Effectiveness of non-pharmacological school-based therapies for cigarette smoking cessation among adolescents in South and Southeast Asian countries: a systematic review and meta-analysis

Article information

Osong Public Health Res Perspect. 2025;.j.phrp.2024.0320

Publication date (electronic) : 2025 April 30

doi : https://doi.org/10.24171/j.phrp.2024.0320

Fahad Ali Mangrio ¹

, Penpaktr Uthis^,¹^,²

, Suwimon Rojnawee ¹

, Alicia K Matthews ³

¹Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand

²Research Unit for Enhancing Well-being in Vulnerable and Chronic Illness Populations, Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand

³Columbia University School of Nursing, New York, NY, USA

Corresponding author: Penpaktr Uthis Faculty of Nursing at Chulalongkorn University, Borommaratchachonnani Srisataphat Building Rama1 Road, Pathumwan Bangkok 10330, Thailand E-mail: penpaktr.u@chula.ac.th

Received 2024 November 22; Revised 2025 February 14; Accepted 2025 March 6.

Abstract

Objectives

This review and meta-analysis examined the effectiveness of non-pharmacological therapies delivered through school-based interventions for smoking cessation among adolescents in South and Southeast Asian countries.

Methods

A systematic search was conducted across PubMed, Scopus, Science Direct, BioMed Central, the Cochrane Library, and ProQuest Dissertations & Theses Global from inception to October 2024. Eligible studies comprised randomized controlled trials and quasi-experimental studies that compared non-pharmacological smoking cessation interventions delivered in schools or other educational institutions. Data on smoking abstinence outcomes were extracted from published studies, and odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model via the Mantel-Haenszel estimator.

Results

Seven studies involving 1,260 participants were included. The meta-analysis demonstrated that non-pharmacological school-based therapies significantly increased smoking abstinence compared to controls (OR, 2.83; 95% CI, 1.83–4.40; p<0.001. Subgroup analyzes revealed benefits across both randomized controlled trials and quasi-experimental studies with varying abstinence rates. Studies utilizing biochemical verification showed significant positive effects despite substantial heterogeneity, and short-term (<3 months) abstinence was significantly higher in intervention groups compared to controls. Overall, no differences were found between subgroups regarding intervention effectiveness.

Conclusion

This meta-analysis indicates that non-pharmacological school-based interventions positively impact smoking abstinence rates, although effectiveness may vary based on study design, follow-up duration, and use of biochemical verification. The findings underscore the need for further research with larger sample sizes, extended follow-up periods, and improved methodological rigor in these regions.

Keywords: Non-pharmacological; School-based; Smoking cessation interventions; Southeast Asia; Systematic review and meta-analysis; Tobacco control

Introduction

Tobacco smoking is a major global health issue, with an estimated 24 million adolescents starting to smoke each year [1]. Epidemiological models predict that smoking may cause 1 billion deaths in the 21st century [2]. Smokers face a mortality rate 2 to 3 times higher than non-smokers and lose an average of 10 years of life expectancy due to smoking [3]. In South and Southeast Asia, tobacco use has been linked to over 40 to 160 million all-cause deaths [4,5]. Adolescence is a critical period of vulnerability to addictive substances such as nicotine. In Southeast Asia, adolescent smoking prevalence ranges from 11.3% to 19.2% in countries including Thailand, Malaysia, Cambodia, the Philippines, Singapore, Indonesia, East Timor-Leste, Brunei, Lao People’s Democratic Republic, Myanmar, and Vietnam [6]. In the South Asian Region (SAR), which comprises Afghanistan, Bangladesh, Nepal, Bhutan, Pakistan, Maldives, Sri Lanka, and India, adolescent smoking rates range from 9.0% to 47.2% [7-11]. Initiating smoking during adolescence often leads to continued use into adulthood, and early nicotine exposure can adversely affect brain development, impairing cognition, attention, and mood [12,13]. Therefore, addressing nicotine dependence and promoting smoking cessation among adolescents is a critical public health priority.

During their formative years, children spend a substantial amount of time in school, where health behaviors are shaped through education, role modeling, and access to health promotion resources [14]. As such, school-based interventions have effectively enhanced adolescent health promotion and disease prevention, including tobacco control [14]. A previous systematic review of 14 school-based smoking cessation programs conducted between 2007 and 2019 concluded that these interventions can be effective for adolescent smokers [15]. These interventions incorporated behavioral support, peer-led initiatives, comprehensive health education, and integration into broader health curricula, contributing to successful smoking cessation. Nevertheless, limitations were identified, such as inconsistent results, short follow-up durations, a focus on public schools only, and challenges in program implementation across diverse settings. The heterogeneity in program designs and outcomes further complicated pooled statistical analysis [15]. Therefore, non-pharmacological interventions continue to be the primary recommendation for adolescent smoking cessation, with pharmacotherapy considered an alternative that warrants further investigation regarding its long-term efficacy and safety in adolescents [16].

