Effectiveness of Smoking Prevention Programs on the Knowledge, Attitudes, and Anti-Smoking Exposure Self-Efficacy among Non-Smoking Rural Seventh-Grade Students in Taiwan

Round 1

Reviewer 1 Report

Your paper could improve in a number of areas such as a more thorough discussion of the design, development, testing and evaluation results; clarifying the key significance of the research contribution; ascertaining that the research fits the aims and scope of the journal; and a better command and flow of English writing throughout the paper.  

The references should be updated with the most recent in your paper's research field of relevance. I recommend the authors to consult the following survey and empirical papers to contextualize your findings. This should help the readers to understand the novelty of your work. 

An Integrated Cluster Detection, Optimization and Interpretation Approach for Financial Data, IEEE Transactions on Cybernetics,  (2021), DOI: https://doi.org/10.1109/TCYB.2021.3109066

Jun, J., Yeo, E. Central bank digital currency, loan supply, and bank failure risk: a microeconomic approach. Financ Innov 7, 81 (2021). https://doi.org/10.1186/s40854-021-00296-4

Liu, J., Zhang, Z., Yan, L. et al. Forecasting the volatility of EUA futures with economic policy uncertainty using the GARCH-MIDAS model. Financ Innov 7, 76 (2021). https://doi.org/10.1186/s40854-021-00292-8

 

Author Response

We thank the reviewers for your thoughtful suggestions and insights, which have enriched the manuscript and produced a better and more balanced account of the research. We have revised our manuscript based on your comments and believe it has greatly improved as a result. Please find our responses to all comments below.

Review 1:

Your paper could improve in a number of areas such as a more thorough discussion of the design, development, testing and evaluation results; clarifying the key significance of the research contribution; ascertaining that the research fits the aims and scope of the journal; and a better command and flow of English writing throughout the paper.  

The references should be updated with the most recent in your paper's research field of relevance. I recommend the authors to consult the following survey and empirical papers to contextualize your findings. This should help the readers to understand the novelty of your work. 

An Integrated Cluster Detection, Optimization and Interpretation Approach for Financial Data, IEEE Transactions on Cybernetics,  (2021), DOI: https://doi.org/10.1109/TCYB.2021.3109066

Jun, J., Yeo, E. Central bank digital currency, loan supply, and bank failure risk: a microeconomic approach. Financ Innov 7, 81 (2021). https://doi.org/10.1186/s40854-021-00296-4

Liu, J., Zhang, Z., Yan, L. et al. Forecasting the volatility of EUA futures with economic policy uncertainty using the GARCH-MIDAS model. Financ Innov 7, 76 (2021). https://doi.org/10.1186/s40854-021-00292-8

Response: We agree with your comments. We have modified the revised manuscript and sent it to a professional English editing service for editing. Furthermore, we have included a more detailed description and reorganized the text in the revised manuscript for study design, instrument development, testing, evaluation results and research contribution (please see yellow highlighted paragraphs in the revised manuscript). In addition, since the references you suggested is not related to smoking or SHS, we have not included them in our manuscript. However, we have cited the following recent studies:  

1. Ministry of Health and Welfare. Global Youth Tobacco Survey (GYTS). Republic of China (Taiwan). Available online: https://www.hpa.gov.tw/Pages/List.aspx?nodeid=1489 (accessed on 13 January 2022).
2. Ministry of Health and Welfare. Global Youth Tobacco Survey (GYTS) Survey Result. Republic of China (Taiwan). Available online: https://www.hpa.gov.tw/Pages/Detail.aspx?nodeid=1725&pid=9931 (accessed on 17 January 2022).
3. MZ, N.A., Suriani, I., HF, R.A., & AR, M.S.A. Knowledge, attitude and perceptions on second hand smoke (SHS) exposure among undergraduate students contribute to avoidance of second hand smoke. International Journal of Public Health and Clinical Sciences. 2017, 4(1), 53-65.
4. Nadhiroh, S.R.; Djokosujono, K.; Utari, D.M. The association between secondhand smoke exposure and growth outcomes of children: A systematic literature review. Tob. Induc. Dis.2020, 18, 12.
5. Wu, T.S.; Chaffee, B.W. Parental awareness of youth tobacco use and the role of household tobacco rules in use prevention. Pediatrics 2020, 146(5), e20194034.

