Background
Tobacco use and the Western diet are two of the most important and most extensively investigated topics related to the health of adolescents and the prevention of any consequent illness during their lifetime. Furthermore, air pollution is a crucial theme for future generations. Tobacco use is currently the leading preventable cause of death worldwide [
1], and reduction of the smoking prevalence among adolescents is a public health priority for several reasons [
2]. Adolescents risk developing lifelong smoking behaviors [
3]. The 1994 Surgeon General Report on preventing tobacco use in young people pointed out that cigarette smoking is the strongest addictive behavior, tending to strengthen during adolescence, and that people who begin to smoke at an early age develop a nicotine addiction more than those who start at a later age [
2,
4]. At the same time, overweight and obesity in children and adolescents are becoming major global public health concerns [
5‐
8].
The major cause of obesity and overweight is an energy imbalance between consumed and spent calories. In particular, increased consumption of sugar-sweetened beverages and sweets ([
9‐
12]; chips [
12], energy-dense and processed foods [
12,
13] on one hand and decreased physical activity [
14,
15] on the other hand induce long-term weight gain in children/adolescents and adults. Furthermore, in children and adolescents, the amount of time spent in front of the television or computer or playing videogames may influence energy consumption, energy expenditure, or both [
16,
17]. Obesity during childhood and adolescence is associated with a higher probability of obesity during adulthood [
18], premature death, disability [
19,
20] and psychological problems.
Additionally, research into the individual and combined factors that influence our choices related to health, such as tobacco use and type of diet, indicates that various unhealthy habits may in some way be associated, and that these habits start with adolescence. Even if it is unclear how the Western diet, tobacco use and secondhand smoking together impact on the risk of chronic disease, their synergistic action on health may significantly increase this threat to a greater level than any of these factors alone [
21,
22].
School seems to be a fundamental setting to educate children about smoking behavior risks and implement anti-tobacco policies, but also to provide and promote nutritional education. The perception of smoking restrictions in the school is correlated with lower rates of tobacco use among adolescents [
23‐
26], as well as their perceived general connectedness with school context [
27].
The International Agency of Research on Cancer of the World Health Organization (WHO) classified in 2013 outdoor air pollution as carcinogenic to humans; the most recent data indicate that in 2010, 223,000 deaths from lung cancer worldwide resulted from air pollution [
28].
Although the WHO definition of health as “complete physical, mental and social well-being” (WHO, 1946) goes back more than 50 years, few studies [
21,
22] have combined different areas of intervention in school-based prevention programs and their effects on adolescents’ lifestyles, and none ever included environmental education.
In this paper we will first review the literature on these topics and then present our multi-area experiential school-based intervention “La Scuola della Salute”, aimed at exploring a new way to talk with adolescents about smoking, nutrition and pollution. Care for the environment can be a useful perspective to start talking with adolescents about their health; that is why we decided to include air pollution in the intervention, in addition to tobacco use and the Western diet.
Methods
This intervention protocol was approved by the ethics committee of Istituto Nazionale dei Tumori (INT), Milan. From February to September 2011 the project was defined and the schools were selected and prepared for the intervention through meetings conducted by the project team.
The intervention began at the end of September 2011 and ended in March 2012. Before attending any of the experiential workshops, students filled in anonymous questionnaires regarding personal data, psychological characteristics, and their habits and knowledge concerning smoking and diet. After the questionnaires had been completed, all teachers and students received lifestyle guides. At the end of the study students filled in follow-up questionnaires regarding diet and smoking, and their knowledge about these subjects was tested. Every student was assigned a personal alphanumeric code (composed of subject number, sex, grade class and order of measurement) so that his or her answers could be linked to the final questionnaire and to all data collected in the study. At the end of the school year, students were informed about the general results of the questionnaires.
Food education course
The primary aim of the food education course was to offer practical and cognitive tools to help students develop a more responsible and conscious relation to food and to a healthy diet and lifestyle. The secondary aim was to devise an analytical method that allowed to estimate any change in dietary sugar intake before and after the intervention based on the measurement of urinary fructose. The food education course included a theoretical and a practical part. At the end of the course anthropometric measurements (weight and height) were made and urine samples were collected.
Smoke and environmental pollution experimental laboratory
To make adolescents aware of the effect of direct and secondhand smoke and the pollution it causes, scientific instruments were used and brief experiments were carried out.
