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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Pediatric smoking prevention interventions delivered by care providers: a systematic review

DA Christakis, MM Garrison, BE Ebel, SE Wiehe, and FP Rivara.

Review published: 2003.

CRD summary

This review found little evidence to support the efficacy of interventions delivered by health care professionals to prevent the uptake of smoking in people under 21 years of age. Although the results provided support for this conclusion, a lack of reporting of the review process and the nature of the control interventions made it difficult to verify.

Authors' objectives

To summarise the evidence of smoking prevention interventions for young people that were delivered in the settings of medical or dental care providers.


MEDLINE, the Cochrane Controlled Trials Register and PsycINFO were searched up to July 2002; the search terms were listed. Bibliographies of relevant articles, including review articles and meta-analyses, were checked. Subject experts were contacted to supplement the search. An attempt to locate unpublished trials was made through the Medical Editors Trials Amnesty. Only trials published in English were eligible for inclusion.

Study selection

Study designs of evaluations included in the review

Controlled trials based in a health care setting were eligible for inclusion. All of the included trials were randomised controlled trials (RCTs).

Specific interventions included in the review

The inclusion criteria specified smoking initiation prevention interventions delivered via medical or dental providers. The included trials used a variety of interventions, including one or more of the following: brief counselling or motivational teaching, the provision of written materials at the consultation, regular follow-up postal newsletters or other materials and phone calls. The control interventions included usual care and safety interventions where reported. Follow-up lasted between 12 and 36 months.

Participants included in the review

An inclusion criterion was studies of people aged under 21 years. The included patients were aged 10 to 19 years. Little socioeconomic data were presented.

Outcomes assessed in the review

The primary outcome was self-reported initiation of smoking in the follow-up period, or prevalence of smoking at the end of follow-up. The number of cigarettes smoked per week was also reported. Actual definitions of smoking initiation varied among the studies and included, where reported, ever-smoked and 30 day recall.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

Assessment of study quality

The authors did not state that they assessed validity, but did state that the studies were assessed for blinding of the intervention. The authors did not state how this assessment was performed.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

Methods of synthesis

How were the studies combined?

The authors of the review presented a narrative summary of each trial. They stated that the clinical heterogeneity of the included trials precluded a meta-analysis.

How were differences between studies investigated?

Differences between the studies were commented on within the report.

Results of the review

Four RCTs (21,522 participants) were included.

There was a high loss to follow-up in the included studies, between 7 and 41%.

Of the four studies, one reported a statistically significant reduction in smoking prevalence at the 1-year follow-up (odds ratio 0.63, 95% confidence interval: 0.44, 0.91), whereas none of the other three reported a significant effect at either two (n=2) or three (n=1) years. The study with a 3-year follow-up also reported no significant effect of the intervention on smoking initiation at one or two years.

Authors' conclusions

There was limited evidence on the efficacy of smoking prevention interventions for adolescents in the health care setting. There was no evidence of the long-term effectiveness of these interventions.

CRD commentary

The review question was clear in terms of the study design, intervention and participants' age. The authors did not define smoking initiation, and there was variation in the definitions used in the included studies (such as ever smoked and 30-day recall). Several relevant sources were searched but, since the search strategy was restricted to trials published in English, some relevant studies might have been omitted. A limited effort was made to locate unpublished studies. There was no assessment of validity, other than to assess the included trials for blinding of the intervention. In addition, the included studies were limited by the use of self-reported outcomes and short duration of follow-up. It does not appear that any attempts were made to minimise bias, e.g. in the data extraction and study selection processes.

Insufficient description of the participants and interventions used and the lack of information on the control interventions mean that it was difficult to interpret the results. There was also insufficient information on the number of practices involved in each of the included trials. The authors noted that only one of the included trials accounted for practice-level clustering in the analysis.

The review did not provide sufficient information on the context of the included studies (e.g. whether a median income of $40 to $50,000 relates to a low or high socioeconomic position), which limits the understanding of the generalisability of the results.

The authors' conclusions about there being a lack of evidence to support smoking prevention interventions at health care practices follow on from the results of the review.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice, although they noted that patient counselling for tobacco smoking prevention is not unreasonable and is at the discretion of the provider.

Research: The authors did not state any implications for research.

Bibliographic details

Christakis D A, Garrison M M, Ebel B E, Wiehe S E, Rivara F P. Pediatric smoking prevention interventions delivered by care providers: a systematic review. American Journal of Preventive Medicine 2003; 25(4): 358-362. [PubMed: 14580640]

Indexing Status

Subject indexing assigned by NLM


Adult; Child; Health Personnel; Humans; Randomized Controlled Trials as Topic; Smoking /prevention & control



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 14580640