A School-Based Program to Promote Well-Being in Preadolescents: Results From a Cluster Quasi-Experimental Controlled Study.

Diario della Salute [My Health Diary] is a school-based program designed to enhance the subjective well-being and health of 12- to 13-year-old students. We hypothesized that providing students with the social and emotional skills to fulfill their potential and deal with common developmental tasks of adolescence (e.g., onset of puberty, identity development, increased responsibilities and academic demands) would result in improved well-being and health. The program comprises five standardized interactive lessons concerning common psychosocial and health issues in adolescence, and two narrative booklets addressed to both students and their parents. We evaluated the effectiveness of the program in terms of the students' subjective well-being, aggressive behavior, and health behavior. Using a quasi-experimental study design, schools in the intervention group implemented the full program and those in the comparison group received their regular curriculum. We administered measures of the study's objectives both before and after program implementation. Statistical analyses accounted for within-school clustering, potential socioeconomic and demographic confounding, and pre-implementation levels of these measures. We sampled 62 schools and allocated 2630 students to either an intervention or comparison group. Sociodemographic characteristics and baseline outcomes were balanced across study groups. Unexpectedly, respondents in the intervention group had 0.38 greater mean adjusted score of the WHO/Europe Health Behaviour in School-Aged Children Symptom Checklist instrument than respondents in the comparison group, indicating a reduction in subjective well-being. We did not observe any program effects on aggressive and health behaviors. The apparent reduction in subjective well-being reflected by an increased perception of psychosomatic complaints is suggestive of either increased emotional competence or, potentially, iatrogenic program effects. While greater emotional competence is positively associated with well-being over the course of life, the program in its present form should not be disseminated due to the possibility of adverse unintended effects.

[Socioeconomic and regional inequalities in smoking cessation in Italy, 2014-2017]. / Disuguaglianze regionali e socioeconomiche nella cessazione del fumo in Italia, 2014-2017.

OBJECTIVES: to study regional differences in Italy of quit smoking attempts and of successful abstinence, in relation to socioeconomic status, cigarettes per day (cig/die), and smoking cessation method in a representative sample of the population resident in Italy. DESIGN: cross-sectional survey. SETTING AND PARTICIPANTS: in 2014-2017, PASSI survey (the ongoing Italian behavioural risk factor surveillancesystem) gathered data on smoking and sociodemographic characteristics of 35,157 smokers; 13,130 aged 18-69 years made >1 quit attempt in the previous year, 1,176 of them were successful quitters for >6 months. MAIN OUTCOME MEASURES: proportion of smokers who tried to quit; proportion of smokers who successfully quitted. RESULTS: about 35% of smokers made >1 quit attempt in the last year. Northern Italians and smokers with many economic difficulties were more likely to make a quit attempt, whereas heavy smokers were less likely. About 10% of attempters were abstinent for >6 months: from 6% in Campania and Abruzzo to 17% in the Bolzano province. Attempters who smoked <20 cig/die had higher likelihood to be abstinent, compared to those smoking <20 cig/die. Attempters with many economic difficulties had the lowest likelihood to be abstinent (7%), with no differences by region, educational level, quitting method. Attempters with no economic difficulties recorded the highest cessation rates (12%). Among them, those from Northern Italy, Tuscany, Marche, and Lazio (Central Italy), and Apulia (Southern Italy) compared to attempters from most Southern regions, and those with high education level or using traditional quitting methods compared to those using electronic cigarettes or unaided were more likely to be abstinent for >6 months. CONCLUSIONS: smokers with many economic difficulties in all Italy, and those with no economic difficulties residing in Umbria and in most Southern Italian regions, except for Basilicata and Puglia, recorded lower chances to quit. Regional differences may have two possible explanations integrating each other: Northern-Central regions are in a slightly more advanced stage in the tobacco epidemic; regions which developed specific tobacco control interventions in their Prevention Plans recorded higher quitting rates. Not-yet-implemented interventions could promote smoking cessation in smokers from Southern Italy and in those with lower socioeconomic status: reimbursement of smoking cessation treatments, a well-developed national Quitline linked to a webplatform and to mobile phone application or text-messaging, an opt-out smoking cessation service offered systematically to all smokers at every encounter in hospitals or health services.

Quit attempts and smoking cessation in Italian adults (25-64 years): factors associated with attempts and successes.