Measurement of carbon monoxide in exhaled air (ex-CO) and tobacco smoke
Measurement of ex-CO in breath was used to show what happens in smokers. The analyzer (see Instruments section) was operated by personnel expert in the procedure. We used this instrument to make adolescents aware of the impact of smoke on their bodies, and to biologically assess the degree of physical tobacco dependence. Students were invited to measure ex-CO themselves in order to practice with the analyzer and understand the impact of smoking. In addition, the CO level in the smoke plume of a cigarette was measured at a few centimeters from the cigarette. The analyzer display immediately signaled very high levels of CO.
Air quality assessment
Fine particulate matter, black carbon and organic carbon were measured during this workshop. The pollutants’ analyzers were connected to a wall screen initially showing indoor background concentrations (typically <50 mcg/m3), which rose enormously after a cigarette was lit in the room. These experiments were indicative of the vast quantity of particles emitted by a cigarette, and of the high level of pollution due to secondhand smoke.
Tobacco smoke workshop. Measurement of tobacco smoke pollution in a park
Real-time measurement of particulate pollution (PM1, PM2.5 and PM10) with portable instruments allows students to recognize that cigarettes can result in marked exposure to passive smoking even in outdoor environments such as parks. Workshops were held with groups of students representing each grade class.
Behavioral and lifestyle workshops
The aim of these workshops was to prompt students to reflect upon and be more conscious of their behaviors related to health under the guidance of a psychologist. The behavioral and lifestyle experiential workshops also served as a connection between all the workshops of the project. Students’ opinions, observations and criticisms about the other workshops were discussed in order to learn if and how the activities proposed had an influence on the students’ lifestyles. Photo collage and role playing methods were used.
Other
A website, Facebook page and YouTube channel were created to involve students and inform them about the project. Students were directly involved in two press conferences regarding the project. Students and teachers were given two different guides about smoking and diet.
Nutrition
Students reduced salty snack consumption rates (
p = 0.03). Stronger differences were observed in 2
nd year students (−1.8, ±SD 5.9 vs 0.2, ±SD6.6;
p = 0.01). We registered a significant reduction of TV hours per day (
p < 0.05) as well. In the classes were a BMI reduction was observed, fructose level was significantly lower if compared to classes where BMI increased (p < 0.05 = 0.03;
R = 0.68; p = 0.01). More relevant and significant changes were observed in the female group if compared to the male (Table
10).
Table 10
Differences in antropometrics and nutrition at T1 and T2 in the total sample
Weight | 57.2 (SD 10.4) | 57.9 (SD 10.5) | <.001 |
Height | 165.0 (SD 8.2) | 166 (SD 0.54) | <.001 |
BMI | 20.9 (SD 3.0) | 21.0 (SD 3.0) | <.01 |
Sugar beverages | 8.0 (SD 8.7) | 7.2 (SD 7.6) | <.05 |
Sweet snacks | 8.5 (SD 8.3) | 7.8 (SD 6.6) | <.05 |
Saulty snacks | 4.5 (SD 5.6) | 3.6 (SD 4.8) | <.01 |
Sport | 2.0 (SD1.5) | 2.1 (SD 1.5) | N.S. |
TV hours/day | 2.7 (SD 1.1) | 2.3 (SD 1.1) | <.001 |
% Overweight between boys and girls | 19.5% | 18.2% | <.001 |
Urinary pools
Urines were collected with 141 subjects, grouped into 12 pools, one for each class. Subcjets affected by diabetes (n = 2) and insulin resistant (n = 1) were excluded.
For each class we studied the relation between being overweight and food consumption frequency. Linear regressions revealed a significant statistical relation between overweight and sweet and salty snacks consumption also if controlling the age (Table
11).
Table 11
Relation between overweight and nutrition
Sweets | 2.41 | <.05 | 1.00–3.82 |
Sweetened beverage + sweet snacks | 1.05 | <.05 | 0.10–2.01 |
Chips | 3.75 | 0.01 | 0.10–6.38 |
No significant relation was observed comparing fructose concentration before and after the intervention. In the classes where a reduction of BMI was observed, fructose levels significantly reduced as well, with an opposite tendency if compared to the classes were we registered an increased BMI and which showed a higher level of fructose (p = 0.03; R = 0.68; p = 0.01) Table
12.
Table 12
Fructose levels and IMC variations at T2
Δ Fructose | −1.02 (SD 2.50) | 2.18 (SD 1.86) | <.05 |
Discussion
The aim of this article is to describe and discuss a new method of intervention among secondary school adolescents that is aimed at promoting a healthy lifestyle. This pilot study is characterized by the application of multimodal integrated strategies: we integrated (a) prevention areas (smoking, diet and environment), (b) methods of intervention (experiential workshops, school courses, informative material, dedicated web platform, scientific research, media communications), and (c) different roles (students, teachers, parents, researchers, journalists, citizens).
