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A Stop Smoking in Schools Trial (ASSIST)

Evidence level:
Best PracticePromising PracticeEmergent Practice
 
Evidence of Effectiveness:
?-0+++
Transferability:
?-0+
Enduring Impact:
?-0+
Review criteria and process

Recommendation Pillars

Improve the responsiveness of health systems to address the needs of disadvantaged children

Countries that have implemented practice

United Kingdom

Age Groups

Teenagers (age 13 to 19), Middle Childhood (age 6 to 12)

Target Groups

Children

Years in Operation

2001  - still operating

Type of Organization Implementing Practice

City or Town Government

Practice Overview

A Stop Smoking in School Trial (ASSIST) is an intervention aimed at spreading and sustaining non-smoking behaviours through school social networks that targets children in grade 8 (12-13 years old).  The phases of the intervention include: 1) nomination of peer supporters, 2) recruitment of peer supporters,3) training of peer supporters, 4) intervention period, and 5) acknowledgement of peer supporters’ contributions. Potential peer supporters are first identified as students who received the most nominations on a questionnaire in which students identify influential peers. The 2-day training is conducted outside of school and focuses on teaching peer supporters how to have informal conversations with their peers about smoking. During the 10-week intervention period, peer supporters undertake informal conversations with other students about smoking and log their conversations. During the intervention, trainers provide additional support through four in-school visits. ASSIST was first pilot tested in 1996 in six schools in South Wales. Early Adopters started rolling out the programme in 2007 and in 2010, DECIPHer Impact Ltd, a non-profit spinout company was set up by the University of Bristol and Cardiff University to distribute ASSIST more widely. It is currently being implemented in 27 Local Authority areas across the United Kingdom including the whole of Wales, England and the Channel Islands. Scotland has recently announced that they are going to be setting up a pilot of ASSIST starting in 2014.

Transferability

ASSIST has not been evaluated in any additional population since the Campbell et al. (2008) study.

As noted in Holliday, Audrey, Moore, Parry-Langdon, & Campbell (2009), the ASSIST program includes documentation and guidelines for training peer supporters. In order to inform future implementation, Holliday et al. (2009) also identified variations in implementation that are acceptable and avoidable, acceptable and unavoidable, unacceptable and avoidable, and unacceptable and unavoidable, information which could guide future implementation of the programme.

Evidence of Effectiveness

Evaluation 1

Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., Parry-Langdon, N., Hughes, R., & 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.

This study examined the impact of ASSIST in 59 schools in West England and Southeast Wales. The intervention was implemented among year 8 students (ages 12-13). Outcomes measured included the prevalence of smoking in the last week for all year 8 students in the school and the prevalence of smoking in the last week for the sub-group of year 8 students who were “high-risk” smokers (i.e., occasional, experimental, or ex-smokers).

Summary of Results for Evaluation 1

Outcome

Results

Outcomes improved (statistically significant)

 

 

Prevalence of smoking in the last week for all students

 

Immediately after intervention

The odds that students in the treatment group would be a smoker was .75 lower than students in the control group

1-year follow-up

The odds that students in the treatment group would be a smoker was .77 lower than students in the control group

2-year follow-up

The odds that students in the treatment group would be a smoker was .85 lower than students in the control group

Prevalence of smoking in the last week for sub-group of occasional, experimental, or ex-smokers

1-year follow-up

The odds that students in the treatment group would be a smoker was .75 lower than students in the control group

2-year follow-up

The odds that students in the treatment group would be a smoker was .85 lower than students in the control group

Outcomes with no effect

 

Prevalence of smoking in the last week for occasional, experimental, or ex-smokers

Immediately after intervention

The odds that students in the treatment group would be a smoker were not significantly different from students in the control group.

 

 

Issue to consider

ASSIST received a “Promising” rating.  Schools were randomized to treatment and control groups, however, baseline differences between these two groups persisted. The study authors found no significant differences in unadjusted percentages or odds of smoking between the treatment and control groups. However, after adjusting for baseline smoking status and other stratification variables in the analysis, they found that the treatment group was less likely to smoke than the control group for five of the six outcomes of interest, including one and two years after programme implementation.

