Systematic review of school tobacco prevention programs in African countries from 2000 to 2016
Systematic review of school tobacco prevention programs in African countries from 2000 to 2016
Akihiro Nishio 0 1
Junko Saito 1
Sachi Tomokawa 1 2
Jun Kobayashi 1
Yuka Makino 1
Takeshi Akiyama 1
Kimihiro Miyake 1 2
Mayumi Yamamoto 0 1
0 Health Administration Center, Gifu University , Gifu , Japan , 2 Japanese Consortium for Global School Health Research, Nishihara, Japan, 3 School of Public Health, The University of Tokyo , Tokyo , Japan
1 Editor: Jacobus P. van Wouwe, TNO , NETHERLANDS
2 Faculty of Education, Shinshu University , Nagano , Japan , 5 Faculty of Medicine, University of the Ryukyus, Nishihara, Japan, 6 Nagano College of Nursing , Komagane , Japan
The World Bank has reported that global smoking rates declined from 2000 to 2012, with the only exception found in males in Sub-Saharan Africa. Sub-Saharan Africa is considered to be in stage one of the tobacco epidemic continuum. To address this problem, school-based programs for smoking prevention are considered cost-effective and promising. Since tobacco prevention programs are influenced by social competence or customs of each country, tobacco prevention programs that have success in Western countries are not always effective in African countries. Therefore, the current study systematically reviewed relevant literature to examine the effects of these types of programs in African countries.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: This work was supported by the Grant for
National Center for Global Health and Medicine
(27A-1) (AN) and by Ministry of Health, Labour and
Welfare of the Government of Japan (2016-2017)
Competing interests: The authors have declared
that no competing interests exist.
Online bibliographic databases and a hand search were used. We included the studies that
examined the impact of school-based programs on preventing tobacco use in Africa from
2000 to 2016.
Six articles were selected. Four were conducted in South Africa and two were performed in
Nigeria. Four programs were systematically incorporated into annual curriculums, targeting
8th to 9th graders, while the other two were temporary programs. All programs were based
on the hypothesis that providing knowledge and/or social skills against smoking would be
helpful. All studies utilized smoking or polydrug use rates to compare outcomes before/after
intervention. There were no significant differences between intervention and control groups
in three studies, with the other three demonstrating only partial effectiveness. Additionally,
three studies also examined change of knowledge/attitudes towards smoking as an
outcome. Two of these showed significant differences between groups.
All RCTs studies showed no significant change of smoking-rate by the intervention. The
effectiveness of intervention was observed only in some sub-group. The cohort studies
showed school-based interventions may be effective in improving knowledge and attitudes
about smoking. However, they reported no significant change of smoking-rate by the
Smoking is one of the largest threats to public health. Smoking is associated with nearly one
out of every three deaths from cancer, nearly one out of every five deaths from heart disease,
and importantly, nine out of ten lung cancer deaths [
]. In high-income countries, the trend
of smoking rates is in decline . Therefore, it is estimated more than 80 percent of the world's
smoking-related deaths will be in low- and middle-income countries by the year 2030 [
The World Bank reported that smoking rates were seen to decline from 2000 to 2012 in almost
all regions of the world, such as the Euro area, East Asia/Pacific, Latin America/Caribbean,
North America, and South Asia in both males and females . The only exception noted were
males in Sub-Saharan Africa. The estimated prevalence of smoking in sub-Saharan Africa in
2012 was 22% in males (increasing from the level of 21% in 2000) and 3% in females. Thus,
Sub-Saharan Africa might still be in stage one of the tobacco epidemic continuum [
Adolescence is one of the highest risk developmental phases for the initiation of tobacco
use. In Africa, the estimated prevalence of smoking is 9.3% for boys, 3.8% for girls, and 6.6%
for both sexes [
]. This developmental period also avails itself as a critical chance to prevent
tobacco use. Therefore, intervention programs in schools have the unique advantage of
reaching a large number of at-risk youth within a short period of time, making these programs one
of the most promising methods to prevent tobacco use. In 2000, UNESCO, UNICEF, and The
World Bank developed the Focusing Resources on Effective School Health (FRESH) initiative
to strengthen health promotion and educational activities in schools [
]. FRESH consists of
four components: 1) health-related school policies; 2) water, sanitation, and the environment;
3) skills-based health education; and 4) health and nutrition Services. Further, FRESH
recommends that governments implement school-based health programs, including tobacco
prevention, in efficient, realistic, and result-oriented ways [
]. Taking this information into account,
tobacco prevention school programs should be implemented with the best method based on
scientific evidence throughout Africa.