(a)
Consistent with a concept of health that includes the influence of multiple factors, recent research has focused on the integration of multiple health areas in prevention interventions. Furthermore, smoking and dietary prevention projects have already been conducted, but none of these included environmental pollution as part of the educational intervention. Many adolescents are informed about the health risks associated with smoking but rarely receive information about the content of cigarette smoke and how it influences the indoor and outdoor environment. The relation between smoking and pollution therefore brings new and more articulated considerations onto the prevention path.
(b)
The aim of our multimodal approach is to stimulate adolescents to think about smoking and dietary concerns at different moments in their everyday life. The website, the public park research and the press conferences have the common goal of making adolescents actual partners in the project and social promoters of healthy changes.
Web instruments have the capacity to rapidly and easily connect people who are interested in these matters, and also bring us closer to the social market. Although there are studies in the literature that used web instruments in prevention interventions [
31‐
33], their use in this field is recent, and this is another innovative and relevant aspect of the project described here.
(c)
Finally, our project involved not only school components and families, but also the wider urban community. Adolescents perceptions and beliefs about tobacco use are the most proximal influence on their behaviour: for example, the number of family members and friends who smoke is strongly associated with youth smoking. The results of this paper confirm this finding. At the same time, to make students more involved in the wider living context, we wanted them to be interviewed and invited to take part in television broadcasts.
The choice to use biological markers to assess the samples’ characteristics and the impact of our intervention is an innovative aspect of this project.
Regarding the smoking area, it’s already assessed that Ex-Co is a reliable indicator of smoking status in adult and in several subgroups of smokers [
34‐
36]. Despite this, few studies investigate if CO measurement among adolescents is an instrument able to discriminate smokers and non-smokers. In the Vançelik’s et al. study [
37] was found that CO measurements between adolescents with a median age of 17 have a good sensitivity (90%) in assess the smoking status. Our results confirm Vançelik’s data: comparing the current smokers group to the rest of the sample, we observed a significant difference (
p < 0.01) of the ex-CO values between the two groups. Further studies are needed to confirm these results in this smokers’ sub-group.
Regarding the dietary area, one of the methodological purpose of this pilot study is to test the feasibility to create a class pool of urinary fructose as biomarker for the estimation of dietary sugar intake. We decided to use a biological biomarker because typically interviews or dietary questionnaires are known to be prone to measurement errors [
30].
So, to test the urinary fructose levels we decided to create a pool of urinary for each class in the study. All classes pools presented normal value of urinary fructose and we didn’t observe any significant differences between class grades. However, when we stratified each class by the prevalence of overweight we observed a higher level of fructose in the classes with a higher prevalence of overweight .
In the dietary area, urinary fructose was used to estimate dietary sugar intake because recent research [
38] demonstrated that sugar consumption is a significant determinant of obesity, with a clear dose effect. So, to test the urinary fructose levels we decided to create a pool of urinary samples for each class in the study. The use of a single urinary sample pool as we did in this study allows to extrapolate the average situation of the individuals of that particular class. Therefore, a very limited number of analyses is needed to test dietary changes. This means saving considerable time and money for the execution of a analytical assays, especially in large epidemiological studies.
Considering the changes in the behaviors, Ex-CO and fructose levels showed interesting trends, but did not yield statistically significant results at the 3 months follow up. These results can be explained with the short exposure the students had to the intervention. Furthermore, 3 months is a too short time to answer the question whether the intervention is effective or not, or whether these biological markers are effective or not in the assessment with adolescents.
The study has several others limitations, first of all its challenging replicability. This project, in fact, needs spaces expressly equipped with instruments for particulate matter, black carbon and CO measurements and experiments, as well as large kitchens where students can cook healthy food. Furthermore, it requires (at least for the first edition) considerable financial resources for the purchase of instruments and equipment.
Secondly, we proposed our intervention within a limited time frame, while the literature suggests that repeated recalls and family involvement result in a more effective intervention. We could not carry out extended follow-up, and to fill the gap we integrated the themes of the project (pollution, diet, smoking) into the school curriculum so that teachers could refresh them during the following years, and stimulate students to follow the website.
Finally, the management of biological markers can be difficult in this age group, in particular urine collection, which involves a very intimate sphere during adolescence.