Reduction of smoking rates among teenagers can be achieved by training more influential students in secondary schools to promote anti-smoking messages in everyday conversations with their friends and peers, according to an article released on May 9, 2008 in The Lancet.

A young person's smoking habits are strongly associated with the behaviors their friends perform and usually, this is attributed to peer pressure. However, evidence suggests that peer selection, in which young people tend to choose to associate with like-minded people who engage in similar behaviors to themselves, is also a cause. Peer influence itself is not solely destructive, and can be protective, leading to efforts to harness its positive effects through peer education.

To this end, Professor Rona Campbell, University of Bristol, UK, and Professor Laurence Moore, Cardiff University, UK, and colleagues performed A Stop Smoking in Schools Trial (ASSIST). The goals of ASSIST were to spread and sustain new standards of non-smoking behavior in students between 12 and 13 years old. Taking place in 59 schools across western England and Wales, it examined almost 11,000 students in this group. Of these, 29 schools, encompassing 5,372 students, were randomly assigned to the control group, and continued their normal education related to smoking. The other 30 schools, with a total of 5,358 students, were assigned to receive the ASSIST training program in addition to their normal education.

Follow up data were collected at three points: immediately after the intervention, and after one and two years. The outcomes measured were the instances of smoking in the previous week, specifically in the school graduation year group and in a separate group of student identified at the start of the study as occasional, experimental, or ex-smokers and therefore at high risk of becoming regular smokers. Saliva samples were analyzed and self reporting was also used to determine whether the young person had participated in smoking.

The ASSIST training program itself took place in several phases. First, young people nominated influential students in their year of school, and the most prevalent nominees were invited to attend a recruitment meeting. At this meeting, the role of a peer supporter was described, and both their consent and their parents' consent was requested. Smokers were told that they could train to be peer supporters under the condition that they sought to give up smoking themselves. The training event lasted two days, was held outside of school, and used external trainers. In it, peer supporters were educated about the risks of smoking, economic benefits they might have if they stopped, communication skills, group work, negotiation, conflict resolution, sensitivity to others, personal values, and factors for building confidence and self esteem.

Four subsequent school-based sessions were further performed to additionally support their education through the study. In the ten week period following training, peer supporters were asked to have conversations with other students in their graduation year group about the various benefits of abstaining from smoking. These conversations, combined with their complimentary behavior, was meant to encourage other young people not to smoke and therefore reduce smoking uptake.

Students in the intervention group were 25% less likely to take up regular smoking than those in the control group in the initial period, after ASSIST intervention had been run in their school. They were 23% less likely to start regular smoking after one year and 15% less likely after two years. The high risk group, profiled separately, showed similar trends, and were 21% less likely to start immediately, 23% less likely to start after one year, and 15% less likely after two years. Overall, modeling the data from all follow-ups, students in the intervention group had a 22% reduced chance of becoming smokers than the control group.

On the basis of this data, which encompassed two years, it is estimated that, if implemented, it could result in a 3% difference in smoking prevalence in the 14-15 year age group. If implemented through the entire UK, the researchers esimate that the reduction in 14-15 year old students taking up smoking could be about 43,000 each year.

The authors say that this is a promising result for this approach of smoking prevention: "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 2 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%), 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." Then, they highlight that by preventing smoking, many of the diseases caused by smoking are also avoided. Combined with the trend that middle-class people are more successful at quitting than poorer people, they conclude: "Therefore, increasing resources to prevention in adolescence rather than entirely focusing on cessation could to help to avoid further widening health inequalities."

Dr Robin Mermelstein, Institute for Health Research and Policy, University of Illinois at Chicago, IL, USA, contributed an accompanying comment in which she says that the progressive weakening of ASSIST over time argues for some modifications to the system, including a yearly renomination of peer supporters. Additionally, she notes the need to focus on smoking cessation, and on other factors that could influence youth smoking in addition to peer influence.

An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial
R Campbell, F Starkey, J Holliday, S Audrey, M Bloor, N Parry-Langdon, R Hughes, L Moore
Lancet 2008; 371: 1595-1602
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Anna Sophia McKenney

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