The results of previous studies on the effectiveness of school-based programs in preventing
tobacco use among school children are mixed. According to a review by Thomas et al. reported
longest follow-up found an overall significant effect with average 12% reducation in starting
smoking compared with controls, but no effect for all trials pooled at less than 1 year.
However, trials of combined social competence/social influence curricula had a significant effect on
smoking prevention at both follow-up periods[
]. While a review of 25 studies by Skara and
Sussman provided long-term empirical evidence of the effectiveness in preventing or reducing
substance use for up to 15 years after program completion [
], little to no rigorous evidence
of effectiveness was found in a review of eight studies in individuals up to 18 years old (i.e.,
12th grade) [
]. However, almost all of the studies selected in these reviews contain data from
high-income countries. Tobacco prevention programs demonstrated to perform best in
developed countries will not always perform well in African countries, because tobacco prevention
2 / 16
programs require much social information to create curricula. To the best of our knowledge,
no systematic reviews have been performed to quantify the effects of school-based programs
on preventing tobacco use among school children in Africa, where the tobacco epidemic is still
occurring. Therefore, to provide contemporary school-based prevention programs in African
countries, following establishment of the FRESH framework, the current manuscript
conducted a systematic review of all available research on this subject.
Material and methods
The protocol for this systematic review was registered in February 20, 2017, in the PROSPERO
Search strategy for relevant articles
In October 2016, PubMed, Web of Science, SCOPUS, ERIC, PsycINFO, Popline, CINAHL,
and CENTAL were used to search for relevant articles. We created the search terms based on a
previous review, and then adapted them to all other databases according to vocabulary and
syntax of each database.
We adapted the search formula to each database style. The basic formula utilized was as
school AND (child OR adolescen OR student OR pupil ) AND (Africa OR Cameroon
OR "Central African Republic" OR Chad OR Congo OR "Democratic Republic of the Congo"
OR "Equatorial Guinea" OR Gabon OR Burundi OR Djibouti OR Eritrea OR Ethiopia OR
Kenya OR Rwanda OR Somalia OR ªSouth Sudanº OR Sudan OR Tanzania OR Uganda OR
Angola OR Botswana OR Lesotho OR Malawi OR Mozambique OR Namibia OR "South
Africa" OR Swaziland OR Zambia OR Zimbabwe OR Benin OR "Burkina Faso" OR "Cape
Verde" OR "Cote d'Ivoire" OR Gambia OR Ghana OR Guinea OR "Guinea-Bissau" OR Liberia
OR Mali OR Mauritania OR Niger OR Nigeria OR Senegal OR "Sierra Leone" OR Togo OR
Algeria OR Egypt OR Libya OR Morocco OR Tunisia) AND (tobacco OR smok )
In addition, we hand-searched five key journals, including School Health Research, Health
Education Research, Health Promotion International, Tropical Medicine & International
Health, and Cochrane Library.
Two reviewers (AN and MY) independently searched articles, utilizing identical
methodology, and evaluated articles to find relevant studies following pre-established inclusion criteria.
Any disagreements between the reviewers were resolved by discussion and, if necessary, by
consulting a third reviewer (ST).
The title and abstracts of the results generated from the searching database were screened
using the following inclusion criteria:
1. Study design: all quantitative study designs, including randomized controlled trials (RCT),
non-randomized trials, cohort studies (controlled and uncontrolled), and cross-sectional
2. Study objectives: studies that examined the impact of school-based programs on preventing
3. Participants: students in Grades 1 to 12
4. Location: African counties
3 / 16
5. Program: any type of school-based program targeting students to prevent smoking
We examined each of the selected articles from the viewpoint of country, targeted children,
and type of intervention. We also evaluated the risk of bias of RCTs or cluster-randomized
control trials by the Cochrane Collaboration's tool for assessing risk of bias [
non-randomized studies, we evaluated their risk of bias by the Risk of Bias in Non-randomized Studies
of Intervention (ROBINS-I) assessment tool [
]. Finally, we determined effective intervention
programs in African school settings from these results.
