Web-Based Smoking Prevention among Adolescents

Background and Significance

Schools offer the most convenient avenue to deliver tobacco prevention/cessation programs for children and adolescents. The evidence about their efficacy in preventing/stopping tobacco use is mixed.  2013 Cochrane review - no overall effect of preventive programs, at one year or less, except for those combining social competence and social influences interventions. Face-to-face school-based programs encounter multiple challenges (recruitment, compliance, commitment. Computer/web based interventions (WBI) can reach a large proportion of young people, offer relative anonymity, enable tailoring of information at individual level and have a high cost-effectiveness ratio. 


The objective of the study was to measure the short-term effects of ASPIRA, the translated and adapted computer-assisted, web-based smoking prevention curriculum, on smoking behavior of ninth grade Romanian and Hungarian students in Tîrgu Mureş, Romania.


Study design

- The study was designed as a cluster randomized parallel trial and the  randomization was done at the school level in order to minimize contamination.
- The ethical approval was obtained from the Board of the University of Medicine and Pharmacy of Tirgu Mures and an active written consent was obtained from all the parents before randomization.
- The sampling frame included all the 16 high schools in Tirgu Mures. 
- 3 classes from one of the schools declined participation for organizational reasons. 
- Schools were allocated in equal numbers to the intervention and control group. 
- The analytical sample included 1369 students (675 in the intervention vs 694 in the control group). The retention rate was 69% in the intervention group and 72% in the control group.


The measurements included:
- socio-demographic data (age, sex, ethnicity, academic achievement)
- social influence factors (ex. Perceived peer smoking) and psychosocial factors (sensation seeking, depressive symptoms, decisional balance scale) and the 
- primary outcomes
1. ever trying smoking (Q and A)
2. last 30 days smoking (Q and A)

Data collection was done using an online questionnaire,  in the computer lab during one teaching hour under the supervision of trained field assistants unknown to the participants.
Students in both conditions completed the baseline questionnaire in November 2014 (one week before intervention) and the follow-up questionnaire in May 2015 (six months after baseline, five months from the completion of the intervention). 

Intervention description

The intervention consisted of the ASPIRA- the translated and adapted version of ASPIRE online curriculum. 
The original ASPIRE was developed by a team lead by Alexander Prokhorov, at the MD Anderson Cancer Center and The University of Texas Health Science Center in Houston.

The ASPIRE curriculum is based on SCT and the TTM.
The curriculum includes 
- videos, 
- animations, and 
- interactive activities like quizzes and games.
The curriculum is structured in five learning modules and covers the basics of smoking prevention and cessation: 
- individual and social determinants of smoking
- health and financial consequences of smoking
- nicotine addiction
- the impact of smoking on the environment
- strategies to resist smoking, dealing with stress, peer pressure, social temptations, mood changes. 

The ASPIRE program adaptation was done in  consultations with Romanian and Hungarian specialists, the team who developed the original ASPIRE, and incorporated the feedback received through a formal pilot study from prospective participants.
Adaptations included not only the program interface, menu labels, text subtitles, and audio tracks translation but also localization of statistics, culturally specific messages and symbols (for instance: any refferences to the American baseball were replaced with the more familiar soccer game).

The students in the intervention group received five weekly sessions of ASPIRA during Nov-Dec 2014 and one ‘‘booster’’ session in May 2015, in the computer lab.
Each session: 45 - 50 minutes. 
Field assistants provided the students with general guidance at the beginning of each session and offered individual help at request during the sessions. 
Students were provided with headphones.

Statistical analyses

We applied logistic regression models to compare the odds of smoking experimentation and current cigarette use in the intervention vs. control group. 
All analyses were performed controlling for the design effect due to cluster sampling by using complex sample analyses in SPSS 21.0.


The average age of the students at baseline was 14.9 years, more than half were females, and approximately half were Romanians. Also, 48% of the students in the baseline sample had ever tried smoking and 21% were current smokers. 
Although there were some differences in the characteristics of the control vs intervention group at baseline, (ex. more females than males, more ever smokers than never smokers) the differences were no longer statistically significant after controlling for cluster effect. 