Additionally, 2 reviews have produced mixed findings. One systematic review, which included 6 interventions, reported mixed results for school-based smoking cessation programs and found insufficient evidence to support their efficacy [17]. The review attributed this to high heterogeneity in intervention delivery methods and outcome measurement durations, which hindered robust statistical analysis [17]. In contrast, another rapid review and meta-analysis of 32 non-pharmacological interventions concluded that the intervention group achieved a 30% higher abstinence rate than the controls [18]. However, most studies in that review were conducted in the United States and Europe, and the smoking cessation programs varied considerably in terms of setting and counseling type [18].

Therefore, the efficacy of school-based smoking cessation therapies may differ significantly by geographical region, influenced by cultural, social, and economic factors that affect adolescents’ responses to these interventions. For instance, most studies included in previous reviews [15,16,18] were conducted in Western countries, and their findings may not be applicable to regions such as Asia. Furthermore, earlier systematic reviews predominantly focused on public schools, overlooking private and alternative educational settings [15]. This narrow focus may neglect the distinct challenges and opportunities present in various educational environments.

Additionally, a Cochrane review analyzing randomized controlled trials (RCTs) demonstrated the effectiveness of both pharmacological and non-pharmacological smoking cessation therapies [16]. Non-pharmacological approaches, such as counseling, cognitive-behavioral therapy, and motivational interviewing, aim to modify behavior and thought patterns without the use of drugs [19]. This minimizes the risk of side effects commonly associated with pharmacological treatments, including nicotine replacement therapy, varenicline, and bupropion [19,20]. However, the review did not disaggregate data to examine outcomes specific to school-based interventions or to assess region-specific results globally [16].

Given the limitations of previous reviews and the increasing prevalence and consequences of adolescent smoking, it is essential to focus on smoking cessation interventions tailored to adolescents in South and Southeast Asia. Therefore, this review aims to statistically synthesize evidence on non-pharmacological therapies in various educational settings, including both public and private institutions, for adolescent smoking cessation. The study concentrates on South and Southeast Asian regions to identify regional trends and explore how cultural, social, and economic factors may influence intervention efficacy. Moreover, it highlights a gap in the literature due to the limited number of studies available in these settings. Ultimately, this review seeks to provide evidence-based recommendations for enhancing smoking cessation programs for adolescents in these regions, thereby reducing the prevalence and adverse effects of smoking.

Materials and Methods

Eligibility Criteria

This systematic review and meta-analysis followed the methodologies outlined in the Cochrane systematic review [21] and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines [22]. The review is registered with PROSPERO (CRD42023431655). Studies published in any language from school-based or educational institutions were included, although searches were conducted in English. Articles published from the inception of the databases until October 30, 2024, were considered.

Population

Studies were eligible if they provided data on outcomes for adolescent school-based smoking cessation programs conducted in the SAR, which comprises Afghanistan, India, Maldives, Bangladesh, Nepal, Pakistan, Sri Lanka, and Bhutan [23], or in Southeast Asia, which includes Thailand, the Philippines, Cambodia, Myanmar (Burma), Vietnam, Singapore, Malaysia, Indonesia, Brunei, Timor-Leste, and the Lao People’s Democratic Republic [24]. These countries were selected due to their higher rates of adolescent smoking.

Interventions

Non-pharmacological therapy studies were defined as those that provided participants with non-drug treatments aimed at evaluating their effects on smoking cessation [19]. Examples include (1) psychological interventions (e.g., cognitive-behavioral education, counseling), (2) behavioral interventions (e.g., exercise), and (3) other interventions (e.g., meditation).

Control/comparator

Any type of control group was eligible, including waitlist controls, treatment-as-usual, or comparisons of the new experimental intervention with an existing intervention.

Outcome

The primary outcome of interest was the quit rate following exposure to the smoking cessation intervention. Given the heterogeneity of intervention approaches and follow-up assessment time points, the review included all reported quit outcomes, regardless of the definition of quit status (e.g., 7-day point prevalence versus continuous abstinence) and assessment timing (e.g., 1, 3, or 6 months post-treatment).

Study Design

Only RCTs and quasi-RCTs were included.

Exclusion Criteria

Interventions involving (1) drug-related treatments, (2) e-cigarettes containing nicotine, (3) studies that did not report any smoking cessation outcomes, and (4) review articles, protocols, case reports, letters, abstracts, or studies lacking data were excluded.

Search Strategy

In consultation with a librarian, a search strategy was developed using key terms—including Medical Subject Headings (MeSH), Boolean operators, and wildcards—based on previous reviews [19] and the guidelines for each database. We searched 6 databases—PubMed, Scopus, Science Direct, BioMed Central, the Cochrane Library, and ProQuest Dissertations & Theses Global—for relevant articles. Additionally, a manual search was conducted using reference lists from the included studies and publication profiles of smoking cessation experts (e.g., ResearchGate or university faculty pages).

Data Collection and Processing

Two reviewers (F.A.M. and S.R.) independently screened titles, abstracts, and full texts using the Joanna Briggs Institute Summary platform [25]. Any discrepancies were resolved through discussion among the reviewers or by consulting a third reviewer (P.U.) to reach consensus. Data extracted by F.A.M. and S.R. included basic study information (first author, year, country, and setting), participant characteristics (age, sex, sample size), intervention details (intervention fidelity, study design, outcome measurement, intervention duration, follow-up period, type of intervention, intention-to-treat analysis, and main findings), and risk of bias ratings. A third reviewer (S.R.) verified all extracted information. Cohen kappa statistics were calculated to assess inter-rater agreement; the kappa statistic was 0.78 for title/abstract screening (indicating substantial agreement) and 0.85 for full-text screening (indicating almost perfect agreement), according to Landis and Koch’s criteria [26].