Results of literature search
The PubMed search yielded 549 articles. Searches of Web of Science, ERIC, PsycINFO,
Popline, CINAHL, and CENTRAL yielded 173, 13, 206, 51, 19 and 25 articles, respectively.
SCOPUS limited the length of search formula. Therefore, we divided the section of the formula
concerning country name into three parts and conducted three separate searches. These
searches yielded 220, 184, and 155 articles, respectively. We found one article through a hand
search. The most common reasons for exclusion were that studies were not prevention studies
at schools (e.g., simple smoking prevalence surveys). Six articles [15±20] were included in the
review. Fig 1 shows our flow chart of the review to selected articles. Table 1 shows the outline
Fig 1. Flow chart of the review.
4 / 16
No significant difference was
found in the rate of 30-days
smoking in LST group, HM
group and the control group after
1 and 2 years follow-up nor in
knowledge, attitudes, or skills, to
refuse smoking among the three
HW girls were significantly less
likely to initiate smoking, or to
have smoked in the past month,
compared to control girls.
However, there were no
treatment effects among baseline
non-smoking boys on these two
outcomes. Among the full sample
(both baseline smokers and
nonsmokers), increases in
pastmonth and heavy smoking were
larger for the control group.
Heavy smoking was lower among
the HW subsample who had not
smoked prior to the beginning of
There were not significant
gender, cohort, or treatment
main effects for lifetime polydrug
use. Results of the main effect
models for past 30 days polydrug
use showed there was no
significant difference in analysis
of all participants. However,
among non users, there was a
significant effect in cohort by
treatment interaction (β = 0.12,
SE = 0.06, p < 0.05).
Among baseline non-smokers,
HW's effect on preventing
cigarette use by the start of 10th
grade was moderated in girls (OR
= .64, p = .02). The likelihood of
initiating cigarette use was
reduced in girls with the
intervention, (OR = .73, p = .01)
but not boys' (OR = 1.14, p = .35).
5 / 16
No significant difference was
found in the rate of 30-days
smoking in intervention group
and the control group.The mean
knowledge score of respondents
in the study group significantly
increased from 61.24 before the
intervention to 92.31 after the
intervention (p < 0.01). Attitudes
towards smoking also changed.
For example, 71.9% of
respondents in the study group at
baseline felt that cigarettes should
not be sold to people less than 18
years old, this increased to 91.7%
post-intervention (p < 0.01).
No significant difference was
found in the rate of 30-days
smoking in intervention group
and the control group. Students
in the intervention group had
significantly higher mean
knowledge scores after
(p < 0.001). The mean score of
attitudes towards smoking was
also significantly higher in the
intervention group (p < 0.001).
478 and 495 for
control of junior and
The intervention was based on Smoking rate in
the anti-smoking awareness last 30 days,
program which was developed on knowledge and
the Health Belief Model of attitude towards
behavioral change. This program smoking
consisted of two health talks
about the effects of smoking on
health for one hour, providing
information leaflets, and putting
posters within school.
of the included articles. Figs 2 and 3 were created using Review Manager 5.3 and show the
evaluation of their risk of bias.
Risk of bias
Selection bias of four RCTs survey [15±18] was not evaluated enough because of lack of
information. Performance and detection bias of four RCT was equally judged a low risk among
four RCTs studies since the intervention group and control group were separated by school.
Percentage attrition of Resnicow et al.[
], Smith et al.[
], Tibbits et al.[
], Motamedi et al
] were 11%, 38%, 10% and 10%, respectively. All studies measured the last outcome two
years or less from baseline. We judged Smith et al. to have a high risk of attrition bias. The
other three studies were judged as having low risk of attrition bias since the percentage of
attrition was small and the reason for attrition was mainly considered to be natural decrease
because of dropping out or repeating a year. Reporting bias of four RCTs surveys was also
judged to be low risk since these studies were not related to commercial activities.
