rural communities, especially those that are medically underserved. Feasible options for rural schools may include mobile or text messaging-based tobacco education and prevention programmes for students, parents and/or educators, as used for other health behaviours in rural youth populations (Brown et al, 2019).…”

“…Beyond policy-level approaches, alternative strategies to tobacco prevention have included school-based education delivered to students (Brinker et al, 2019; Little et al, 2015; Nagler and Lobo, 2019; St Germain et al, 2017) and mass public health campaigns, such as The Real Cost (Brubach, 2019). Given research suggests young people believe e-cigarettes to be less harmful and less addictive than combustible cigarettes, a belief found to influence ever and past 30-day use of e-cigarettes (Dobbs et al, 2016), schools have been encouraged to include more education about these emerging products within their tobacco prevention education (Anand et al, 2015).…”

“…However, such recommendations do not identify who should be delivering this education and how it should be delivered. While most educational programmes have been developed to be delivered directly to youth (Brinker et al, 2019; Little et al, 2015), no literature was found about tobacco prevention education created for middle school and high school educators. In Jamaica, student–teacher relationships were found to be a strong predictor of students’ decision to use combustible cigarettes (Oshi et al, 2018), and in Spain, children who saw a teacher smoke were more likely to try cigarettes than those with parents’ who smoked, identifying teachers as an important opinion leader for adolescents (Escario and Wilkinson, 2018).…”

Healthcare students’ prevention training in a sanitary service: analysis of health education interventions in schools of the Grenoble academy

“…The interventions of students, who are close in age, seem to be particularly effective with adolescents on subjects such as alcohol, drug and tobacco consumption. In experiments reported by Brinker et al medical student interventions appeared to be effective in primary prevention of tobacco use, and in promoting smoking cessation [ 20 – 22 ]. In France, a health service study conducted by medical students reported positive effects in terms of knowledge, skills and behaviour on pupils and positive effects on the students themselves [ 23 ].…”