Sign Up For Newsletter

A Stop Smoking in Schools Trial (ASSIST)

A peer support program to reduce the uptake of smoking among young adolescents.

Program Outcomes

  • Tobacco

Program Type

  • Peer Counseling and Mediation
  • School - Individual Strategies

Program Setting

  • School

Continuum of Intervention

  • Universal Prevention

Age

  • Early Adolescence (12-14) - Middle School

Gender

  • Both

Race/Ethnicity

  • All

Endorsements

Blueprints: Promising

Program Information Contact

Sally Good
CEO (Acting)
DECIPHer IMPACT Limited
2 Farleigh Court
Old Weston Road
Flax Bourton
Bristol
BS48 1UR
Tel: +44 (0)1275 464779
Mob: +44 (0)7791 692815
www.decipher-impact.com

Program Developer/Owner

Suzanne Audrey
University of Bristol


Brief Description of the Program

A Stop Smoking in Schools Trial (ASSIST) is a smoking prevention intervention based on an informal, educational, peer-led approach. Influential students nominated by their peers are trained by health promotion trainers for two days on the risks of smoking, the benefits of remaining smoke-free, and skills for promoting non-smoking among their peers. The trained students then use informal contacts with peers over a 10-week period to promote non-smoking and keep a diary record of these conversations.

Outcomes

Compared to students in control schools, students in ASSIST schools reported significantly lower

  • regular smoking at the 1-year follow-up

Brief Evaluation Methodology

The evaluation used a clustered randomized controlled design with 59 selected secondary schools randomized to either the ASSIST intervention or a control group that used regular smoking education curricula. The 29 schools assigned to the control group contained 5,562 students and the 30 schools assigned to the intervention group contained 5,481 students. Self-reported smoking at baseline, posttest, 1-year follow-up, and 2-year follow-up served as the outcome, while saliva tests for a smoking by-product validated the smoking measure.

Study 1

Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., Parry-Langdon, N., . . . Moore, L. (2008). An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster randomised trial. The Lancet, 371(9624), 1595-1602.


Risk Factors

Neighborhood/Community: Laws and norms favorable to drug use/crime


* Risk/Protective Factor was significantly impacted by the program

See also: A Stop Smoking in Schools Trial (ASSIST) Logic Model (PDF)

Gender Specific Findings
  • Male
  • Female
Race/Ethnicity/Gender Details
Program effects did not differ for boys and girls, while differences across ethnic groups were not examined.

ASSIST Training Content Overview for Schools

The ASSIST smoking prevention programme follows an alternative model of peer education which, rather than asking young people to deliver classroom-based sessions to their peers, asks them to disseminate information or messages to their peers through informal contacts.

According to the model, behaviour change is encouraged by 'early adopters' who are often influential or well-regarded individuals. With ASSIST, these influential students are identified by their peers through the completion of a simple questionnaire by the whole of Year 8 resulting in 18% of the year group being recruited as peer supporters.

The ASSIST peer supporter training takes place over two consecutive days and is delivered by external trainers in a venue away from the school site. Aside from making the students feel valued, this approach also reduces the burden on schools in terms of staffing and resourcing. The students are supported through four follow-up sessions over an 8-10 week period upon returning to school. Sessions continue to be delivered by external trainers, but on the school site as each one lasts between 45-60 minutes.

The programme builds incrementally, using the three main categories of information, skills and personal development, with peer supporters being asked to distinguish which of these was being developed at the end of each activity. This encourages them to reflect on their learning whilst considering how this new-found knowledge can be used in their peer supporter role.

Starting with a review of the skills and information which the students already possess boosts confidence and allows the group to get to know each other. The students then progress from demonstrating existing skills to acquiring new ones, from listening and observing to decision-making and team negotiation. In the final stages of the programme, the peer supporters are asked to combine both old and new skills in various scenarios so that they can put into practice what they have learned.

Throughout all of the activities, discussion using focused open-ended questioning helps to tease out the reasons why people hold particular views, and trainers provide frequent opportunities for young people to articulate their opinions in the safety of the group to see how they are received. With little emphasis on literacy skills, the programme is very accessible, but also has opportunities for differentiation built in.

