Stopping smoking in schools

May 8 2008

Smoking rates among teenagers can be reduced by training influential students within secondary schools to promote anti-smoking messages in their everyday conversations with their friends and peer group. This is the conclusion of authors of an article in this week's edition of The Lancet.

Whether or not a young person smokes is strongly associated with their friends' smoking behaviour. Peer pressure is often used to explain this finding, although evidence suggests that peer selection, whereby young people choose to associate with like-minded people engaging in similar behaviours, is also a cause. However, peer influence can be protective, leading to attempts to harness it to positive effect through peer education.

Professor Rona Campbell of the University of Bristol and Professor Laurence Moore of Cardiff University, and colleagues did the ASSIST (A Stop Smoking in Schools Trial) study in 59 schools across western England and Wales.

ASSIST aimed to spread and sustain new norms of non-smoking behaviour amongst students aged 12-13 years (UK year 8 children). The study involved nearly 11,000 students aged 12-13 years across the 59 schools. Of these, 29 schools (5,372 students) were randomly assigned to the control group, and continued their normal smoking education, and 30 schools (5,358 students) were assigned to receive the ASSIST training programme (intervention group) in addition to their normal education.

Follow-up data were collected immediately after the intervention and after one and two years. The outcomes examined by the research team were smoking in the past week in both the school year group, and in a group of students identified at baseline as occasional, experimental or ex-smokers and therefore at high risk of regular smoking uptake. Saliva samples were analysed as well as self-reporting to establish whether the young person had been smoking.

The ASSIST training programme had several phases. Firstly, young people were asked to nominate influential students in their year group, and the most popular nominees were invited to a recruitment meeting. The role of being a peer supporter was explained to them, and their consent was requested to attend a training course, as well as their parents' consent. Those who smoked were told they could train to be peer supporters provided they tried to give up smoking themselves.

At a two-day training event, held outside of school and using external trainers, peer supporters learned about the risks of smoking, economic benefits of stopping, communication skills, group work, negotiation, conflict resolution, sensitivity to others, personal values, and building confidence and self-esteem. They also received further training and support during four school-based sessions. Over a ten-week period following the training, the peer supporters were asked to have conversations with other students in their year group about the benefits of not smoking. Through these conversations and their own behaviour, it was hoped that the peer supporters would encourage other young people not to smoke thus reducing smoking uptake.

The researchers found that students in the intervention group of schools were 25 per cent less likely to take up regular smoking than those in the control group immediately after ASSIST intervention had been run in their school; 23 per cent less likely to start regular smoking after one year and 15 per cent less likely after two years.

The corresponding percentage reductions for the high-risk group were 21 per cent (immediately after), 25 per cent (after one year) and 15 per cent (after two years). Overall, in a statistical model with data from all three follow-ups, students in the intervention group of schools were 22 per cent less likely to be a smoker than those in the control group.

On the basis of the two-year follow up data ASSIST, if implemented, could result in a 3 per cent difference in smoking prevalence among all students in Year 10 (age 14-15 years). If implemented on a UK-wide basis it is estimated that ASSIST could potentially reduce the number of 14-15-year-old school students taking up regular smoking by around 43,000 each year.

The authors say: "Our study has shown that the ASSIST training programme was effective in achievement of a sustained reduction in uptake of regular smoking in adolescents for two years after its delivery. Furthermore, it was well received by both students and staff. Confidence in the robustness of this finding is enhanced by the very high response rates achieved (over 90 per cent), the retention of all schools for the duration of the trial, the diversity of the schools involved, and the concurrence of self-reported smoking data with saliva testing."

They also point out that if smoking prevention is successful, nearly all disease associated with it is avoided; and that middle-class people are more successful at quitting than poorer people. The authors conclude: "Therefore, increasing resources to prevention in adolescence rather than entirely focusing on cessation could to help to avoid further widening health inequalities."

In an accompanying Comment, Dr Robin Mermelstein of the Institute for Health Research and Policy, University of Illinois at Chicago, says that weakening of the effect of ASSIST over time "argues perhaps for a reinstatement of the peer-supporter nomination and training process on a yearly basis." She also discusses the need for focus on smoking cessation, and to consider other social influence factors that could have an equal, if not greater, effect on youth smoking than could peers.

An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial by R Campbell, F Starkey, J Holliday, S Audrey, M Bloor, N Parry-Langdon, R Hughes, L Moore The Lancet Vol 371 May 10, 2008

Our study has shown that the ASSIST training programme was effective in achievement of a sustained reduction in uptake of regular smoking in adolescents for two years after its delivery. Furthermore, it was well received by both students and staff.

Professor Rona Campbell