The analyses of primary outcomes at the follow-up evaluation showed that 
- the percentage of students who ever initiated smoking during the trial was smaller in the intervention group than in the control group (14% vs 20%). The OR indicated that (never smoker) students in the intervention group were 35% less likely to report smoking initiation six months after the baseline assessment (OR=0.65, 95%CI: 0.44-0.97).
- the “raw” percentage of current smokers among students in the intervention group was also smaller than in the control group (10% vs 17%), but the analysis was unable to detect a statistically significant effect on current smoking because of insufficient statistical power.


Our results are generally in line with those reported by author authors. Thus, 
- Prokhorov et al (2008), who measured the effects of the original ASPIRE, in the US, reported significantly lower smoking initiation rates at 18-month follow-up.
- Buller et al (2008) who implemented another computer assisted program called “Consider this” in USA & Australia, reported significant reduction in last 30 days cigarette smoking but only in the Australian adolescents using the program.
- The authors of “Smoke Alert”, in Netherlands, reported significantly reduced smoking initiation but only in the 14-16 year age group.
There are several limitations to consider in interpreting the results of this study:
- Measurements were based on self-reported data. 
- The lower level of program exposure probably limited the curriculum's effect on the respective students.
- Although the attrition rates were acceptable and of equal size in the intervention and control group, they resulted in a lower than optimal sample size and statistical power.


The ASPIRA prevention program had a significant impact on smoking experimentation and current use among adolescents in Romania. 
Despite the limitations of the current study, our findings suggest that the dissemination of the ASPIRA program in Eastern Europe could prevent smoking initiation in adolescents.


Project director

Valentin Nădășan (University of Medicine and Pharmacy Tirgu Mures, Romania)

Team members

Zoltán Ábrám (University of Medicine and Pharmacy Tirgu Mures, Romania), Iosif Bálint  (University of Medicine and Pharmacy Tirgu Mures, Romania), Monika Csibi (University of Medicine and Pharmacy Tirgu Mures, Romania), Stefan Mihaicuta (University of Medicine and Pharmacy Timisoara).


Kristie Foley (Davidson College - NC, USA), Douglas Easterling (Wake Forest Medical School - NC, USA), John Spangler (Wake Forest Medical School - NC, USA), Todd Rogers (Public Health Institute - CA, USA), Robert Urbán (ELTE University - Budapest, Hungary), Melinda Pénzes (Semmelweis University - Budapest, Hungary), Péter Balázs (Semmelweis University - Budapest, Hungary)

IT team

Emil Goicovici, Beniamin Ganea  and Valentin Nădășan



Alexander V. Prokhorov and all his team at MD Anderson Cancer Center - Houston, TX, USA

Florin Mihălțan and Ioana Munteanu (Institutul de Pneumoftiziologie "Marius Nasta", Bucuresti, România)

Antigona Carmen Trofor (University of Medicine and Pharmacy Grigore T. Popa - Iasi, Romania)

Oana Maria Pop (Center for Health Policy and Public Health, Faculty of Political, Administrative and Communication Sciences, Babeș-Bolyai University Cluj-Napoca, Romania)

Felicia-Stela Ionescu (Casa Corpului Didactic, Tirgu Mureș, Romania)

Special thanks to Tudor Gliga, Ovidiu Atanasiu, Andreea Morariu, Otto Konrad Kiss and Rodica Kiss for their valuable contribution to the audio recordings of the Romanian and Hungarian scripts.



Mureș County School Inspectorate (Inspectoratul Școlar Județean Mureș) - Prof. Ștefan Someșan (To see the colaboration protocol as a PDF file, in Romanian language, click here.)

Mureș County Teachers' Training Centre (Casa Corpului Didactic Mureș) - Prof. Mariela-Mariana Corneanu

Mureș County School Students' Union (Consiliul Județean al Elevilor) - Răzvan Azamfirei



1. Nădăşan V, Ferencz L, Ábrám Z, Foley K. Predictors of High Program Exposure Among Adolescents Participating in a Smoking Prevention Intervention in Romania. Tob Use Insights. 2019. DOI 10.1177/1179173X19845337.

2. Pénzes M, Foley KL, Nădășan V*, Paulik E, Ábrám Z, Urbán R. Bidirectional associations of e-cigarette, conventional cigarette and waterpipe experimentation among adolescents: A cross-lagged model. Addict Behav. 2018;80:59-64.