Reviewer 2 Report

A straightforward piece of research that would benefit from a random and balanced allocation of subjects (n) to groups ("intervention" Vs. "usual care"). A reference to the Validity of the outcome measures used would to be considered (the authors only reported the reliability coefficients). 

 

Author Response

We thank the reviewers for your thoughtful suggestions and insights, which have enriched the manuscript and produced a better and more balanced account of the research. We have revised our manuscript based on your comments and believe it has greatly improved as a result. Please find our responses to all comments below.

 

Reviewer 2

1. A straightforward piece of research that would benefit from a random and balanced allocation of subjects (n) to groups ("intervention" Vs. "usual care").

Response: We agree on the need to be straightforward in the paper. Hence, we have rephrased the text in the revised manuscript.

“A quasi-experiment design with convenience sampling” was adopted to evaluate the effectiveness of a smoking prevention program on the knowledge, attitude, and anti-smoking exposure self-efficacy of seventh-grade students in rural Taiwan. (page 3)

“Convenience sampling was employed to enroll all eligible seventh-grade students from two junior high schools with similar value teaching systems in rural and coastal areas in Taiwan.” (Page 3)

We selected two different junior high schools in the same county with similar value teaching systems as intervention and usual care group. We adopted all classes in both schools that meet the inclusive criteria for both groups. However, since the size of the schools differed, the sample size of these groups differed as well. There is no study documenting the bias regarding different sizes between intervention and usual care groups. However, we have stated this issue in the study limitations. 

“Further, our results may be biased owing to the different sample sizes of the intervention and control schools in this study.” (page 11)

 

2. A reference to the Validity of the outcome measures used would to be considered (the authors only reported the reliability coefficients). 

Response: We concur and have added the content validity for the instruments (Please see page 6–7).

“The scale’s content validity has been approved by experts; based on Shi’s study, the scale-content validity index/average (SCVI/Ave) is 0.92, indicating good validity [27].” (Page 6)

For the remaining instruments, since the scales we have used were developed by other researchers, we do not need to prove the validity; nevertheless, we have cited these works previously.  

Reviewer 3 Report

The paper is well presented and addresses an important topic.  There are some basic problems related to the study design and this, together with weak and anomalous results, do call into question whether this manuscript is suitable for publication.

 

The study’s weakness relates primarily to limits related to the convenience sampling and small size of the control group. This alone may not be problematic, except that the research question is modest insofar as it seeks only to measure (short-term?) changes in knowledge and attitudes about smoking and SHS, and these may only have a tenuous link to later behaviors.  We might be able to accept this weak link, except the anomalous results suggest a very limited impact of this intervention. For instance, there is not a credible explanation as to why knowledge of smoking would decline among the control group except to point to a problem with measures or the small sample size. Likewise, there is also no good explanation for the decline in anti-smoking efficacy in both the control and experimental groups. 

 

There is also room for improvement in a few areas.  In the Discussion area of the manuscript there is a review of studies that might be included in Section 1.   Also, it is notable that Taiwan has seen a large decline in adolescent smoking in recent years – this merits further explanation. Finally, I believe the analysis would be easier to follow with a more detailed description and discussion of Table 4.

 

Author Response

We thank the reviewers for your thoughtful suggestions and insights, which have enriched the manuscript and produced a better and more balanced account of the research. We have revised our manuscript based on your comments and believe it has greatly improved as a result. Please find our responses to all comments below.

Reviewer 3

1. The study’s weakness relates primarily to limits related to the convenience sampling and small size of the control group. This alone may not be problematic, except that the research question is modest insofar as it seeks only to measure (short-term?) changes in knowledge and attitudes about smoking and SHS, and these may only have a tenuous link to later behaviors.  We might be able to accept this weak link, except the anomalous results suggest a very limited impact of this intervention. For instance, there is not a credible explanation as to why knowledge of smoking would decline among the control group except to point to a problem with measures or the small sample size. Likewise, there is also no good explanation for the decline in anti-smoking efficacy in both the control and experimental groups. 