Background: Over the past 50 years there was a substantial decrease in the prevalence of smoking in Italy. The objective of this work is to describe attempts to quit and cessation success in Italian smokers. Methods: A surveillance on health-related behaviors (PASSI) was conducted in 2007-13 on a sample of 203 610 Italian adults 25-64 years of age. An analysis of smokers' characteristics and behaviors was performed, focusing on attempts to quit and quit success. Data from national surveys (ISTAT) from 1983 to 2013 (Italian adults, 25-64 years of age, 1983: 46 634; 1987: 40 915; 1990: 36 622; 2000: 77 531; 2005: 71 032; 2013: 64 205) were used to explore if a cessation trend in Italy exists. Results: Smokers who quit in the previous year and were still abstinent when interviewed increased from 1990 to 2013. In the years 2011-13, 38% of people who had smoked in the last 12 months reported at least a quit attempt during the same period and 7% were still abstinent when interviewed. An association of successful recent quit attempts with higher educational level, absence of economic difficulties and younger age was found. In the years 2007-13, the great majority tried to stop unaided. Having received assistance from a cessation program did not increase the probability of enduring abstinence. Conclusions: In Italy interventions to drive more smokers to quit should be focused in particular on disadvantaged groups. Initiatives have to be studied not only to incentive more smokers to try to quit, but also to maintain abstinence over time.

[Interventions for healthy diet promotion in Italy]. / Gli interventi per la promozione di un'alimentazione corretta in Italia.

OBJECTIVES: to describe the prevention interventions conducted by the Regional health services to promote a healthy diet. MATERIAL AND METHODS: the database ProSA, which contains prevention interventions conducted by some Italian regions, has been analysed. Programmes identified as «Diet - physical activity¼ were selected, and the ones that had the promotion of healthy diet in unselected populations as objective were included. Then, the programmes were analysed and described. RESULTS: a total of 87 programmes were included, 23 of which are certainly conducted during 2013-14. 91% are school-based, particularly targeted to middle schools, and 37% are based on classroom lessons. No programme made any reference to specific evidence, while 11% of them cited scientific generic but relevant papers. 15% of the programmes described some evaluation process, but only 1% has proposed a study design with controls. Limiting the analysis to the region that contributed with the largest amount of recorded programmes, it can be estimated that programmes does not reached more than 0.03% of the general population, and 4% of the school population. CONCLUSIONS: in Italy, there is not a survey system to collect preventive interventions conducted by regional health authorities. The analysis of ProSA, an experimental system, allows us to highlight that the promotion of a healthy diet is based on interventions targeting only the school population and referring to scientific evidence in a very limited way. Moreover, they seem to cover very small part of the target population.

Anti-tobacco policy in schools: upcoming preventive strategy or prevention myth? A review of 31 studies.

OBJECTIVE: To summarise the evidence on effectiveness of school anti-tobacco policies (exposure) in preventing tobacco use (outcome) among high school students. DATA SOURCES: The search was conducted between 1 September and 30 November 2011 on six electronic databases with keywords: 'policy', 'ban', 'restriction' and 'environment' in combination with 'adolescent' or 'student', 'school' and 'smoking' in titles, abstracts or keywords. Restrictions were made to articles published in English. STUDY SELECTION: Studies were included if they targeted the relevant grades/age; reported at least one outcome measure of students' ever or current tobacco use; reported on the effects of exposure to policy separately from other interventions. Inclusion criteria were assessed independently by two of the coauthors. Of 2723 articles initially identified, 31 articles met the inclusion criteria (1.1%). DATA EXTRACTION: Independent multiple observers extracted the data following the GRADE system guidelines to classify the level of evidence in relation to the review objective. DATA SYNTHESIS: Studies were very heterogeneous in the definitions of exposure to school anti-tobacco policy and of tobacco use, adjustment for potential confounders and reporting of results, therefore summary quantitative measures of effect were not calculated. Qualitative summary statements were derived by reviewing the results reported in text and tables for distinct policy constructs. Evidence could be classified as low or very low, resting on cross-sectional studies with high risk of bias. Studies were rather consistent in indicating that comprehensive smoking bans, clear rules, strict policy enforcement, availability of education and prevention were associated with decreased smoking prevalence. Formally adopted and written policies, surveillance of students' behaviour and presence/severity of sanctions were not consistently associated to students' tobacco use. CONCLUSIONS: The evidence concerning the effectiveness of a school policy alone in preventing youth tobacco use is weak and inconclusive. Experimental studies or observational studies with longitudinal design are warranted, employing clear definitions of policy components and careful control for confounding.