Study Risk of Bias Assessment and Quality

Two reviewers (F.A.M. and S.R.) independently assessed the risk of bias using guidelines from the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Tobacco Addiction Group [27]. Disagreements were resolved by consensus. The risk of bias for RCTs was evaluated using the RoB2 tool, which examines 5 domains: (1) randomization process, (2) deviations from intended interventions, (3) missing outcome data, (4) outcome measurement, and (5) selection of reported results. RCTs were categorized as having low risk, some concerns, or high risk of bias in accordance with Cochrane guidelines [23]. Additionally, the ROBINS-I tool was employed for quasi-experimental non-randomized studies, assessing 7 domains: (1) confounding variables, (2) participant selection, (3) intervention classification, (4) deviations from intended interventions, (5) missing data, (6) outcome measurement, and (7) selective reporting. Quasi-experimental studies were rated as having low, moderate, serious, or critical risk of bias, or as indeterminate [28]. The overall quality of evidence for each reported outcome was evaluated using the GRADE approach (Table S1) [29].

Data Synthesis

Cochrane Review Manager software version 5.4 was used to calculate odds ratios (ORs) with 95% confidence intervals (CI) for abstinence outcomes at all reported follow-up durations and the earliest available endpoints in each study. The Mantel-Haenszel method, fitted with a random-effects model, was employed to account for expected cross-trial variations in study design and intervention characteristics. This pooling method was also applied in all subsequent subgroup analyzes [30]. Heterogeneity between studies was assessed using the I² statistic according to the Cochrane guidelines for interpretation [31]. Publication bias was assessed using funnel plots and the Begg, Egger, and trim-and-fill tests [30], in Jamovi ver. 2.6. In addition, we conducted sensitivity and subgroup analyzes to examine whether study characteristics (e.g., design, sample size, outcome measurement report, type of abstinence measure, and follow-up period) affected the results [31]. Intention-to-treat analyzes were conducted, considering individuals lost to follow-up as current smokers [32].

Results

The initial search yielded 8,640 articles, including 3,610 from PubMed, 205 from Scopus, 999 from Science Direct, 515 from the Cochrane Library, 3,310 from ProQuest, and 1 from citation searching [18]. Most studies were published in English; no eligible non-English language trials were identified in the abstracts. After excluding ineligible automated records and duplicates, 4,643 articles were removed. Specifically, 100 observational studies, 3,713 articles unrelated to the research question and outcomes, and 10 articles based on abstract reviews were excluded. A full-text review and eligibility assessment were then performed on the remaining 171 articles by 2 independent reviewers, with discrepancies resolved by a third reviewer. Ultimately, 7 articles were deemed appropriate for inclusion (Figure 1).

Figure 1.

Inclusion of studies following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Study Characteristics

Four of the 7 studies were conducted in Thailand and 3 in Malaysia [33–39]. Participants ranged from early adolescence to young adulthood, with an average age of 17.06 years. Two studies [37,39] included only male participants, while the remaining studies included both sexes [33–36,38]. Regarding study design, 5 studies were 2-arm RCTs (with 1 control and 1 intervention group) [33,35,36,38,39], and 2 studies employed a quasi-experimental 2-arm design without randomization [34,37] .

Intervention durations varied from 1 to 12 weeks; 71.4% of studies had short-term durations (1 to 6 weeks), while 28.6% had medium-term durations (10 to 12 weeks). Smoking cessation outcomes in 5 studies (71.4%) were confirmed via biological verification methods, such as expelled carbon monoxide, salivary cotinine, or urine cotinine levels. In contrast, 2 studies [34,38] relied solely on self-reported quit rates (Table 1) [33–39].

Table 1.

Summary of findings from the included studies

All studies utilized non-pharmacological smoking cessation interventions within school and university settings. For instance, 3 studies incorporated group-based cognitive-behavioral counseling [33,34,36], while 2 studies offered one-on-one counseling sessions [35,38]. Additionally, 2 studies implemented both group-based and individual face-to-face as well as mobile application–based counseling [37,39]. The interventions included the Fit and Smart Adolescent Smoking Cessation Program [33], the Project EX smoking cessation program [34], a smartphone application named “Quit with US” along with smoking cessation counseling [35], a group counseling smoking cessation package [36], a smoking cessation program based on information-motivation-behavioral skills and stages of change [37], brief advice for smoking cessation [38], and a smoking cessation program [39].

Intervention facilitators varied considerably. Facilitators included a school teacher [33,34], a school counselor [33,36], a buddy [33], a pharmacist [35], a medical officer [38], and researchers from public health and sports science faculties [37,39]. Three studies described the training and supervision provided to the facilitators [33,34,36], whereas the remaining studies did not include any details regarding facilitator training [35,37–39] (Table 2).

Table 2.