 Response: We concur and have added statements regarding the reasons for the decreased knowledge of smoking in the control group and the decline in anti-smoking efficacy in both groups. (Page 11–12)

“However, studies examining the changes in smoking exposure-related knowledge following a prevention intervention are sparse. Most studies on SHS knowledge have used correlational designs and surveys to elucidate the relationship between SHS knowledge, attitudes, and behaviors [34,35]. Future studies may further examine longitudinal and practical outcomes (such as smoking initiation, trying smoking, or SHS avoidance behavior) in addition to changes in knowledge after delivering prevention interventions.” (Page 11)

 “According to this analysis, school-based smoking prevention programs’ impact on anti-smoking self-efficacy has been lower than expected. This is an anomalous finding that may be explained by potential extraneous unknown factors within the school environment or social atmospere. Likewise, as previously mentioned, adolescents experiencing SHS exposure at home [4] might believe that smoking is a normal behavior and should be allowed by people of authority, including their parents and relatives. Furthermore, adolescence is the most varying stage of life development. This period is often characterized by energy, impulsivity, rebelliousness, and self-centeredness. These traits can often precipitate deviant behavior. Moreover, adolescents’ social skills are underdeveloped, and thus, they often use smoking as a means to blend into their peer groups, applying self-righteous methods to find their social position [39]. Therefore, it is possible that even if they were taught to use refusal skills for anti-smoking with their peers, their self-efficacy would not be significantly changed. Furthermore, the lack of attractiveness in the design of program activities could be another reason for the lack of significant differences in students' anti-smoking self-efficacy in the intervention group. Future studies may need to examine the effects of program content, activities, and different stages of adolescence on anti-smoking self-efficacy.” (page 12)

2. There is also room for improvement in a few areas.  In the Discussion area of the manuscript there is a review of studies that might be included in Section 1.   

Response: As per your suggestions, we have moved the review of studies to Section 1. Please see the revised manuscript.

“Furthermore, although few studies have found an increase in the refusal skills of tobacco among adolescents [19], others have reported no change in anti-smoking self-efficacy following prevention programs [20].” (page 3)

3. Also, it is notable that Taiwan has seen a large decline in adolescent smoking in recent years – this merits further explanation.

Response: We have addressed this issue in page 2 as follows:

“Moreover, the prevalence of cigarette smoking among Taiwanese younger adolescents (aged 13–15) decreased from 7.8% to 3.0% between 1998 and 2019. Possible reasons for this decline are the 1997 Tobacco Hazards Prevention Act (THPA) and the 2009 THPA Amendment, which resulted in a strong governance against tobacco—a threat to the population's health [4].”  Additionally, we have mentioned the contents of THPA for further explanation as follows: (please also see the third paragraph in page 2).

 “Accordingly, in 2009, Taiwan implemented the THPA Amendment, which entails the following: prohibiting smoking in individuals under the age of 18; forbidding smoking and cigarette advertisements in public buildings; increasing tobacco price; preventing cigarette sales to adolescents; and completely restricting smoking at all levels of school (up to high school) and in most enclosed public places. With the THPA, school-based anti-smoking education was promoted in most Taiwanese schools.”

 4. Finally, I believe the analysis would be easier to follow with a more detailed description and discussion of Table 4.

Response: We have included a more detailed description and have reorganized the complete text in the revised manuscript (Please see results and discussion sections).

Reviewer 4 Report

This study determined the effectiveness of a school-based prevention program in enhancing the knowledge, attitudes, and anti-smoking exposure self-efficacy of seventh-grade non-smoking students. The topic is interesting. However, the quality of the work should be improved according to the following comments.

 

1. More explanations about why was a quasi-experiment design used in this study should be added to the manuscript.

2. Why were the control and intervention groups' sample sizes different?

3. There may be an order effect in the intervention of the four lessons.

4. The intervention effect was insignificant on smoking-related attitudes or behaviors. It contradicts the results of previous studies, indicating the poor design of the intervention based on the obsolete work published in 2002 and 2006. The content in Table 1 has formatting issues.

5. The results of this study failed to generate practical implications to reduce smoking among students.

Author Response

We thank the reviewers for your thoughtful suggestions and insights, which have enriched the manuscript and produced a better and more balanced account of the research. We have revised our manuscript based on your comments and believe it has greatly improved as a result. Please find our responses to all comments below.

Reviewer 4

This study determined the effectiveness of a school-based prevention program in enhancing the knowledge, attitudes, and anti-smoking exposure self-efficacy of seventh-grade non-smoking students. The topic is interesting. However, the quality of the work should be improved according to the following comments.