School policies for preventing smoking among young people.

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. OBJECTIVES: To assess the effectiveness of policies aiming to prevent smoking initiation among students by regulating smoking in schools. SEARCH 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. SELECTION CRITERIA: 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. DATA COLLECTION AND ANALYSIS: 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. MAIN 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. AUTHORS' 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.

The Pap smear screening as an occasion for smoking cessation and physical activity counselling: effectiveness of the SPRINT randomized controlled trial.

BACKGROUND: The organized Cervical Cancer Screening Programme (CCSP) in Italy might represent an occasion to deliver smoking cessation (SC) counselling to women attending the Pap test examination. Evidence of effectiveness of physical activity (PA) promotion and intervention in adjunct to SC counselling is not strong.Objective of the SPRINT trial was to evaluate the effectiveness of a standard SC counselling intervention delivered by trained midwives in the CCSP, and whether the adjunct of a PA counselling to the SC counselling might increase quit rates. METHODS/DESIGN: We undertook a randomized controlled trial of 1,100 women undergoing the Pap examination in the three study centres Florence, Turin, and Mantua: 363 were randomly assigned to the SC counselling arm, 366 to the SC + PA counselling arm, and 371 to the control group. The intervention was a standard brief SC counselling combined with a brief counselling on increasing PA, and was tailored according to the Di Clemente-Prochaska motivational stages of change for SC and/or PA. Primary outcomes were quit rates, improvement in the motivational stages of change for SC, and reduced daily cigarette consumption. Analysis was by intention to treat. RESULTS: Participants randomized in both intervention arms and in the preparation stage of change for SC doubled their likelihood of quitting at 6-month follow-up in comparison to controls (odds ratio [OR]=2.1, 95% confidence interval [95% CI]:1.0-4.6). Moreover, participants in the intervention arms and in the contemplation stage were more likely to reduce their daily cigarette consumption after the intervention (OR=1.8, 95% CI:1.1-3.0). Our study did not show any effect of PA counselling on various outcomes. CONCLUSIONS: Smoking cessation counselling delivered by midwives to smokers in preparation and contemplation stages of change during the Pap-smear screening was effective and should be recommended, given the high number of women attending the cervical cancer screening programme in Italy. Moreover, the daily number of women invited for the Pap-smear examination should be slightly lowered, in order to let midwives deliver SC counselling to smokers. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52660565.

The Dedalo Project, a Community-based Prevention Program for the Promotion of Healthy Behaviors in Adult Population: Model Description and Target Population Assessment.

Noncommunicable diseases (NCDs) are the leading global cause of death. The Italian National Prevention Plan (INPP) highlights the importance of health promotion and NCD prevention while avoiding health inequalities. In line with the INPP guidelines, we initiated a multicomponent community-based intervention program, named the Dedalo project, to promote healthy and active aging among population living around the Vercelli's municipality, Italy. A cross-sectional analysis, that used the baseline data of a longitudinal study of the project, evaluated the program's ability to enroll participants participants who represent the socioeconomic conditions present in the municipality. To this end, we compared the main social characteristics and behaviors of 40-74-year-old subjects (n = 155), who had attended at least one Dedalo activity, to those of same age individuals (n = 124) randomly extracted from the general population. We found that most participants were women (81.3%) and had a higher SES compared to the general population. Furthermore, they were healthier-OR 0.52, 95% CI 0.31-0.87 for self-reported diseases-and displayed healthier behaviors-OR 0.20, 95% CI 0.08-0.46 for smokers; 0.32 95%, CI 0.16-0.64 for fruit/vegetable consumers; and 0.36 95% CI 0.20-0.64 for sweet beverages consumers. Overall, our initial evaluation indicates that the Dedalo project has so far struggled to enroll individuals with low SES, men with any SES, and subjects displaying unhealthy behaviors, thereby failing to meet the INPP goal of preventing NCDs while avoiding health disparities. Thus, efforts should be made to ensure that this community-based intervention program can effectively reach all the target population, in particular those individuals most exposed to behavioral risk factors.

The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial.