Bias due to confounding of two cohort studies was judged a low risk because of very simple
surveys at schools. Bias in selection of two cohort surveys was judged a low risk since selection
of participants into the survey did not base on participant characteristics. Bias in classification
of two cohort surveys was judged a low risk since intervention groups cleary defined. Bias due
to deviation of two cohort surveys was equally judged a serious risk since it is considered a lot
of other factors such as children's life style or human relationship affect the results. Bias due to
missing data of two cohort surveys was judged a low risk since the percentage attrition of Raji
6 / 16
Fig 2. Risk of bias for RCT studies.
], Odukoya et al[
] were 4.4%, 2.5%, respectively and very low. Bias in measurement
of outcomes was judged moderate risk in two cohort surveys since the outcome would be
partially influenced by children's interest of tobacco issue. Bias of selection of reported result was
judge a low risk in two cohort surveys since these studies were considered related to any
intention of authors.
The study design was very similar in every study. Therefore, evaluation of risk of bias was
similar for all studies.
7 / 16
Fig 3. Risk of bias for non-RCT studies.
Characteristics of included studies
Four studies [15±17, 20] were conducted in South Africa and the other two [
conducted in Nigeria. One study  targeted high school students, four studies [15±18] targeted
junior high school students, and one study [
] targeted both junior high and high school
students. Four intervention programs [15±18] were systematically incorporated into annual
curriculums, and targeted 8th- to 9th-grade learners. The other two interventions [
temporary programs. Classroom lecture education using a textbook was the standard
education style in the six studies. The intervention intensity varied from 2 to 18 sessions. The
intervention programs, which contained a higher amount of sessions, also included other health
related issues. Thus, the intensity of intervention programs against smoking was considered
relatively similar. All intervention programs were based on the hypothesis that providing
knowledge or social skills against smoking were helpful, in other words, skills-based programs.
The Health Wise (HW) program was one of the skills-based programs. This was modified and
used as intervention program in three studies [
]. The HW program is a school-based
prevention program developed to reduce substance use and risky sexual behavior in South
Africa . One study [
] used two types of intervention programs: one skills-based program
and a second program based on the hypothesis that elimination of smoking entirely was not
8 / 16
attainable, with the focus placed instead on the reduction of adverse physical, psychological,
and social consequences of heavy use.
All six studies utilized smoking or polydrug use rates before and after program
implementation as outcome measures. There were no significant differences between intervention and
control groups in three studies [
], and the effectiveness of the other three studies [16±
18] was only partial. One article [
] showed that girls of the intervention group were
significantly less likely to have initiated smoking and to have smoked in the past month. Another
] showed that non-polydrug users at baseline in the intervention group showed a
significantly lower onset of frequent polydrug use, when compared to the control group.
Although this study did not evaluate the effects on smoking independently, the findings
suggest that the program may have been somewhat effective in preventing substance use overall,
including smoking, among adolescents in South Africa. The other study [
] showed that
nonsmoking girls of the intervention group were significantly less likely to have initiated smoking.
Three studies [
] also used change of knowledge and/or attitudes towards smoking
as outcome measures. Two [
] of these studies showed significant differences between
intervention and control groups. The other  did not show any significant difference.
In total, only five studies [16±20] reported positive results of programs focused on smoking
prevention. All of these studies could only demonstrate partial effectiveness.
In the study by Resnicow et al. [
], 36 public schools were randomly recruited from two
provinces in South Africa. The total number of valid participants was 4684, and the 36 schools
were randomly assigned into three groups: control group, Life Skills Training (LST) group,
and Harm Minimization (HM) group. The LST program, which was one of the skills-based
programs developed in the U.S., has been shown in several randomized trials to reduce tobacco
and other substance use [22±33] and is a common program for tobacco intervention utilized
]. The LST program included the following elements: training in social skills,
training in problem solving, enhancement of self-esteem, correction of overestimations of
tobacco consumption, preparation for facing puberty-related physical changes without stress,
and information on the effects of tobacco consumption on health. On the other hand, the
concept of the HM program is that eliminating cigarette and other drug use entirely is neither
philosophically tenable, nor practically attainable [
]. The focus of HM is on reducing
adverse physical, psychological, and social consequence of use, particularly heavy use. Each
intervention program comprised eight units each of grade 8 and 9. The two intervention
program was designed to be taught by life orientation (LO) teachers. LO is a separate mandatory
topic in South Africa which includes student outcomes for health behaviors and social skills
development. Effectiveness was measured by smoking rate in the past 30 days,
knowledge/attitudes toward smoking, and refusal skills at the beginning of eighth grade as baseline, and later
in eighth and ninth grade as the time points following intervention. The rate of smoking in the
past 30 days in the control group at baseline increased at 1 and 2 year follow-ups (18% vs. 21%
vs. 24%). The corresponding rates in the LST group were 17% vs. 20% vs. 20%, respectively.