Summary of study intervention description

Main Outcomes

A total of 1,260 adolescents and young adults participated in all 7 studies. All studies were theory-based and employed an intention-to-treat approach for outcome analysis. Three studies reported a 7-day point prevalence abstinence rate [33,35,36], 1 study reported a 30-day point prevalence abstinence [34], and 1 reported continuous 6-month abstinence [38]. Two studies did not report smoking cessation outcomes in terms of point prevalence or continuous abstinence [37,39]; however, they did document smoking abstinence immediately following intervention completion.

Due to the varied measures of smoking abstinence outcomes, all available results were pooled to provide a comprehensive analysis, ensuring that neither point prevalence nor continuous abstinence rates were disproportionately emphasized [30]. The analysis indicated that non-pharmacological school-based interventions were associated with significantly higher smoking abstinence rates compared to controls (OR, 2.83; 95% CI, 1.83–4.40; p<0.001). The overall analysis showed moderate heterogeneity (I²=55%), suggesting some variability among study results that could affect the consistency and reliability of the overall conclusion (Figure 2).

Figure 2.

Non-pharmacological school-based smoking cessation interventions versus control. The plot presents the odds ratios (ORs) with 95% confidence intervals (CIs) for each study, along with the overall pooled estimate utilizing a random-effects model with the Mantel-Haenszel (M-H) method. Study-specific ORs (blue squares) are weighted by study size, with horizontal lines indicating 95% CIs. The pooled OR (black diamond) demonstrates an overall effect of 2.83 (95% CI, 1.83–4.40; Z=4.65; p<0.001) favoring the intervention. Heterogeneity analysis revealed tau²=0.16, χ²=13.43, degrees of freedom (df)=6, p=0.04, and I²=55%, indicating moderate heterogeneity. The x-axis is presented on a logarithmic scale; values >1 favor the intervention, and values <1 favor the control.

Subgroup Comparisons

Subgroup analyzes were conducted to assess clinical and methodological heterogeneity that might influence the meta-analysis outcomes. First, smoking abstinence rates were compared based on study design. In 5 RCTs, abstinence rates ranged from 15% to 60%, while in 2 quasi-experimental studies, rates ranged from 23% to 60%. The RCT subgroup, comprising 5 studies with 1,005 participants, showed a significant positive effect (OR, 3.13; 95% CI, 1.69–5.82; p=0.0003) with substantial heterogeneity (I²=70%). The quasi-experimental subgroup, consisting of 2 studies with 255 participants, also demonstrated a significant effect (OR, 2.66; 95% CI, 1.42–4.97; p=0.002) and exhibited no heterogeneity (I²=0%). Overall, no significant subgroup difference was found in intervention effectiveness (p=0.72, I²=0%) (Figure 3).

Figure 3.

Efficacy of non-pharmacological smoking cessation interventions in randomized control trials vs. quasi-experimental studies. The forest plot depicts odds ratios (ORs) with 95% confidence intervals (CIs) for each study, as well as pooled estimates for each subgroup utilizing a Mantel-Haenszel (M-H) method of random-effects model. Study-specific ORs (blue squares) are weighted by study size, with horizontal lines indicating 95% CIs. The pooled OR (black diamond) illustrates the overall effect of each and the total subgroup analysis effect. The heterogeneity within randomized controlled trials is moderate (tau²=0.28, χ²=13.34, degrees of freedom [df]=4, p=0.01, I²=70%), while the heterogeneity in quasi-experimental studies is low (tau²=0.00, χ²=0.04, df=1, p=0.84, I²=0%). The overall test for effect shows statistical significance in favor of the intervention group (Z=4.65, p<0.001). The test for subgroup differences indicates no significant variation between study designs (χ²=0.13, df=1, p=0.72, I²=0%).

Next, the subgroup with biochemical verification, which included 5 studies with 995 participants, showed statistically significant effects favoring the interventions (OR, 2.83; 95% CI, 1.68–4.77; p<0.001), with abstinence rates ranging from 41.8% to 60.0%, despite substantial heterogeneity (I²=66%). Conversely, the subgroup without biochemical verification, comprising 2 studies with 265 participants, reported higher quit rates; however, the differences were not statistically significant (OR, 3.62; 95% CI, 0.85–15.45; p=0.08), with abstinence rates ranging from 15.0% to 23.0% and lower heterogeneity (I²=30%). Overall, no subgroup differences in intervention effectiveness were identified (Figure 4).

Figure 4.

Comparison of interventions that included biological verification of smoking cessation versus interventions that did not. This forest plot displays odds ratios (ORs) and 95% confidence intervals (CIs) for studies using biochemical verification and those without. Blue squares represent study-specific ORs, with size proportional to study weight. Horizontal lines indicate 95% CIs, and black diamonds show pooled estimates. The x-axis is logarithmic, with values >1 favoring the intervention and <1 favoring the control. Studies using biochemical verification (n=5) show a significant effect favoring the intervention (OR, 2.83; 95% CI, 1.68–4.77; p<0.001) with moderate heterogeneity (I²=66%). Studies without biochemical verification (n=2) show a non-significant effect (OR, 3.62; 95% CI, 0.85–15.45; p=0.08) with low heterogeneity (I²=30%). The overall effect favors the intervention (OR, 2.83; 95% CI, 1.83–4.40; p<0.001). No significant difference was found between verification methods (p=0.76, I²=0%). M-H, Mantel-Haenszel; df, degrees of freedom.