1. More explanations about why was a quasi-experiment design used in this study should be added to the manuscript.

Response: This is a quasi-experimental design because this study employed convenience sampling and did not randomly assign participants to experiment or control groups. The explanations have been included in the text. Please see the Study Design section on page 3 and Participants section on page 4. 

“A quasi-experiment design with convenience sampling was adopted to evaluate the effectiveness of a smoking prevention program on the knowledge, attitude, and anti-smoking exposure self-efficacy of seventh-grade students in rural Taiwan.” (Page 3)

“Convenience sampling was employed to enroll all eligible seventh-grade students from two junior high schools with similar value teaching systems in rural and coastal areas in Taiwan.” (Page 4)

     2. Why were the control and intervention groups' sample sizes different ?

Response:

We selected two different junior high schools in the same county with similar value teaching systems as intervention and usual care group. We adopted all classes in both schools that meet the inclusive criteria for both groups. However, since the size of the schools differed, the sample size of these groups differed as well. There is no study documenting the bias regarding different sizes between intervention and usual care groups. However, we have stated this issue in the study limitations. 

“Further, our results may be biased owing to the different sample sizes of the intervention and control schools in this study.” (page 11)

3. There may be an order effect in the intervention of the four lessons.

Response: We agree and have added this possibility in the study limitation as follows:

“Moreover, an order effect in the intervention of the four lessons might have impacted our actual intervention, and this problem should be considered in future studies.” (Page 12)

      4. The intervention effect was insignificant on smoking-related attitudes or behaviors. It contradicts the results of previous studies, indicating the poor design of the intervention based on the obsolete work published in 2002 and 2006. The content in Table 1 has formatting issues.

Response: We have modified the format of Table 1 in accordance with your comment.

      5. The results of this study failed to generate practical implications to reduce smoking among students.

Response: The results of this study have some practical implications to improve knowledge of smoking and SHS, and attitude toward avoiding SHS, which might induce insights of self-protection and increase SHS avoidance behaviors [Wang et al. 2007]. Moreover, based on the Taiwan Global Youth Tobacco Survey (GYTS) and a previous study (MHW, 2022; Hong, Guo, & Chen, 2015), curiosity is a factor linked to adolescent smoking. Therefore, the results of this study may reduce smoking behaviors since smoking knowledge might minimize students’ trying to smoke out of “curiosity.”

Round 2

Reviewer 4 Report

There are two comments to be addressed.

1. More explanations about the result "The intervention effect was insignificant on smoking-related attitudes or behaviors" because the intervention was designed based on the previous studies findings. 

2. There should be a subsection of discussion to give specific practical implications of the study.

Author Response

Thanks for all your comments and kind suggestions.

Reviewer 4

1. More explanations about the result "The intervention effect was insignificant on smoking-related attitudes or behaviors" because the intervention was designed based on the previous studies findings. 

Response: Thank you for your comment. However, this study did not evaluate behaviors; rather, it discussed the attitudes related to smoking. We apologize for the confusion this may have caused. We have explained the possible reasons for the insignificant results related to smoking-related attitudes in the manuscript (Page 11, the third paragraph of the Discussion). However, in order to avoid further confusion and clarify the main thrust of our article to both the readers and you, we have reorganized the Discussion and added the following subheadings:

• 4.1. Effects of smoking prevention programs on knowledge and attitudes
• 4.2. Effects of smoking prevention programs on anti-smoking exposure self-efficacy
• 4.3. Strengths and limitations
• 4.4. Clinical practical implications

 

2. There should be a subsection of discussion to give specific practical implications of the study.

Response. Based on your suggestion, we have added subsection “4.4. Clinical Practical Implications” to the Discussion (Page 13). You can also see the details as follows:

4.4. Clinical practical implications

Although this program did not improve anti-smoking attitudes and self-efficacy among adolescents, it improved knowledge on smoking and SHS and the attitude toward avoiding SHS exposure, and may have provided some preliminary evaluation data on the effectiveness of such programs in rural settings. Therefore, current interventions can be applied to rural adolescent populations; however, additional technical lessons and practice hours or workshops may be required to improve adolescent anti-smoking self-efficacy.

 

Author Response File: Author Response.docx