The corresponding rates in the HM group were 17% vs. 18% vs. 20%. No significant difference
at 1 and 2-year follow-ups was noted among the three groups. Overall, knowledge/attitudes
towards smoking and refusal skills demonstrated no significant differences among the three
groups. It was mentioned that the HM program appeared to be more effective for black
African students, whereas the LST program appeared to be more effective in reducing the 30-day
smoking rate in other demographics.
Smith et al. [
] randomly selected four junior high schools as an intervention group, and
15 junior high schools as a control group, in the Mitchell's Plain area of South Africa.
Participants were a total of 2383 8th-grade students. The intervention was based on the HW
curriculum, and was designed based on the premise that increasing basic life skills, knowledge of the
9 / 16
risks associated with substance use/sexual behavior, and enhancing the skills needed to resist
substance use/sex is necessary. It was also considered that promoting healthy free time
experiences would decrease substance use and sexual behaviors among youth [37±39]. The program
consisted of 12 lessons in 8th grade and 6 booster lessons in 9th grade. Each lesson took two or
three class periods to deliver. Lessons covered topics included in most social-emotional skills
programs (e.g., anxiety/anger management, decision making, self-awareness), and also
targeted the positive use of free time (e.g., beating boredom, overcoming leisure constraints,
leisure motivation). These lessons were complemented by specific lessons on attitudes,
knowledge, and skills surrounding sexual risk and substance use and sexual risk, including
tobacco use. The lessons were provided in either English or Afrikaans. Effectiveness was
measured by lifetime smoking rate and frequency of use in the past four weeks. Data were collected
at the beginning and end of 8th grade. The results showed HW girls were significantly less
likely to have initiated smoking, or to have smoked in the past 30 days, as compared to control
group girls. However, there were no treatment effects among baseline non-smoking boys on
these two outcomes. Among the full sample (both baseline smokers and non-smokers),
increases in past 30 days and heavy smoking were also larger for the control group. Heavy
smoking was also lower among the HW group who had not smoked prior to the beginning of
Tibbits et al. [
] randomly selected four schools as an intervention group and five schools
as a control group in Cape Town, South Africa. The total participants were 4040 8th-grade
students. The intervention was based on the HW curriculum. The program consisted of 18
lessons from 8th to 9th grade. The effectiveness was measured by the lifetime and previous
30-day polydrug use rate, including tobacco. Data were collected at the beginning and end of
8th grade. The results showed no significant effects of the HW program relating to gender,
cohort, or treatment for lifetime polydrug use. Females of the intervention group had a smaller
increase (32%) in substance use than females in the control group (36%). However, the results
of the main effect models for polydrug use in the past 30 days showed no significant difference
in analysis of all participants. On the other hand, the rate of polydrug use in the HW program
group was significantly lower than the control group among non-users (β = 0.12, SE = 0.06,
p < 0.05).
Motamedi et al. [
] randomly selected four high schools as an intervention group and 15
schools as control group in the Mitchell's Plain area of South Africa. A total of 5610 high
school students participated. The intervention was based on HW curriculum. The program
consisted of 12 lessons (each approximately two to three class periods long) in 8th grade and
six lessons in 9th grade. Lessons were provided in either English or Afrikaans. Effectiveness
was measured by lifetime smoking rate. Data were collected through self-report surveys for
youth prior to the start of the intervention, in the first two months of the beginning of 8th
grade (pre-intervention), and at the start of 10th grade (follow-up). The results showed that
HW's effect on preventing cigarette use by the start of 10th grade was moderated among
females who were non-smokers at baseline [odds ratio (OR) = .64, p = .02. The likelihood of
initiating cigarette use was reduced by the intervention in females (OR = .73, p = .01), but not
in males (OR = 1.14, p = .35).