The pooled analysis of 5 studies with follow-up assessments at 3 months or less yielded an OR of 3.15 (95% CI, 1.89–5.23; p<0.001), indicating a substantial increase in short-term abstinence rates among intervention participants compared to controls, with moderate heterogeneity (I²=55%). In the 4–6-month follow-up subgroup, comprising 2 studies, a positive trend was observed, although it did not reach statistical significance (OR, 3.18; 95% CI, 0.46–21.92; p=0.24). Overall, no subgroup differences in intervention effectiveness were identified (Figure 5).

Figure 5.

Comparison of studies with ≤3-month follow-up versus studies 4- to 6-month follow-up periods. The odds ratio (OR) (Mantel-Haenszel [M-H], random, 95% confidence interval [CI]) is presented for each study, with corresponding weight and CIs. The subtotal effect estimates for the <3-month and 4- to 6-month follow-up subgroups are provided, along with the overall pooled effect estimate. The results indicate that in the <3-month follow-up subgroup, the pooled OR is 3.15 (95% CI, 1.89–5.23), favoring the intervention group, with moderate heterogeneity (I²=53%). In the 4- to 6-month follow-up subgroup, the pooled OR is 3.18 (95% CI, 0.46–21.92), showing a wider confidence interval and higher uncertainty. The test for subgroup differences (χ²=0.00, degrees of freedom [df]=1, p=0.99) indicates no significant variation between follow-up periods (I²=0%).

Risk of Bias in Studies

All studies were evaluated for risk of bias using guidelines from the Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Tobacco Addiction Group classified blinding-related bias as low risk, given the inherent challenges in blinding within smoking cessation intervention research [30]. A risk of bias assessment was conducted for 5 studies using the standardized RoB2 tool, which evaluates 5 key domains [33,35,36,38,39]. Two studies were categorized as having a low risk of bias (2/5, 40.0%), indicating low bias risk across all domains [33,35]. Two studies raised some concerns (2/5, 40.0%) [36,39]; specifically, 1 study had concerns in 1 domain (missing outcomes) without any high-risk ratings [36], while another study had concerns in 2 domains (randomization process and outcome measurement) but no high-risk ratings [39]. One study exhibited a higher risk of bias (1/5, 20.0%) in the randomization process domain [38].

Three quasi-experimental studies were assessed using the ROBINS-I tool across 7 domains [34,37,40]. Two studies showed moderate risk (2/3, 66.6%), indicating moderate risk in at least 2 domains [34,37], with 1 study showing concerns in 3 domains (Figures 4, 5; Supplementary Materials 1–3; Figure S1–S3) [40]. Due to the critical risk identified in the quasi-experimental study by Sidhu et al. [40] and potential publication bias, that study was excluded from the analysis. Potential bias in participant selection (domain 2) may arise from disparities in baseline characteristics or inadequate reporting of deviations from the intended intervention (domain 4), which could impact the outcomes and introduce bias due to the lack of fidelity assessment and inconsistencies in the implementation of the intervention. Low retention rates may lead to bias due to missing outcome data (domain 5) and concerns about bias in measuring the outcome (domain 6) as a result of relying solely on self-reports without biochemical verification. Bias in selecting reported results (domain 7), with significant prevention effects but not cessation effects, may indicate selective outcome reporting. Additionally, the study included a small sample size (n=16) of cigarette smoker participants. A sensitivity analysis comparing results with and without this study was conducted, and the main findings remained statistically significant and clinically meaningful even after its exclusion [40].

GRADE Approach

The GRADE assessment indicated that the certainty of evidence for the treatment effect on quit rates at less than 6 months in the RCTs was moderate. Similarly, the 2 quasi-experimental studies demonstrated moderate certainty regarding quit rates at less than 3 months (Table S1).

Discussion

This is the first systematic review and meta-analysis examining the effectiveness of non-pharmacological, school-based therapies for smoking cessation among adolescents in South and Southeast Asian regions. The review included 7 studies conducted in the screened, eligible, approached, randomize (SEAR), providing valuable insights into the efficacy of these interventions. Notably, the review exposes a significant research gap regarding school-based smoking cessation interventions in the SAR. Despite the high prevalence of cigarette smoking among adolescents in this region [7–11], there is a notable absence of studies addressing this critical issue. This finding aligns with previous research and underscores the urgent need for more focused investigations in this geographical area [41]. The varying levels of bias across the included studies highlight the importance of employing rigorous methodological approaches. Robust testing strategies were applied to assess the risk of bias, resulting in the exclusion of 1 quasi-experimental study due to its critical risk of bias associated with a small sample size and insufficient reporting on intervention allocation and outcomes [40]. Such exclusions are essential to ensure the reliability of the synthesized evidence and maintain the integrity of the review process [31].

