Journal of Preventive Medicine

Introduction
The prevention against tobacco dependence project (PAD) in Iran, as a collaborative interventional project, focuses on the prevention of tobacco use from childhood to adolescence in Iranian people. This plan has been carried out in four phases (pilot, smoke-free school, smoke-free neighborhood, smoke-free city) in Varamin City [1, 2]. The studies of the first phase have indicated that the use of hookah is more common than cigarettes among seventh grade students, and they use tobacco in public places such as parks, hookah lounges, and coffee lounges. Also, the students considered “satisfying their curiosity” as one of the most important reasons for consumption and admitted that their close friends were cigarette and hookah users. The hookah use is more among students, their close friends and relatives, and it is less indecent than cigarettes, and has become a normal behavior [3]. During the COVID-19 pandemic, online tools were used for education to avoid losing their trained group (PAD helpers). Thus, although the second phase of the POD project faced obstacles, it was carried out with the aim of investigating the students’ awareness of the harms of tobacco products and the effectiveness of new interventional methods. Therefore, the intra-familial, extra-familial, environmental and social factors affecting smoking and tendency to smoking among students with and without receiving PAD education in order to compare the two groups and measure the effectiveness of the PAD project.

Methods
This is a quasi-experimental study that was conducted on 400 students of both sexes, in the seventh to 12th grades in Varamin City, Iran, who were selected using proportional stratified sampling method. The experimental group included students who received education about the harms of tobacco smoking based on the PAD project (PAD helpers). The control group included students who did not receive such education (non-helpers). For the implementation of the project, we visited the selected government schools, semi-government schools, the schools for gifted children, and non-profit schools. A researcher-made questionnaire was used to measure knowledge, attitude, and practice of the two groups using the Likert scale. To evaluate the effectiveness of the PAD-based education, a questionnaire with 57 items was designed in accordance with the World Health Organization (WHO) questionnaire. In the PAD project, education is provided by developing booklets for students and PAD helpers, using Pamphlets introducing the PAD project in schools, using brochures and posters about smoking installed on the walls around the schools, educational videos, holding scientific, cultural and artistic competitions (e.g. wall newspaper contests, painting, etc.), providing consulting services for target groups, recreational and training camps, and holding a festival and honoring the PAD helpers. 

Results
Most of the students were studying in government schools (n=368, 92%), of whom 173(43%) were PAD helpers and 195(48%) were non-helpers. Most of the students were female (n=237, 59%). Most of the students from the PAD group were studying at the 11th grade (64%) while most of the students in the non-PAD group were at the seventh grade (61%). Most of the students were hookah users (36.2% of non-PAD group and 83.3% of the PAD group). The mean score for the knowledge of the harms of tobacco in the PAD (24.41) and non-PAD (21.02) groups showed the significantly higher knowledge of the PAD group (t=10.5, P<0.05). Moreover, the mean score for the attitude variable in the PAD (18.156) and non-PAD (15.752) groups showed the significantly higher attitude of the PAD group (t=7.7, P<0.001). 

Conclusion
The level of knowledge and attitude in the PAD helpers who received training and had anti-tobacco activities during the pandemic are relatively favorable compared to the control group (non-helpers). With higher knowledge of the personal and social harms and of smoking, more negative attitude towards tobacco products can be created in students. The prevalence of hookah use is higher than that of cigarette smoking among students, especially among females. Therefore, it seems necessary to carry out educational interventions for them. It is recommended that, considering the prevalence of the use of other modern tobacco products among the new generation, different awareness-increasing strategies should be used and the educational content related to the tobacco products should be updated systematically.

Ethical Considerations
Compliance with ethical guidelines
This study has received ethical approval from the Ethics Committee of the Research Vice-Chancellor of Tehran University of Medical Sciences (Code: IR.TUMS.DDRI.REC.1398.006).

Funding
This work is funded by the Iranian Anti-Tobacco Association.

Authors' contributions
Conceptualization and validation: Mojtabi Hemayatkhah; Methodology: Mohammadreza Masjedi; Writing the original draft: Mojtabi Hemayatkhah and Mohammedreza Masjedi; Review and editing: Nahid Shahabi- and Shahin Abbaszadeh.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank Iranian Anti-Tobacco Association as their financial support. The authors would also like to express their gratitude to the participants for their sincere cooperation in this study.



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