Ground rules, games and group dividing activities are used to manage the energy levels and behaviour of the group as well as making the training more engaging. Activities are active or interactive wherever possible.

Day 1 of the training is designed to provide the peer supporters with sufficient information about tobacco and the benefits of remaining smoke free, to enable them to have conversations with their peers using a range of topics. There is an emphasis on facts which are relevant to Year 8 students and the importance of accuracy when passing on information is stressed. This is important because students need to have a bank of correct facts which their friends will find engaging. These include, but are not limited to:

The Media
Health
E-cigarettes/Shisha
The Environment
The Law

There is also input on dispelling common myths about smoking, especially around the link to managing weight, dealing with stress, or having smaller babies. There is time built in to deal with local issues and beliefs that the students present with on the day.

Day 2 uses the information gained on the previous day in activities which are now skills based. There is considerable input around speaking and listening, including non-verbal communication, active listening, effective questioning, and developing the ability to see the bigger picture. Debate is encouraged and facilitated.

Being non-judgemental is an important element of the peer supporter role and the second day also highlights empathy, and interpersonal skills. Trainers understand that peer supporters often have family members who smoke and the benefits of being smoke free has a greater focus than the negatives of smoking, although these are covered.

Making positive and personal choices instead of following the crowd is discussed as a way of encouraging students to think about what influences them. This highlights the impact that they can have on their peers by demonstrating positive behaviour in terms of both their knowledge around smoking and also hopefully, their choice not to smoke. The concept of choice is one which is applicable across most health behaviours and links are made to the pressures faced by young people from external sources. Reasons for choices are explored and the impact of those potential choices discussed.

Opportunities are also provided for the students to gain confidence by practicing the types of conversations that they may have back in school. These conversations are then recorded in their Peer Supporter diaries which are also a useful source of information and can be used as a prompt.

Through both training days there is an emphasis on independent learning and the students are encouraged to see themselves as part of a learning community of peer supporters so that they can support each other during and after the programme.

The four follow-up sessions have the same structure but with different activities. The purpose of these sessions is:

To reinforce the role of peer supporter.
To monitor diaries as a way of highlighting successes and areas where input is required.
To support students and boost their confidence.
To refresh and provide new information.
To practice the skills they have learnt on the training.

Also worth noting is that throughout the training the student/trainer ratio will either be 10:1 or 15:1, and there will always be a minimum of two trainers working with the group.

Anecdotally, ASSIST is well received by schools and the contact teachers who attend the sessions speak very positively of the 'hidden curriculum' elements to the programme, which is far more than just a smoking prevention intervention. The emphasis on speaking and listening and interpersonal skills will benefit the peer supporters across the curriculum long after they have finished the follow-up sessions.

For schools, aside from the potential reduction in the uptake of smoking, they also have a group of peer supporters who, subject to their desire to do so, could use their new skills in other areas.

Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.


No information is available


No information is available

Program Developer/Owner

Suzanne AudreyUniversity of BristolDept. of Social MedicineCanynge Hall, Whiteladies RoadCanynge Hall, Whiteladies RoadBristol BS2 8PSBristol BS2 8PSUKsuzanne.audrey@bristol.ac.uk

Program Outcomes

  • Tobacco

Program Specifics

Program Type

  • Peer Counseling and Mediation
  • School - Individual Strategies

Program Setting

  • School

Continuum of Intervention

  • Universal Prevention

Program Goals

A peer support program to reduce the uptake of smoking among young adolescents.

Population Demographics

ASSIST targets young adolescents in school.

Target Population

Age

  • Early Adolescence (12-14) - Middle School

Gender

  • Both

Gender Specific Findings

  • Male
  • Female

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

Program effects did not differ for boys and girls, while differences across ethnic groups were not examined.

Risk/Protective Factor Domain

  • Individual

Risk/Protective Factors

Risk Factors

Neighborhood/Community: Laws and norms favorable to drug use/crime

Protective Factors


*Risk/Protective Factor was significantly impacted by the program

See also: A Stop Smoking in Schools Trial (ASSIST) Logic Model (PDF)

Brief Description of the Program

A Stop Smoking in Schools Trial (ASSIST) is a smoking prevention intervention based on an informal, educational, peer-led approach. Influential students nominated by their peers are trained by health promotion trainers for two days on the risks of smoking, the benefits of remaining smoke-free, and skills for promoting non-smoking among their peers. The trained students then use informal contacts with peers over a 10-week period to promote non-smoking and keep a diary record of these conversations.