Results indicated that the interventions significantly increased smoking abstinence rates compared to control conditions. However, the presence of moderate heterogeneity among the studies (I²=55%) suggests some variability in intervention effects, which may be attributable to differences in study populations, sample sizes, intervention types, or methodological variations. These findings are consistent with previous systematic reviews and meta-analyzes that demonstrated the efficacy of various smoking cessation interventions despite considerable heterogeneity [18,42]. Nonetheless, the observed variability highlights the need for further research to identify the factors contributing to these differences.

The subgroup of studies that employed biochemical verification demonstrated a significant positive effect of the interventions. This robust effect size, based on objective outcome measures, provides strong evidence for the effectiveness of the smoking cessation programs evaluated in this review. In contrast, the subgroup relying on self-reported quit outcomes showed a positive effect that did not reach statistical significance, and the wide CI indicates less precision in the estimate, likely due to a smaller number of studies and participants. Previous research has documented substantial differences in smoking cessation outcomes between verified and non-verified measures, with evidence suggesting that reporting bias can inflate estimates of intervention effects [43]. This bias may occur because participants tend to overstate their progress due to social desirability [44]. Therefore, biochemical verification remains the gold standard for rigorously evaluating the effectiveness of smoking cessation interventions [45]. Once efficacy has been firmly established using objective measures, self-reported outcomes from school-based studies may still offer valuable insights into how the intervention performs in everyday life and capture social and environmental factors that are difficult to replicate in controlled trials.

Subgroup analysis of follow-up periods of 3 months or less indicated a substantial increase in short-term quit rates among intervention participants compared to controls. This finding aligns with previous meta-analyzes that demonstrated the effectiveness of behavioral interventions for short-term smoking cessation among adolescents [18,42]. The 4- to 6-month follow-up subgroup exhibited a positive trend, although it did not reach statistical significance. While less definitive, this result is consistent with the known challenges of maintaining quit rates over time, as observed in other non-pharmacological intervention studies [46].

The included studies displayed significant variability in intervention duration, ranging from short to medium-term programs. This diversity suggests that short to medium-term programs can effectively promote smoking cessation among adolescents. However, 1 study featured a 1-week intervention duration and reported lower smoking abstinence rates than interventions of longer duration [38]. These findings are consistent with previous systematic reviews that indicate the effectiveness of tobacco cessation programs across durations ranging from 4 to 12 weeks, as well as longer-term interventions lasting up to 6 months [18,42].

The individuals delivering non-pharmacological interventions were diverse, including schoolteachers, public health researchers, pharmacists, school counselors, and trained researchers. This diversity suggests a multi-faceted approach to addressing adolescent smoking, drawing on expertise from various fields to design and implement effective cessation programs. However, the reviewed studies varied in the level of detail provided regarding the training received by intervention providers. Three studies described the training interventions in detail, while the remaining studies did not report any information on the training of providers [31,32,34]. This discrepancy complicates the assessment of intervention effectiveness, as the quality of provider training can significantly influence smoking cessation outcomes. Future research would benefit from comprehensive reporting on the nature and content of training, along with ongoing supervision to ensure fidelity to the intervention protocol. Such reporting would facilitate a better understanding of the role of training in the success of smoking cessation interventions and support the development of more effective programs.

The limitations of the current research include its exclusive focus on non-pharmacological interventions within school and educational institution settings, which may not capture the full spectrum of smoking cessation programs available outside academic environments. Furthermore, the geographical concentration of the included studies in Southeast Asian countries may limit the generalizability of the findings to other regions. We also acknowledge inherent limitations in meta-analysis, such as the small number of studies and moderate heterogeneity, which may influence the overall results.

This review confirms that all studies obtained informed consent, including parental consent and adolescent assent for participants under 18. However, some studies provided insufficient details regarding procedural descriptions, raising concerns about the adequacy of ethical reporting [35,38,39]. Comprehensive documentation of consent processes is essential for transparency and ethical rigor in adolescent smoking cessation interventions [47]. Future research should prioritize standardized reporting of ethical procedures to enhance study comparability and integrity.

Moreover, future research should explore additional methodological approaches, such as the Hartung-Knapp adjustment and the use of R calculator to refine effect estimates. Studies should also address these limitations by expanding the focus beyond educational institutions to encompass a broader geographic scope, including various South and Southeast Asian countries. These interventions show potential efficacy and warrant adaptation and evaluation in other nations in the region. Methodological considerations such as biochemical verification, detailed training protocols, fidelity evaluations, and standardized cessation assessment periods should be addressed to strengthen methodological rigor. Additional research is needed to identify the minimal intervention components required to achieve optimal outcomes, particularly in resource-constrained settings.

Future research should focus on customizing smoking cessation interventions to address the unique cultural and socioeconomic factors influencing smoking behavior in South Asian countries. Further studies should aim to increase sample sizes and standardize long-term follow-up periods to better understand the long-term efficacy of non-pharmacological, school-based smoking cessation interventions.

Conclusion

This review provides significant insights into the effectiveness of school-based non-pharmacological interventions for smoking cessation among adolescents in the Southeast Asian region. While these interventions have demonstrated short-term effectiveness, long-term follow-up studies are needed to assess sustained outcomes. Healthcare providers and policymakers should consider implementing and promoting these interventions to reduce smoking prevalence and mitigate its associated health burdens.