Additional studies have been undertaken using the data from the Campbell et al. (2008) programme evaluation. Holliday, Audrey, Moore, Parry-Langdon, & Campbell (2009) looked at the implementation quality and found that there were variations in implementation across schools (e.g., venue, peer nomination and recruitment process, length of recruitment sessions, intervention timetables, trainer-to-student ratios, school staff involvement, training approach) but that overall fidelity to the intervention was high. Starkey, Audrey, Holliday, Moore, & Campbell (2009) looked at the peer nomination process used to identify students to lead the ASSIST intervention. They found that the peer supporters were broadly representative of the students in their school, but an in-depth analysis of four schools revealed that only 48 to 60% of clusters of students had a peer supporter in it. They also found that some students and teachers had doubts about the ability of all nominated students to be effective peer supporters. Hollingworth et al. (2012) conducted a cost effectiveness study and found that the program cost £32 (95% CI = £29.70–£33.80) per student. The incremental cost per student not smoking at 2-year follow-up was £1,500 (95% CI = £669–£9,947).

Additionally, Audrey, Cordall, Moore, Cohen, & Campbell (2004) conducted a feasibility study of the ASSIST programme and found that it was feasible to implement and deemed acceptable by the schools. 82% of the 835 peer supporters fulfilled their role throughout the entire programme. The cost per school of implementing the intervention was £4,702.

Years in operation

ASSIST was first piloted in 2001 and continues to be implemented within the United Kingdom under the name DECIPHer-ASSIST.

Contact Information

Name

Michael Day

Title

 

Organization

DECIPHer IMPACT

Address

2 Farleigh Court, Old Weston Road, Flax Bourton, Bristol, BS48 1UR

Phone

Tel: +44 (0)1275 464779
Mob: +44 (0)7791 692815

Email

michael.day@decipher-impact.com

Website

Available Resources

http://www.decipher-impact.com/

Evaluation Details

The study summarised above was a group-randomised control trial. 113 schools that agreed to participate in the study were stratified by six variables (i.e., county, type of school, mixed-sex or single-sex, English-speaking or Welsh-speaking, size of school, level of entitlement to free school meals), and then 66 were randomly selected to participate in the experiment. Of those, 59 agreed to be randomly placed into either the treatment or control groups and were again stratified by the same variables and randomly assigned to the treatment or control groups. 5,372 students in 29 schools were in the control group that used their usual smoking education programs and tobacco policies. 5,358 students in 30 schools were in the treatment group that used ASSIST. The authors controlled for certain characteristics and accounted for the fact that students that attend the same school are similar.

Despite randomisation, there were baseline differences between the treatment and control groups. More students in the control group reported smoking at baseline than in the treatment group (7% versus 5%). Students in the control group had significantly lower levels of family affluence scores than the treatment group (27% of the control group had a family affluence score of 0-2 versus 23% of the treatment group) and were significantly less likely to have families that own more than one vehicle (49% of the control group had families that owned two or more cars versus 57% of the treatment group). Otherwise, groups were comparable in terms of sex and high-risk smoking behaviour (i.e., occasional, experimental, or ex-smokers). Because of these baseline differences, we only report the adjusted outcomes here.

Bibliography

Audrey S., Cordall K., Moore L., Cohen D., & Campbell R. (2004). The Development and Implementation of a peer-led intervention to prevent smoking among secondary school students using their established social networks. Health Education Journal, 63, 3,266-284.

Audrey, S., Holliday J., & Campbell, R. (2008). Commitment and compatibility: Teacher perspectives on the implementation of an effective school-based, peer-led smoking intervention. Health Education Journal, 67:74-90.

Audrey S., Holliday J., & Campbell R. (2006). It’s good to talk: An adolescent perspective of talking to their friends about being smoke-free. Social Science and Medicine, 63(2):320-344.

Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., Parry-Langdon, N., Hughes, R., & 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.

Holliday J., Audrey S., Moore L., Parry-Langdon N., & Campbell R. (2009). High fidelity? How should we consider variations in the delivery of school-based health promotion interventions? Health Education Journal, 68(1):44-62.

Hollingworth, W., Cohen, D., Hawkins, J., Hughes, R. A., Moore, L. A., Holliday, J. C., Audrey, S., Starkey, F.,  & Campbell, R. (2012). Reducing smoking in adolescents: cost-effectiveness results from the cluster randomized ASSIST (a stop smoking in schools trial). Nicotine & Tobacco Research, 14(2), 161-168.

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 [ISRCTN55572965]. BMC Public Health, 5(1), 43.

Enduring Impact

The Campbell et al. (2008) study conducted a follow-up at two years and had at least one positive outcome where p<.1.

The Audrey, Cordall, Moore, Cohen, & Campbell (2004) pilot study of ASSIST found that the cost per school of implementing the intervention was £4,702. Hollingworth et al. (2012) conducted a cost effectiveness study of the Campbell et al. (2008) study and found that ASSIST cost  £32 (95% CI = £29.70–£33.80) per student with an incremental cost per student not smoking at the 2-year follow-up of £1,500 (95% CI = £669–£9,947).