Anshorulloh Abd Fath, Rabid Yahya Putradasa, Hera Afidjati, Bernie Endyarni Medise, Eldesta Nisa Nabila, Hamzah Pratama Megantara, Raysha Farah, Rizta Aulia
Faculty of Medicine, Universitas Indonesia
e-mail: anshoraf@gmail.com
Background
The school is an ideal environment to conduct tobacco prevention programs, because it ensures that almost all children and teenagers can be targeted. However, the pandemic creates a new demand: how can we provide a universal anti-smoking education to schools, when the government limits the duration and the number of students that attend offline classes? The internet and social media seem promising to address this question. Online-based intervention has been studied to help smoking cessation in adults, but to our knowledge, only a limited literature about online-based prevention programs for adolescents is available.
E-cigarette contributes to the double burden of tobacco epidemics in Indonesia. Consuming e-cigarette is a gateway for adolescents to also use conventional cigarette in the future. However, e-cigarettes have unique properties and are marketed differently than conventional cigarettes, offering a distinct type of appeal to adolescents. Therefore, it is important for prevention programs to address each product as separate entities. To date, limited literature has been published about e-cigarette prevention, and all of them comes from the United States. The fact that such program has not been published in Indonesia seems concerning, considering the poor handling of the industry by the Indonesian government.
In our attempt to address the challenges mentioned above, we have designed the SMART TEENS Project (TSTP). “SMART TEENS” stands for Social Mastery and Resilience Training against Tobacco and E-Cigarette Using E-Learning and Social Media. It is a 4-week online program delivered by Zoom, WhatsApp, and numerous short videos. It is designed to be comprehensive, evidence-based, and enjoyable for high schoolers. This paper aims to examine whether TSTP is effective to improve adolescents’ knowledge and attitude towards conventional and e-cigarette, and whether it can reduce their desire to smoke and vape in the future.
Methods
TSTP educated the participants about a.) the socio-biological negative impacts of conventional and electronic cigarettes, b.) emotional intelligence stress coping strategies, c.) psychological mindfulness, d.) how to resist pro-smoking peer pressure, e.) advertisement literacy, and f.) the harmful, unethical practices done by the tobacco and e-cigarette industries.
We invited participants to a WhatsApp group. We have prepared 25 short educational videos. Professional designers-animators and a social media expert were hired in creating these video contents. We sent one of these every day and discuss each of them with the participants through the group chat (duration of group chat: 90 minutes, every day from 18.30-20.00 WIB). Two doctors facilitated a WhatsApp group consisting of around 50 students.
We also conducted five Zoom-based interactive meetings weekly, each 90 minutes in duration. In the first 45 minutes, we delivered interactive lectures (one large class consisting of around 50 students). In the second part, we divided the large class into smaller breakout rooms, with 10–12 students facilitated by one doctor. In sum, the duration of each component of TSTP was 37,5 hours of WhatsApp group discussion, 7,5 hours of Zoom session, and 37 minutes of short videos (a total of 45,5 hours of education over the course of one month).
We have nine general practitioners and six medical students as mentors for the students. All of these 15 mentors have been trained in a 5-session course, 120 minutes each, about adolescent mental health, the dangers of cigarette/e-cigarette products and industries, and other counseling skills related to the program. Both the students’ and the mentors’ curricula are developed with supervision by a pediatrician with expertise in adolescent growth and development.
This study is a school-based, randomized controlled trial. We used the list of 1.000 Top High Schools in Indonesia (provided by Lembaga Tes Masuk Perguruan Tinggi). We selected schools that were located in Lampung and Jakarta Provinces. We divided the schools into three groups based on the academic achievements of the students: schools ranked 1-500, schools ranked 500-1000, and schools that were not included into the list. We chose a total of eight schools by random and allocated each into intervention and control randomly. We chose one or two classes (depending on class sizes) from each school by random. The final result of randomisation is eight schools across three cities: Kota Metro Lampung, East Jakarta, and South Jakarta. Two matched schools were from the top 500, two schools from schools ranked number 500-1000, and four schools that were not on the Top 1.000 Schools list.
To measure the outcome, we used a 50-item questionnaire. The questionnaire captured participants’ demographic data and confounding variables (parental and peer smoking status). Knowledge was assessed using a “True/False” question format, with 4 questions asking about conventional cigarette and 7 questions about e-cigarette (Cronbach’s Alpha= 0,88). Attitude was assessed using the Likert Scale, with 6 questions each for conventional and e-cigarettes (Cronbach’s alpha= 0,910). Intention to smoke/vape in the future was assessed using 6-item question, asking students’ intention to smoke/vape in the next year, in college, and in adulthood (Cronbach’s Alpha= 0,86). The rest of the questions measured advertisement literacy and smoking/vaping habits and behaviours, which will not be addressed in this abstract. Statistical analyses were performed using SPSS.
Result
A total of 532 students (270 girls and 262 boys) participated in the study, with 270 in the control group and 262 in the intervention group. 182 and 350 students were from social class and science class, respectively. All of the schools were public schools.
Compared to the control group, students that received intervention demonstrated higher knowledge about conventional cigarette (mean score of 7,52 ± 0,79 in the control group versus 7,82 ± 0,47 in the intervention group, with a maximum score of 8; p-value= < 0.0001 with Mann-Whitney test). This significant increase is also shown in e-cigarette knowledge scores (mean score of 12,65 ± 1,544 in the control group versus 13,68 ± 0,91 in the intervention group, with a maximum score of 14; p-value= < 0.0001 with Mann-Whitney test).
Compared to the control , students in the TSTP arm earned a slightly higher score in anti-tobacco attitude (mean score of 13,6 ± 1,97 in the control group versus 13,97 ± 1,73 in the intervention group, with a maximum score of 14), but the difference was not statistically significant (p-value= 0,054 with Mann-Whitney test). Regarding attitude towards e-cigarette, students who participated in TSTP demonstrated a higher score than those in the control group (mean score of 12,75 ± 2,1 in the control group versus 13,44 ± 2,0 in the intervention group, with a maximum score of 14), and this difference is statistically significant (P Value= 0,0001 with Mann-Whitney Test).
Students receiving TSTP also expressed less intention to smoke (mean score of 10,95 ± 1,95 in the control group versus 11,52 ± 1,39 in the intervention group ; statistically significant with P value <0,0001 with Mann-Whitney Test) and to vape (mean score of 10,68± 2,14 in the control group versus 11,46 ± 1,47 in the intervention group ; statistically significant with P value <0,0001 with Mann-Whitney Test) in the future, be it next year, in college, or in adulthood.
Conclusion
Compared to the students in the control group, students receiving our community program were more knowledgeable about electronic and conventional cigarette, scored higher in anti-smoking/vaping attitude questionnaire, and were less interested in smoking/vaping in the future. All of these differences are statistically significant, except for the anti-tobacco attitude.
This is our attempt in making an evidence-based, school based, online community program against tobacco and e-cigarette. We are analyzing the data on whether TSTP is able to reduce smoking/vaping behavior. We are also analyzing student’s engagement in our program. A repeat study in a larger population is warranted, preferably using a biomarker verification for the assessment of smoking/vaping behavior. Since this study used a non-active control arm, it might also be of interest to test TSTP against the traditional smoking/vaping prevention. We also believe that it is possible to conduct TSTP in a hybrid, online/offline format.
Keywords:
E-Cigarette, Smoking, Prevention, Adolescent