BACKGROUND: Gender-specific smoking cessation strategies have rarely been developed. Evidence of effectiveness of physical activity (PA) promotion and intervention in adjunct to smoking cessation programs is not strong. SPRINT study is a randomized controlled trial (RCT) designed to evaluate a counselling intervention on smoking cessation and PA delivered to women attending the Italian National Health System Cervical Cancer Screening Program. This paper presents study design and baseline characteristics of the study population. METHODS/DESIGN: Among women undergoing the Pap examination in three study centres (Florence, Turin, Mantua), participants were randomized to the smoking cessation counselling [S], the smoking cessation + PA counselling [S + PA], or the control [C] groups. The program under evaluation is a standard brief counselling on smoking cessation combined with a brief counselling on increasing PA, and was delivered in 2010. A questionnaire, administered before, after 6 months and 1 year from the intervention, was used to track behavioural changes in tobacco use and PA, and to record cessation rates in participants. DISCUSSION: Out of the 5,657 women undergoing the Pap examination, 1,100 participants (55% of smokers) were randomized in 1 of the 3 study groups (363 in the S, 366 in the S + PA and 371 in the C groups). The three arms did not differ on any demographic, PA, or tobacco-use characteristics. Recruited smokers were older, less educated than non-participant women, more motivated to quit (33% vs.9% in the Preparation stage, p < 0.001), smoked more cigarettes per day (12 vs.9, p < 0.001), and were more likely to have already done 1 or more quit attempts (64% vs.50%, p < 0.001). The approach of SPRINT study appeared suitable to enrol less educated women who usually smoke more and have more difficulties to quit. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN52660565.

Time and classical equations of motion from quantum entanglement via the Page and Wootters mechanism with generalized coherent states.

We draw a picture of physical systems that allows us to recognize what "time" is by requiring consistency with the way that time enters the fundamental laws of Physics. Elements of the picture are two non-interacting and yet entangled quantum systems, one of which acting as a clock. The setting is based on the Page and Wootters mechanism, with tools from large-N quantum approaches. Starting from an overall quantum description, we first take the classical limit of the clock only, and then of the clock and the evolving system altogether; we thus derive the Schrödinger equation in the first case, and the Hamilton equations of motion in the second. This work shows that there is not a "quantum time", possibly opposed to a "classical" one; there is only one time, and it is a manifestation of entanglement.

Psychosocial empowerment-based interventions for smoking reduction: concepts, measures and outcomes. A systematic review.

Although empowerment is a widely used concept in health-related areas, its definition remains unclear. While there is evidence for the effectiveness of empowerment interventions in improving some psychosocial factors linked to health (e.g. patient self-care strategy, coping skills, access and effective use of health services) and some health outcomes like mental health and HIV/AIDS-related behaviour, other data appear to contradict this. Moreover, concepts, measures, and outcomes related to empowerment are operationalized in different ways. Using the case of tobacco control programmes, we wanted to explore: (a) how research on smoking reduction/prevention has conceptualized empowerment; (b) which measures and instruments have been used to assess behaviour outcomes and the empowerment process. We hypothesized that the transformative potential that characterizes empowerment is marginally considered.A total of 18 studies reporting on the effect of prevention interventions on smoking and/or empowerment outcomes were reviewed. Two kinds of study were distinguished: (a) studies reporting behaviour outcomes without data about the impact on empowerment; (b) studies analysing the empowerment process. Among this latter type, some studies did not provide information about the specific behaviour (smoking), while others examined the impact of intervention on both smoking and empowerment. In about half of all studies, empowerment strategies were found to be effective in improving smoking outcomes, while no differences were found between intervention and control groups in the remaining studies. The present review suggests that pragmatic definitions of empowerment need to be developed in order to promote its transferability and evaluation.

[Community interventions among tobacco control strategies: coping with their definition and evaluation]. / Definizione e valutazione degli interventi di comunità nell'ambito delle strategie di contrasto al fumo di tabacco.

Community interventions represent a key component of the current anti-smoking strategies. We propose a conceptual framework for classifying these interventions, based on the concept of community utilised in different studies. We identified 5 different focuses: geographical areas (i.e. city, county, region); targets (sub-group of a population); settings (school, workplace); culture and individual attitudes; multilevel networks. These two latter views refer to functional rather than to structural aspects of a community and they represent the most promising approaches to design intervention strategies. Communities are represented as a group of organizations, systems and social networks investigating individual, environmental and cultural factors that can strongly influence behavioural changes. The great heterogeneity in what the authors mean as community interventions has in our opinion affected the evaluation of their impact. To facilitate their evaluation and to contribute to the detection of determinants, as well as of barriers, it is necessary to compare community interventions sharing similar theoretical approaches and focuses. Also, studies aimed at assessing the steps of the implementation process of community programmes may allow to identify those components related to specific levels of intervention, thus enabling the generalisation of results. To reach this goal it may be helpful to combine study designs allowing for both quantitative and qualitative assessments, such as action research and participatory evaluation research.

