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Bulletin 7 August 2008
School-based smoking prevention: popular peers can help
A UK study successfully harnessed respected peers to prevent smoking, but not through classroom activities. Instead the 12–13-year-olds simply exerted their influence in normal social interactions with same-age school mates. 
Findings 
223 Welsh and English secondary schools were approached in 2001. About half were prepared to consider participating in the featured study. Of these, 59 were randomly sampled and agreed to participate. They were randomly selected to continue with their normal smoking education (the control schools) or additionally to host the ‘ASSIST’ intervention. 
To prepare for this, participating year 8 pupils (12–13 years old) nominated year-mates they respected or who were good leaders. In ASSIST schools only, the research project’s trainers asked roughly the top 1 in 6 most nominated pupils to act as ‘peer supporters’, excluding only smokers who were unwilling to try to stop, or those about whom the school had serious concerns. Few were excluded for these reasons. Nearly all the chosen pupils completed two days of out-of-school training with health promotion staff and youth workers.
Through interactive learning methods such as role play and discussion, the training aimed to equip the 835 peer supporters with the confidence, social skills and knowledge to talk informally with their peers about the effects of smoking and the benefits of not smoking. They were asked to do this for 10 weeks and to keep a log of their conversations, supported by four follow-up visits from the health promotion trainers.
In each set of schools well over 5000 pupils completed questionnaires about their smoking before and after the intervention and then about one and two years later. At first few (6%) admitted smoking in the past week, growing to 20% by the final follow-up. After adjusting (among other things) for starting levels of smoking, at the one- and two-year points ASSIST schools had about a fifth fewer pupils who had smoked in the past week. At two years the unadjusted percentages of past-week smokers were about 19% in ASSIST schools and 22% in control schools. Apart from (at least at one-year) a minimal impact among the few regular weekly smokers, the intervention was about as effective with pupils who had and had not smoked, with boys and girls, and regardless of whether the pupil had been a peer supporter. However, its impact faded slightly over the follow-up period, and was much greater in schools serving the small communities of the south Wales valleys than in towns and cities, where it failed to achieve a statistically significant impact.
In Context 
Related studies
The innovation in the featured study was to harness peer influence outside the classroom. Other studies have instead paired peer leaders with the pupils who nominated them (so-called ‘network’ method) in small-group, classroom-based substance misuse prevention activities devised and overseen by adult educationalists. Typically these US studies favoured the network option over whole class teaching or randomly selected groups, but sometimes not to a statistically significant degree, and with important exceptions.
In one study of 16-year-olds excluded from mainstream schools, the network method curbed growth in cannabis and cocaine use and smoking and drinking more effectively than the same curriculum delivered by health educators to whole classes. The exception was the minority of pupils who used substances most frequently, who tended to choose like-minded friends and leaders. Here the network option seemed counterproductive. Another study of 11–12-year-olds in mainstream schools found the network method retarded growth in smoking more effectively than whole-class lessons from teachers or peer educators chosen by teachers. 
In a third study of the same age group, both the network method and groups/leaders chosen by the teacher led to fewer pupils starting to smoke than a hybrid method which let the pupils choose group leaders, but then paired them with randomly selected pupils rather than with the pupils who had nominated them. However, this differential was noticeable only in one of the two curricula tested in the study, one devised to reflect the cultural heritage of the largely Hispanic pupils. 
Similar variations may partly lie behind the findings of a meta-analysis which combined relevant studies. This concluded that peer-led school-based substance use prevention had a slightly better record than adult-led programmes, but also that the advantage is inconsistent, apparent in some circumstances but not in others.
In contrast to most studies, in the featured study pupils could exercise judgement over who to approach, how and when, rather than teachers mandating who they interacted with (even if on the basis of their own friendship networks) and the programme they used. As might be expected of these socially advanced youngsters, they appear to have used this discretion to good effect. Feedback suggested they found it easier and thought it would be more profitable to talk to friends and to pupils who were not yet regular smokers. Their activity levels tailed off over the 10 weeks, partly because they risked repeating the message to the same circle of contacts. For this reason, continuous intervention for more than a few weeks seems unrealistic, but, as the authors comment, impacts might have been greater had the intervention been implemented each year in each school grade. 
Inevitably several features of the study and of its findings raise questions about whether the approach would work as well elsewhere. First, schools self-selected in to the study on the basis of their willingness to participate in the research. In particular, they were generally prepared to go along with their pupils’ choices of peer leaders (thought important to their credibility) and to release these pupils for training, even when the teachers had misgivings about the choices made. On the other hand, while the schools did have to cooperate in these and other ways, their staff were not directly involved in delivering the intervention. 
Secondly, impacts may be dependent on the socialisation patterns of the youngsters. The greater impact in the Welsh valleys was not due to their relative deprivation. Instead it seems likely that in these circumscribed, stable communities, pupils were in contact not just at school but on the way there and back and during leisure time. Influential pupils at school may also have been influential out of school where smoking occurs. 
The intervention benefited from external trainers and external venues. This and the nomination procedure makes it unlikely that peer leaders will be seen as having been co-opted by the school, an image unlikely to appeal to the youngsters most likely to flout adult convention by smoking. However, external help comes at a cost. Overall the intervention cost £4700 per school, a figure which would be slightly lower if local trainers were available. 
It is not unusual for preventive interventions to curb smoking but not (or not as much) other forms of substance use, making it unsafe to assume that similar methods would work in respect of drinking and illegal drug use. Unlike most other common forms of substance use, the health case against smoking is overwhelming and there is little countervailing ‘benefit’ in terms of desired psychoactive effects, other than those consequent on regular smoking itself. 
Though rarely resorted to, it seems wise to have retained a veto over peer leaders who were committed to smoking or over whom the school had serious concerns. The potential for substance using pupils to reinforce each other was apparent in one school study which used the network method. In this and other studies, socially advanced teenagers likely to be chosen by their peers (socially, competent, confident and popular) have also tended to be advanced in their experimentation with substance use.     
Practice Implications
Given the potential for counterproductive impacts, if the featured study’s method is tried some monitoring of outcomes would be advisable. It does have the great advantage of not occupying classroom teaching time, always in short supply. This means such initiatives can (as in the study) supplement rather than displace classroom drug education and leave this (as some teachers argue should be the case) to focus on education rather than prevention, but at the cost of funding external staff and venues. Such work could however be incorporated within existing youth work projects, reducing the costs, and usefully placing these projects in contact with the most influential youngsters in their areas. If the featured study’s methodology is followed, unless this can be arranged for school holidays or weekends, schools will have to be prepared to release about 15% of their pupils for the training (thought to be the ‘critical mass’) and to trust the pupils as a whole to take the lead in selecting who is trained.