Evaluating School-Based Interventions for Preventing and Reducing Tobacco Use Among Adolescents in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Abstract

Tobacco-related disease and death remain high in many low- and middle-income countries, and most people start using tobacco during adolescence. This study evaluated the effectiveness of school-based interventions in preventing and reducing tobacco use among adolescents in low- and middle-income countries. Seven databases were searched until 20 April 2024. The primary outcome was tobacco use prevalence (ever or point prevalence) at the longest follow-up. Risk of bias was assessed, and random-effects meta-analyses were conducted, exploring heterogeneity via meta-regression (PROSPERO registration CRD42022330329). Twenty-seven studies (N=57,292) were summarized descriptively, and 20 were meta-analyzed. Most studies were from Brazil (n=5, 18.5%), India (n=5, 18.5%), China (n=3, 11.1%), and Pakistan (n=2, 7.4%); 12 (44.4%) assessed newly developed and 15 (55.6%) culturally adapted existing interventions; and over half (n=14, 51.9%) focused solely on preventing and reducing tobacco use while the rest addressed multiple behaviors. Overall, interventions reduced adolescent tobacco use (OR=0.76, 95% CI=0.64, 0.91; I²=47%; n=20; 50,056 participants). Stratification by outcome measure showed significant reductions in point prevalence (OR=0.69, 95% CI=0.57, 0.85; I²=32.4%). After adjusting for study duration, interventions with higher contact time had lower effectiveness than shorter interventions (AOR=1.36, 95% CI=1.01, 1.84; p=0.045; I²=22%). Low risk of bias studies demonstrated lower odds of tobacco use among participants (OR=0.66, 95% CI=0.50, 0.87; I²=14%; n=6). School-based interventions in low- and middle-income countries effectively reduce the proportion of adolescents who use tobacco. Shorter interventions appeared to be effective, suggesting that brief yet engaging interventions may offer practical advantages and could contribute to addressing the tobacco epidemic in low- and middle-income countries. Further research is needed to determine optimal intervention duration and intensity for sustained effectiveness.