Raji et al. [
] recruited 114 students each for study and control groups in senior secondary
schools in Sokoto metropolis, Nigeria. The intervention consisted of two peer-led health
education sessions. Each session consisted of a didactic lecture, showing an 18-minute video clip,
and interactive discussion. Each session lasted about 60 minutes and was repeated four weeks
after the first health education intervention. Effectiveness was measured by a 44-item,
selfadministered questionnaire, modified from the core questions of the Global Youth Tobacco
Survey. The questionnaire consisted of four sections; specifically, information regarding
10 / 16
demographic characteristics, knowledge about smoking, attitudes toward smoking, and
behavior of respondents related to smoking. Data were collected before and three months after the
intervention program. Results showed the mean knowledge score of respondents significantly
increased, from 61.24 prior to the intervention, to 92.31 after the intervention (p < 0.001).
Attitudes towards smoking also changed significantly. For example, 71.9% of respondents in
the study group at baseline felt that cigarettes should not be sold to people less than 18 years
old, and this increased to 91.7% post-intervention (p < 0.001). After the intervention, the
number of students who had smoked in the last 30 days decreased by 0.6% in the intervention
group (7.9% vs. 7.3%), whereas this number increased by 0.1% in the control group (8.8% vs.
8.9%). These differences were not statistically significant.
Odukoya et al. [
] randomly selected three schools for the intervention group and three
for the control group from Lagos State in Nigeria. The minimum sample size for the study was
calculated, and one or two classes were randomly selected from each of the five grades. A total
of 511 and 520 students were in the selected classes in the intervention and control groups,
respectively. The intervention was based on the anti-smoking awareness program, which was
developed based on the Health Belief Model (HBM) of behavioral change. The HBM is a
psychological model that addresses individuals' perceptions of threat posed by health problems,
the benefits of avoiding the threat, and factors influencing the decision to act. This
anti-smoking program consisted of the following components; two talks about the effects of cigarette
smoking on health for one hour, providing information leaflets, and putting posters up within
the school environment. For research, assistants were given a one-day training organized by
the research team. The training covered all aspects of study including pre-testing, data
collection and the intervention. Effectiveness was measured by an instrument created by the authors,
which consisted of 16 knowledge, seven attitude, and seven practice items. The data were
collected before and three months after the intervention program. The results showed students in
the intervention group had significantly higher mean knowledge scores after the intervention
program (p < 0.001) compared to the control group. The mean score of attitudes toward
smoking was also significantly higher in the intervention group (p < 0.001). After the
intervention, the number of students who had smoked in the last 30 days decreased by 1.0% in the
intervention group (4.0% vs. 3.0%), whereas this number increased by 0.5% in the control
group (3.5% vs. 3.5%). However, these differences were not statistically significant.
These six selected studies suggest that school-based interventions might have some positive
effects on improving knowledge level of smoking and attitudes towards smoking, and partially
prevent the increase of smoking prevalence among secondary school students in Africa.
However, we could not find robust evidence that school-based interventions decreased smoking
prevalence among school children in Africa. Identical to our analysis, a Cochrane review
reported that school-based interventions in other areas of the world could not detect a
statistically significant decrease in the number of current smokers over time [
We must consider why these six studies could not show strong evidence that school-based
interventions were effective in reducing smoking prevalence in individual students or
populations at large, although selected studies showing improved knowledge and attitudes about
smoking and/or increased smoking prevalence. As a reason, the limited quality and
inconsistent outcome measurements can be considered as follows.
First, the purposes and outcome measurements were inconsistent for each intervention. In
the six selected studies, students targeted for intervention were mixed, composed of
nonsmokers, non-smokers who were likely to initiate smoking, and current smokers. Therefore,
11 / 16
interventions attempted to play a role in preventing the initiation of smoking, quitting
smoking, and/or reducing tobacco or other drug dangers. Such multiple focuses may weaken the
effects for each group of target students. Specific analysis for each type of student may be
required to increase the power of interventions.
Second, it is possible the training for presenters was not appropriate or not sufficient. Only
Resnicow et al.[
] and Odukoya et al. [
] referred to qualification of the presenters. Well
trained presenters might affect the children's smoking behavior.
