Tobacco is the world's main cause of avoidable poor health and early death. Around 8% of the world’s smokers live in lower and middle income countries. Our project focuses on three Asian middle income countries with smoking rates that are high and predicted to increase or remain stable: China Indonesia and the Philippines. Since most smoking starts in youth, it is crucial to prevent uptake in adolescence. This is challenging, but our research showed an intervention called ASSIST (A Stop Smoking In Schools Trial) was effective. ASSIST was developed and evaluated in an MRC-funded trial which took place in Wales and South West England in 2001. It is now recommended by NICE and implemented across the UK, supported by Evidence-To-Impact Ltd. ASSIST recruits 12 to 13 year olds who are influential among their school year group as ‘peer supporters’, to spread messages among their friendship networks via informal conversations about the risks of smoking and the benefits of not smoking. 

The ASSIST model has significant potential to be effective in low and middle income countries and since ASSIST is a relatively low cost it may be suitable these countries, but it's informal peer supporter model may make it less acceptable in countries with more formal or hierarchical school systems. This project will therefore assess: 1) whether ASSIST can be successfully adapted and transferred to one or more of these three countries and 2) whether a full effectiveness evaluation is feasible in one or more of the countries.

To do this, in each country we will consult with key stakeholders to explore whether and how to adapt ASSIST, so it is appropriate both culturally and for contemporary adolescents, but still retains its key elements. A UK not for profit company with experience of training the trainers (who then train the peer supporters) will run train the trainer sessions in each country and support translation of required materials. Each country will recruit ten secondary schools to take part in the study; six will be randomly selected as intervention schools (they will carry out ASSIST) and for comparison four as control schools (carrying on as normal without ASSIST). In the intervention schools, ASSIST trainers will run sessions where the whole 12-13 year-old year group completes a survey to say who they respect, think are good leaders and look up to. The 20% higher scoring students will be invited to become peer supporters and attend a two day training session to improve their knowledge of smoking’s harms and the of not smoking and develop skills and confidence in having conversations about smoking with friends. They will then act as peer supporters in their school for the next 10 weeks, with support from the trainers.

In each country researchers will run surveys among the whole year group in all ten schools before ASSIST and seven months after it is completed. These will include measures of smoking (so rates in intervention and control schools can be compared) and friendship networks (to help understand where supporters fit). Researchers will observe training sessions and conduct interviews and discussions with the trainers, students, staff, and parents in intervention schools to understand how ASSIST worked or didn't work in practice. They will also collect data on the costs of ASSIST.

If research shows that ASSIST is acceptable and feasible, schools support the research and policymakers show interest in providing support for the intervention in one or more of the countries, the next step would be for an effectiveness evaluation to determine whether ASSIST is effective in reducing smoking uptake. 

This project is funded by the Medical Research Council.


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