Feasibility study of a peer-led, school-based, adolescent smoking prevention intervention (ASSIST) in culturally different middle income countries

Tobacco is the world's main cause of avoidable poor health and early death. Around 80% 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.

Because most smoking begins in youth, it is crucial to prevent uptake in adolescence. This is challenging, but UK research showed an intervention called A Stop Smoking In Schools Trial (ASSIST) was effective. ASSIST is unusual, because it does not involve formal health education.

It recruits 12-13-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 benefits of not smoking. Because ASSIST was shown to work, it was widely taken up in the UK.

ASSIST is relatively low cost, and so may be suitable in lower and middle-income countries, but its informal peer-supporter model may make it less acceptable in countries with more formal or hierarchical school systems. Our project will therefore assess: (1) whether ASSIST can be successfully adapted and transferred to one or more of these three countries (which are themselves culturally diverse); and (2) how easy it would be to run a future large study (as happened in the UK) to test if it works to prevent smoking uptake in one or more of the countries.

Our research team was formed during a smaller project, conducted in early 2019, when University of Glasgow researchers contacted international country partners to see if they were interested in this research area and to start talking to policymakers, school staff and students about the idea. This work suggested interest in the ASSIST model in each country, and our project will build on that momentum.

To do this, in each country we will continue consultations on 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 10 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% highest 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 benefits 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 10 schools before ASSIST and 7-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 peer supporters fit). Researchers will observe training sessions and conduct interviews and discussions with the trainers, and 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: ASSIST to be acceptable and feasible; that schools can 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 a larger project with more schools to properly test if it works.