HIGHLIGHTS

• Non-pharmacological therapies delivered in educational settings significantly improved smoking abstinence rates compared to control groups, with moderate heterogeneity (I²=55%).

• Studies employing biochemical verification yielded significant effects, whereas those without verification showed higher quit rates that were not statistically significant.

• Five studies with follow-ups of ≤3 months reported increased abstinence rates and 2 studies with follow-ups of 4 to 6 months showed a positive trend, but without reaching statistical significance.

Supplementary Material

Supplementary data are available at https://doi.org/10.24171/j.phrp.2024.0320.

Table S1.

GRADE approach summary of findings.

j-phrp-2024-0320-Supplementary-Table-S1.pdf

Supplementary Material 1.

Full structured search strategies for each database.

j-phrp-2024-0320-Supplementary-Material-1.pdf

Supplementary Material 2.

Publication bias tests: Begg rank correlation.

j-phrp-2024-0320-Supplementary-Material-2.pdf

Supplementary Material 3.

Full-text screening: excluded studies.

j-phrp-2024-0320-Supplementary-Material-3.pdf

Figure S1.

Funnel plot of primary meta-analysis.

j-phrp-2024-0320-Supplementary-Figure-S1.pdf

Figure S2.

Risk of bias assessment. (A, B) Randomized controlled trial studies risk of bias assessment (RoB2).

j-phrp-2024-0320-Supplementary-Figure-S2.pdf

Figure S3.

(A, B) Risk bias ROBIN-1 assessment of quasi-experimental design.

j-phrp-2024-0320-Supplementary-Figure-S3.pdf

Notes

Ethics Approval

Not applicable.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

None.

Availability of Data

No additional data. The article contains all the data.

Authors’ Contributions

Conceptualization: FAM, AKM; Data curation: FAM, PU, AKM; Formal analysis: FAM, SR, AKM; Methodology: PU, FAM; Supervision: PU, AKM; Writing–original draft: FAM; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Acknowledgements

The author, Fahad Ali Mangrio, would like to acknowledge the scholarship program for Association of Southeast Asian Nations (ASEAN) and non-ASEAN Countries and the 90th Anniversary supported by the graduate school of Chulalongkorn University Bangkok, Thailand. This research work is part of a PhD dissertation in nursing.

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No.	Study	Year	Country & setting	Mean age (y)	Sex	Total (n)	Fidelity	Study design	Outcome measurement	Treatment duration (wk)	Follow-up period (mo)	Intervention type		IT	Main findings	Risk of bias
No.	Study	Year	Country & setting	Mean age (y)	Sex	Total (n)	Fidelity	Study design	Outcome measurement	Treatment duration (wk)	Follow-up period (mo)	Control	Experimental	IT	Main findings	Risk of bias
1	Abdul Halim et al. [33]	2022	Malaysia, schools	15.3	Male & female	266	Yes	RCT	Self-reported biochemical (CO and salivary cotinine levels) 7-day point prevalence abstinence	4	3	Placebo	Fit and Smart Adolescent Smoking Cessation Program	Yes	At the 3-month follow-up, the quit rate in the intervention group (41.8%, 70/168) was significantly higher than that in the control group (24.5%, 24/98)	L
2	Chansatitporn et al. [34]	2016	Thailand, schools	15.12	Male & female	185	Yes	Quasi-exp	Self-reported 30-day point prevalence abstinence rate	6	3	Standard health education	Project EX: smoking cessation program	Yes	At the 3-month follow-up, the quit rate in the intervention group (23.0%, 21/91) was significantly higher than that in the control group (11.0%, 10/94)	M
3	Chulasai et al. [35]	2022	Thailand, universities	21.06	Male & female	273	Not mentioned	RCT	Self-reported biochemical (CO level), 7-day point prevalence abstinence	4	3	Smoking cessation counseling	A smartphone application named “Quit with US”	Yes	At the 3-month follow-up, the quit rate in the intervention group (58.4%, 80/137) was significantly higher than that in the control group (30.9%, 42/136)	L
4	Ismail et al. [36]	2010	Malaysia, schools	14	Male & female	346	Not mentioned	RCT	Self-reported, biochemical (CO level), 7-day point prevalence abstinence	10	4	Standard school programs for smoking cessation	Group Counseling; Smoking cessation package	Yes	At the 4-month follow-up, the quit rate in the intervention group (45.0%, 71/158) was significantly higher than that in the control group (32.0%, 60/188)	S
5	Junnual et al. [37]	2019	Thailand, schools	16.8	Male	70	Not mentioned	Quasi-exp	Self-reported and biochemical (urinary cotinine) point prevalence abstinence or continuous abstinence rate not mentioned	12	3	Placebo	Information-Motivation-Behavioral-Stages of Change Smoking Cessation Program	Yes	At the 3-month follow-up, the quit rate in the intervention group (60.0%, 21/35) was significantly higher than that in the control group (35.0%, 12/35)	M
6	De Silva et al. [38]	2016	Malaysia, university	21.20	Male & female	80	Not mentioned	RCT	Self-reported continuous abstinence rate	1	6	Usual care (paper-based basic information on smoking cessation)	Brief advice	Yes	At the 6-month follow-up, the quit rate in the intervention group (15.0%, 6/40) was significantly higher than that in the control group (0%, 0/40)	H
7	Sarayuthpitak et al. [39]	2011	Thailand, schools	17.05	Male	40	Not mentioned	RCT	Self-reported biochemical (urinary cotinine) point prevalence abstinence or continuous abstinence rate not mentioned	6	Post-test	Usual care (information on smoking cessation)	Smoking cessation program	Yes	At the post-test, the quit rate in the intervention group (60.0%, 16/20) was significantly higher than that in the control group (10.0%, 2/20)	S