Description of the Program

A Stop Smoking in Schools Trial (ASSIST) is a smoking prevention intervention based on an informal, educational, peer-led approach. Selected influential students are trained for two days to use informal contacts with peers to encourage them not to smoke. They are asked to intervene informally in everyday situations over a 10-week period to promote non-smoking and keep a diary record of these conversations. Students in participating schools are given a brief questionnaire to nominate influential students. The nominated students receive a two-day training delivered by health promotion trainers that aims to: increase knowledge about the health, economic, social, and environmental risks of smoking; emphasize the benefits of remaining smoke-free; and encourage the development of skills to enable the selected "peer supporter" students to promote non-smoking among their peers.

Theoretical Rationale

ASSIST is based on the "diffusion of innovation" model, whereby the diffusion of new behavioral norms through social networks is effected by influential local opinion-formers.

Theoretical Orientation

  • Normative Education

Brief Evaluation Methodology

The evaluation used a clustered randomized controlled design with 59 selected secondary schools randomized to either the ASSIST intervention or a control group that used regular smoking education curricula. The 29 schools assigned to the control group contained 5,562 students and the 30 schools assigned to the intervention group contained 5,481 students. Self-reported smoking at baseline, posttest, 1-year follow-up, and 2-year follow-up served as the outcome, while saliva tests for a smoking by-product validated the smoking measure.

Outcomes (Brief, over all studies)

For all students, the program had a marginally significant effect (p = .058) at posttest, a significant effect at 1-year follow-up (p = .043), and a marginally significant effect at 2-year follow-up (p = .067). Across all three assessments, ASSIST achieved a significant reduction of 22% in the odds of being a regular smoker.

Outcomes

Compared to students in control schools, students in ASSIST schools reported significantly lower

  • regular smoking at the 1-year follow-up

Mediating Effects

Not examined.

Effect Size

The odds ratio of .78 indicates a small effect size.

Generalizability

The evaluation was limited to year 8 (ages 12-13) secondary school students in west England and southeast Wales from urban and rural districts.

Potential Limitations

  • Did not follow all students or impute data for intent-to-treat analysis
  • No formal tests for differential attrition, but data were imputed using a growth model that accounted for missing data

Endorsements

Blueprints: Promising

Program Information Contact

Sally Good
CEO (Acting)
DECIPHer IMPACT Limited
2 Farleigh Court
Old Weston Road
Flax Bourton
Bristol
BS48 1UR
Tel: +44 (0)1275 464779
Mob: +44 (0)7791 692815
www.decipher-impact.com

References

Study 1

Certified Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., Parry-Langdon, N., . . . Moore, L. (2008). An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster randomised trial. The Lancet, 371(9624), 1595-1602.

Starkey, F., Audrey, S., Holliday, J., Moore, L., & Campbell, R. (2009). Identifying influential young people to undertake effective peer-led health promotion: The example of A Stop Smoking In Schools Trial (ASSIST). Health Education Research, 24(6), 977-988.

Starkey, F., Moore, L., Campbell, R., Sidaway, M., & Bloor, M. (2005). Rationale, design and conduct of a comprehensive evaluation of a school-based peer-led anti-smoking intervention in the UK: The ASSIST cluster randomised trial. BMC Public Health, 5(43), 1-10.

Study 1

Campbell et al. (2008) presented the program impact results on smoking that are reported below. Starkey et al. (2005) described the design but did not present results, and Starkey et al. (2009) described the peer nomination process and teacher and student satisfaction with the program but only summarized previous results on smoking impact.

Evaluation Methodology

Design:

Recruitment: Of 223 secondary schools in west England and southeast Wales invited to participate in the study, 127 expressed initial interest, 113 agreed to participate, 66 were randomly selected, and 59 agreed to accept the randomization.