[Effective laws for tobacco control: EU directives and Italian legislation]. / Interventi legislativi efficaci per il controllo del tabagismo: direttive dell'Unione Europea e applicazioni in Italia.

Effective tobacco control policies include law issuing: bans/restrictions on smoking in public areas and workplaces, increasing of taxes on tobacco products, bans on advertising of tobacco products, warning labels on cigarette boxes. For some of these policies the European Union (EU) has introduced specific directives that EU member states have to put into law. This paper briefly presents literature data, EU directives and the laws consequently issued in Italy. The importance of standardizing European legislation, especially for those policies that are not enforced by EU directives is also discussed. In Italy and in some other European countries smoking is forbidden in public and work-places, despite no EU directive. The positive impact of this ban in these countries suggests that it should be considered a priority in the European policies against tobacco in order to reduce the gap between literature recommendations and actions.

[Efficacy and effectiveness of prevention programs in the population: for a more rational choice of public health interventions.] / Efficacia teorica e reale impatto dei programmi di prevenzione: per una scelta più razionale degli interventi di sanità pubblica.

INTRODUCTION: Evidence Based Prevention is becoming increasingly important to guide the policy-makers to choose preventive interventions to be offered to the population. Sometimes however the impact of an intervention in real conditions (effectiveness) may be smaller than the efficacy estimated in studies conducted in experimental settings. This can be due for example to suboptimal coverage of the intervention or to poor compliance of the involved subjects. Regrettably, this aspect is rarely taken into account in the planning of preventive interventions. To evaluate the discrepancy between efficacy and effectiveness of prevention programs we used as examples two interventions for smoking cessation currently available in Italy: 1) Interventions offered by Smoking Cessation Centers; 2) "Minimal Advice" provided by family doctors. METHODS: Using epidemiological data we estimated the expected effectiveness of interventions under different scenarios. RESULTS: Even assuming that Smoking Cessation Centers always offer the best available intervention (efficacy: 82%), they do not seem able to have a major effect on smoking cessation in the population (effectiveness: 0.8%). This is due to the very small number of smokers that seek help to these centers (1%). On the contrary, interventions based on minimal advice are anticipated to have much higher effectiveness (21%). CONCLUSION: Evidence of efficacy of an intervention is not sufficient to ensure that this will have a significant impact on health. The decision to implement a preventive action should be preceded by a careful evaluation of the expected effectiveness and be followed by a post-implementation monitoring to estimate the real impact of the intervention.

Public beliefs and attitudes towards depression in Italy: a national survey.

BACKGROUND: Previous studies have shown that attitudes towards depression may be influenced by country-specific social and cultural factors. A survey was carried out to collect beliefs on and attitudes toward depression in Italy, which has an established community-based mental health system. METHODS: A telephone survey was carried out in a probabilistic sample aged ≥15 years. A 20-item questionnaire was administered to explore knowledge of depression, stigma, causal beliefs, treatment preference, and help-seeking attitudes. RESULTS: Of the 1001 participants, 98% were aware of depression, and 62% had experienced it, either directly or indirectly. A widespread belief (75%) was that people suffering from depression should avoid talking about their problem. A minority of the sample viewed depression as a condition that should be managed without recourse to external help or a "socially dangerous" illness. Among perceived causes of depression, most respondents mentioned life stressors or physical strains. Psychologists were often indicated as an adequate source of professional help. Half of the sample believed that depression should be pharmacologically treated, but drugs were often seen as addictive. Referring to a primary care physician (PCP) was considered embarrassing; furthermore, many people thought that PCPs are too busy to treat patients suffering from depression. CONCLUSIONS: Our findings indicate that depression is seen as a reaction to significant life events that should be overcome with the support of significant others or the help of health professionals (mainly psychologists). However, there are still barriers to the disclosure of depressive symptoms to PCPs, and concerns about the addictive effect of antidepressants. In the presence of a gap between people's beliefs and what health professionals consider appropriate for the treatment of depression, a "shared decision making" approach to treatment selection should be adopted taking into account the patients' preference for psychological interventions to ensure active compliance with effective treatments.