No.	Study	Year	Intervention type	Theory	Intervention delivery and training provided	Description
1	Abdul Halim et al. [33]	2022	FSSCP	Social cognitive theory	Teachers, buddies, and trained school counselors received smoking cessation training from an expert counselor at the National Cancer Society of Malaysia. The training focused on program planning and the use of the FSSCP module. Group-based sessions delivered.	The FSSCP is a school-based, multi-component intervention designed to assist adolescents in quitting smoking conventional cigarettes. The intervention included 4 key components: (1) counseling based on social cognitive theory, (2) peer influence through a buddy system, (3) community involvement, and (4) implementation of a tobacco-free school policy. Each session lasts 45 to 60 minutes, focusing on motivation, social support, and maintaining smoke-free conditions.
2	Chansatitporn et al. [34]	2016	Project EX: smoking cessation program	Social cognitive theory	Through group-based sessions, the Thai public health research team trained teachers at Mahidol University on the history of teen tobacco cessation, recruitment, data collection, and curriculum delivery.	Project EX is a comprehensive smoking cessation program tailored explicitly for Thai adolescents. It involves 8 sessions, each lasting 40 to 45 minutes, focusing on motivational factors, personal skills, and coping strategies to help teens quit smoking. The program includes activities such as talk shows, alternative medicine techniques (like yoga and meditation), competitive games, and homework assignments to reinforce the quit attempt.
3	Chulasai et al. [35]	2022	A smartphone application named “Quit with US”	Self-efficacy theory and 5A’s model	Pharmacists did not receive any training. Face-to-face individual session.	The “Quit with US” intervention involved a smartphone application designed to assist young adult smokers in quitting smoking. Participants in the intervention group received smoking cessation counseling from pharmacists at baseline and follow-ups, along with guidance to use the Quit with US app daily for 12 weeks, lasting between 15 and 30 minutes. The app provided self-instructional materials, including illustrations and texts, to support smoking cessation efforts. Participants were encouraged to log their progress and engage with the app to enhance their chances of achieving smoking abstinence.
4	Ismail et al. [36]	2010	Group counseling: Smoking cessation package	Cognitive-behavioral strategies	School counselors received training to implement the smoking cessation package module from psychologists, health promotion experts, educators, and clinical psychiatrists, who collaborated to develop the program. Group-based counseling sessions were provided.	The intervention consisted of a structured “Stop Smoking Module” in group counseling sessions conducted weekly for 10 weeks, each lasting 1.5 to 2 hours. The intervention focuses on various aspects of smoking cessation, such as preparation to stop smoking, decision-making, managing withdrawal symptoms, and maintaining cessation status. The program employed diverse strategies like discussions, handouts, video presentations, puzzles, games, and homework to engage participants and provide them with the necessary knowledge and skills to quit smoking.
5	Junnual et al. [37]	2019	Information-Motivation-Behavioral-Stages of Change Smoking Cessation Program	Self-efficacy theory, information-motivation-behavioral skills model, and stages of change model	Researchers from public health have yet to receive any training. Group-based counseling and face-to-face sessions were provided.	The program employed a group-based counseling program designed to help male high school students quit smoking through a structured 12-week intervention. It combines the information-motivation-behavioral skills model and the stages of change model to enhance self-esteem, attitudes toward smoking, perceived control over tobacco, and reduced smoking behavior. The program included 6 main activities: introduction and motivation, self-esteem building, alternative solutions, counseling, experience sharing, and willpower enhancement.
6	De Silva et al. [38]	2016	Brief advice	Trans-theoretical model	Medical officers did not receive any training. Individual face-to-face sessions were provided.	Participants in the intervention group received 1-time brief advice during a face-to-face individual session focused on smoking cessation. This advice aimed to enhance their motivation to quit smoking.
7	Sarayuthpitak et al. [39]	2011	Smoking cessation program	Trans-theoretical model of health behavior change, Protection motivation theory, and Theory of reasoned action	Researchers from sports science. The researchers did not receive any training—group-based and face-to-face sessions were provided.	The smoking cessation intervention was a structured program designed to assist adolescents in quitting smoking through a combination of educational, behavioral, and social support strategies over 6 weeks. Each session lasted 30 minutes, and both group and individual sessions were used. It included 10 activities to improve knowledge, attitudes, and behaviors about smoking. Key components were health assessments, personalized messages, goal-setting contracts, smoke-free parties, self-help manuals, cessation counseling, buddy support, social networks, web resources, and relaxation techniques.