title: School policies for preventing smoking among young people.
abstract: BACKGROUND
  School tobacco policies (STPs) might prove to be a promising strategy to prevent smoking initiation among adolescents, as there is evidence that the school environment can influence young people to smoke. STPs are cheap, relatively easy to implement and have a wide reach, but it is not clear whether this approach is effective in preventing smoking uptake.
  
  
  OBJECTIVE
  To assess the effectiveness of policies aiming to prevent smoking initiation among students by regulating smoking in schools.
  
  
  METHODS
  We searched seven electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and ERIC. We also searched the grey literature and ongoing trials resources. The most recent search was performed in May 2014.
  
  
  METHODS
  We included cluster-randomised controlled trials (c-RCTs) in which primary and secondary schools were randomised to receive different levels of smoking policy or no intervention. Non-randomised controlled trials, interrupted time series and controlled before-after studies would also have been eligible. Cross-sectional studies were not formally included but we describe their findings and use them to generate hypotheses to inform future research.
  
  
  METHODS
  We independently assessed studies for inclusion in the review, and present a narrative synthesis, as the studies are too limited in quality to undertake a formal meta-analysis.
  
  
  RESULTS
  We found only one study which was eligible for inclusion in the review. It was judged to be at high risk of bias. The study compared two 'middle schools' from two different regions in China. The experimental conditions included the introduction of a tobacco policy, environmental changes, and communication activities, while the control condition was no intervention. After a year's follow-up the study found no differences in smoking prevalence between intervention and control schools. We also described 24 observational studies, the results of which we considered for hypothesis generation. In these, policy exposure was mainly described using face-to-face interviews with school staff members, and the outcome evaluation was performed using self-administered questionnaires. Most studies reported no differences in students' smoking prevalence between schools with formal STPs when compared with schools without policies. In the majority of studies in schools with highly enforced policies, smoking bans extended to outdoor spaces, involving teachers and including sanctions for transgressions, with assistance to quit for smokers plus support by prevention programmes, there was no significant difference in smoking prevalence when compared to schools adopting weaker or no policies.
  
  
  CONCLUSIONS
  Despite a comprehensive literature search, and rigorous evaluation of studies, we found no evidence to support STPs. The absence of reliable evidence for the effectiveness of STPs is a concern in public health. We need well-designed randomised controlled trials or quasi-experimental studies to evaluate the effectiveness of school tobacco policies.
authors.affiliation: Department of Translational Medicine, Avogadro University, Novara, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Coppo
authors.forename: Maria Rosaria
authors.initials: MR
authors.lastname: Galanti
authors.forename: Livia
authors.initials: L
authors.lastname: Giordano
authors.forename: Daria
authors.initials: D
authors.lastname: Buscemi
authors.forename: Sven
authors.initials: S
authors.lastname: Bremberg
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Faggiano
mesh_terms: D000293:Adolescent; D002681:China; D006291:Health Policy; D006801:Humans; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D012572:School Health Services; D012574:Schools; D000074606:Smoking Prevention