Assignment: The evaluation used stratified block randomization to assign schools to treatment and control conditions. The 29 schools randomly assigned to the control group, which continued the usual smoking education and policies, contained 5,562 students, and the 30 schools assigned to the intervention group contained 5,481 students. Two schools withdrew after randomization, one from the control group and one from the intervention group. These schools were replaced by two schools from the same strata in the list of 113 interested schools, which were then "randomly allocated to treatment group as a block of size two." The cluster design added new students entering the intervention and control schools and excluded students leaving the schools.

Attrition: Students were assessed at baseline, posttest (about 4 months later), 1-year follow-up, and 2-year follow-up. According to the CONSORT diagram in Figure 1, the percentage of eligible students analyzed was 92-95% at baseline, 89-95% at posttest, 92-95% at the 1-year follow-up, and 89-94% at the 2-year follow-up. However, the count of eligible students excludes those leaving the schools and adds new students entering the schools.

Loss of subjects came from students lacking parental consent, leaving the study, or moving from an intervention or control school. Two schools closed, but most of the subjects (95%) in the schools moved to a participating intervention school or control school, and remained in the study.

Sample: The sample appears diverse. About 44% of the sample schools had 20% or more students eligible for free school lunches. The family affluence scale was distributed normally, with a mix of low (25%), medium (55%), and high (20%) scores. A majority of the families (53%) had two or more cars. About 6% of the students reported being weekly smokers at baseline.

Measures: The primary outcome measure was self-reported smoking prevalence over the past week. The study distinguished regular smokers from occasional, experimental, or ex-smokers, who were considered at high risk for future regular smoking. The outcome measure was validated by saliva samples measuring cotinine, a metabolite of nicotine and a biomarker of smoke exposure in the previous two to three days. The saliva samples were obtained for all students at baseline and 1-year follow-up and for 24 schools (39% of the sample) at 2-year follow-up.

Analysis: The separate analysis of outcomes at each wave calculated odds ratios and confidence intervals with adjustment for design effects and clustering. The combined analysis of all waves used random effects logistic regression models with school as a random effect and covariates for baseline smoking and the five school-level stratifying variables. The three-level model treated schools at level 3, students at level 2, and repeated follow-up measurements at level 1.

Intent-to-Treat: The study used all available data but dropped randomized subjects who left the schools. The repeated-measures multilevel design allowed the inclusion of individuals with missing data for some of the assessments.

Outcomes

Implementation Fidelity: A survey of students identified influential peers, and the 17.5% of students in the intervention schools with the most nominations were invited to participate as peer supporters. Of the 5,358 nominated students, 835 (16%) completed the training and agreed to work as peer supporters, achieving the prespecified target. Of the students trained, 99% continued to work as peer supporters, and 84% handed in a completed diary at the end of the intervention period. Of possible relevance, the program worked no better for the peer supporters than regular students.

Baseline Equivalence: Figures for schools and students (Table 1) showed no large differences but did not list significance tests. The text notes that more students in control schools (7%) reported smoking every week than did those in intervention schools (5%).

Differential Attrition: The study provided no tests.

Posttest and Long-Term: For all students, the adjusted odds ratios (Table 3) indicate a marginally significant effect (p = .058) at posttest, a significant effect at 1-year follow-up (p = .043), and a marginally significant effect at 2-year follow-up (p = .067). The overall odds ratio across all waves of .78 indicates a small effect size.

For the subsample of students who were occasional, experimental, or ex-smokers at baseline, the adjusted odds ratios were insignificant at posttest, significant at 1-year follow-up, and marginally significant at 2-year follow-up.

Subgroup analyses provided no evidence of the intervention having a differential effect by sex, peer supporter status, or free school meal entitlement. However, the intervention had a "more pronounced effect in schools located in south Wales valleys."

The concentration of salivary cotinine measured at the 1-year and 2-year follow-ups indicated that only 1-3% of students had high levels but reported not smoking in the survey. There was almost no difference in incorrect reporting between intervention and control schools.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

Sign up for Newsletter

If you are interested in staying connected with the work conducted by Blueprints, please share your email to receive quarterly updates.

Blueprints for Healthy Youth Development is
currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.