3. Nădăşan V, Foley KL, Pénzes M, Paulik E, Mihăicuţă Ş, Ábrám Z, Bálint J, Urbán R. Use of electronic cigarettes and alternative tobacco products among Romanian adolescents. Int J Public Health. 2016 Mar;61(2):199-207. doi: 10.1007/s00038-015-0774-8.

4.  Ábrám Z, Nădășan V, Bálint J, Ferencz L. Translation and Adaptation of Computer Assisted Smoking Prevention Program in Romania (ASPIRA). Acta Medica Transilvanica, 2015;20(3):14-16.

5. Nădășan V, Foley K, Ábrám Z, Mihăicuță Ș, Bálint J, Csibi M, Pénzes M, Paulik E, Urban R. The short term effects of ASPIRA – a computer-assisted smoking prevention program for adolescents in Tirgu Mures, Romania: A cluster randomized parallel group prevention trial. Oral presentation. SRNT Europe 2016 Conference, Prague.

6. Nădășan V, Mihăicuță Ș, Bálint J, Csibi M, Ábrám Z. Short term effects of a school-based computer assisted intervention for smoking prevention among adolescents in Tirgu Mures, Transylvania, Romania. Poster presentation. American Thoracic Society 2016 International Conference, May 13-18, 2016 - San Francisco. 

7. Nadasan V, Foley K, Pénzes M, Paulik E, Mihaicuta S, Ábrám Z, Bálint J, Urbán R. Predictors of electronic cigarette and alternative tobacco product experimentation among Romanian adolescents. Poster presentation. 2016 SRNT 22nd Annual Meeting, March 2-5, 2016, Chicago, USA.

8. Nădășan V, Golea C, Bálint J, Ferencz L, Mihăicuță S, Ábrám Z. Electronic cigarettes and other alternatives to smoking among high school students in a Transylvanian city. Oral presentation. 6th National Tobaccology Conference, 28-30 May 2015, Tirgu Mures, Romania.

9. Nădășan V, Mihăicuță Ș, Bálint J, Csibi M, Ábrám Z. Relationship of exposure to pro- and anti-smoking messages with smoking behavior among high school students in Tirgu Mures, Romania. Oral presentation. The University of Medicine and Pharmacy Scientific Session, 7-11 December 2015. Tirgu Mures, Romania. 

10. Ábrám Z, Bálint J, Csibi M, Mihăicuță Ș, Nădășan V. Personal influences on smoking habits of Romanian adolescents. Oral presentation. The University of Medicine and Pharmacy Scientific Session, 7-11 December 2015. Tirgu Mures, Romania.

11. Bálint J, Nădășan V, Csibi M, Ábrám Z. Reasons in favor and against smoking among 9th-grade students in Tirgu Mures, Romania. Oral presentation. The University of Medicine and Pharmacy Scientific Session, 7-11 December 2015. Tirgu Mures, Romania. 

12. Csibi M, Ábrám Z, Nădășan V, Csibi S. Differences in the sensation-seeking and depressive symptoms related to high school students' smoking status. Oral presentation. The University of Medicine and Pharmacy Scientific Session, 7-11 December 2015. Tirgu Mures, Romania. 

13. Nădășan V, Bálint J, Ferencz L, Finta H, Azamfirei R, György I, Ábrám Z. Users' perception of language and cultural barriers in a translated computer assisted smoking prevention program. Oral presentation. The University of Medicine and Pharmacy Scientific Session, 8-12 December 2014. Tirgu Mures, Romania. 

14. Ábrám Z, Nădăşan V, Bálint J, Ferencz L, Azamfirei R, Pénzes M, Urbán R. Adaptation of Aspira Online Program and its Pilot Study. Oral presentation. The University of Medicine and Pharmacy Scientific Session, 8-12 December 2014. Tirgu Mures, Romania. 


Publications In Press

Ábrám Z. [Az ASPIRA számítógépes dohányzásmegelőzési program adaptációja, alkalmazása és hatékonysága]. Book chapter, University of Sapientia.

Ábrám Z, Bálint J, Csibi M, Nădăşan V. Számítógépes dohányzásprevenciós program marosvásárhelyi alkalmazása [Application of online smoking prevention program in Tirgu-Mures]. Egészségtudomány.


Last update: 25.06.2019