Third, the interventions did not focus on the modification of various factors that induce
smoking behaviors in adolescents. The selected studies showed the different impacts of
intervention by gender [
]. Previous literature in Africa also showed different effects by age,
other substance use, socio-economic status, mental status, physical activities, and rural-urban
location among African countries [40±44]. One cohort, conducted by DeVries et al. in six
European countries  demonstrated that adolescents' smoking onset was influenced by
parental behavior and choice of friends with similar smoking behavior. If an intervention can
somehow modify various factors that induce smoking among students, actual smoking
behavior could be more easily affected. A brief review of school-based prevention approaches
targeting individual-level etiologic factors demonstrated some effectiveness of interventions .
Fourth, a comprehensive approach may be needed to enhance the effectiveness of
interventions. All of the selected six studies created intervention programs only from the perspective
of skills-based health education within the FRESH framework. It also may be effective to
combine with other approaches including health-related school policy statements, education for
community people, and increases in tobacco tax. The Health Promoting Schools Framework
provided by the WHO suggests the importance of collaboration with parents and local
communities to develop effective intervention programs in schools . The cultural world of
adolescents (internet, teen idols, and media) are also important components of programs
delivered through the Internet.
Currently, the global trend of smoking is in decline. In light of this, tobacco companies
have begun to expand their markets in low- and middle-income countries, capitalizing on
economic growth, changing social norms, and population demographics. Africa has lower rates of
tobacco taxation, weaker smoke-free policies, and less stringent tobacco advertising
restrictions in comparison to high-income countries. In countries such as Africa, school-based
antismoking intervention programs have many strong points. Since the enrolment rate of primary
school increased from 75.2% in 1990 to 99.2% in 2013  in Africa, intervention programs
can now, theoretically, be provided to nearly all children. Additionally, these programs are
cost-effective and sustainable. This study showed that school-based interventions may be
effective in improving knowledge and attitudes about smoking, and partially effective in preventing
increased smoking prevalence among secondary school students in Africa. However, we could
not find robust evidence that school-based interventions decreased smoking prevalence.
Multi-model, school-based smoking prevention programs, and studies that aim to change the
school environment and state policies, with wider initiatives within and beyond the school,
including programs for parents, schools, and communities, are needed in Africa. Commonly,
tobacco use is a gateway to the use of other substances in later life stages. Comprehensive and
multi-disciplinary approaches are needed to provide powerful evidence of the effectiveness of
The limitations of this review are that only a few papers were selected, and those included were
only carried out in South Africa and Nigeria. Africa contains extreme diversity in religion,
12 / 16
race, and school systems. Therefore, this review may not represent the results for school-based
programs on preventing tobacco use in the whole of Africa. Furthermore, there were no ªpure
prevention cohortº but groups of mixed never-smokers and smokers. Even with these
limitations, this study clarified weak points of existing studies, and provided future directions for
study design within this field.
There were four RCTs studies and two cohort studies of school-based tobacco prevention
program in African countries from 2000 to 2016. The all of RCTs studies showed no significant
change of smoking-rate by the intervention. The effectiveness of intervention was observed
only in some sub-group. The cohort studies showed school-based interventions may be
effective in improving knowledge and attitudes about smoking. However, they reported no
significant change of smoking-rate by the intervention.
S1 File. Prisma doc. This is the PRISMA 2009 checklist.
This work was supported by the Grant for National Center for Global Health and Medicine
(27A±1) and by the Ministry of Health, Labour and Welfare of the Government of Japan
Conceptualization: Akihiro Nishio, Junko Saito, Sachi Tomokawa, Jun Kobayashi, Yuka
Makino, Takeshi Akiyama.
Data curation: Akihiro Nishio, Kimihiro Miyake.
Formal analysis: Akihiro Nishio, Mayumi Yamamoto.
Funding acquisition: Akihiro Nishio.
Investigation: Akihiro Nishio.
Methodology: Akihiro Nishio, Yuka Makino, Takeshi Akiyama.
Project administration: Akihiro Nishio.
Supervision: Sachi Tomokawa, Jun Kobayashi.
Validation: Akihiro Nishio.
Writing ± original draft: Akihiro Nishio, Mayumi Yamamoto.
Writing ± review & editing: Akihiro Nishio, Junko Saito, Sachi Tomokawa, Mayumi
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