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.

Our project focuses on China, Indonesia and the Philippines: 3 culturally diverse Asian middle-income countries with smoking rates that are high and predicted to increase or remain stable.

We aim to assess: 1) if, and how, an informal school-based intervention ('ASSIST'), delivered by 12-13 year old 'peer supporters' to prevent smoking, which was developed and found to be effective in the UK, can be adapted for successful transfer in one or more of these countries; and 2) whether a future implementation effectiveness evaluation is feasible in one or more of the countries.

In each country, we will build on completed small-scale scoping work, continuing stakeholder engagement (policymakers, school staff, students, parents) to ensure appropriate cultural adaptations while retaining ASSIST's key features. Train-the-trainers will be delivered by experienced UK personnel who will also support translation of materials. We will recruit 10 schools and randomise 6 to intervention and 4 to control. In intervention schools, ASSIST trainers will recruit students nominated as influential by the year group as peer supporters, run 2-day training sessions and support them to act as peer supporters in their school for 10 weeks.

We will conduct baseline and 7-month follow-up surveys (which will include self-report smoking, social network data and exhaled carbon monoxide measures for verification of self-report smoking) of whole target year groups in all schools. Qualitative data collection will include: observations of training and selection procedures; focus groups/interviews with trainers and with students, staff and parents from intervention schools; and interviews with small numbers of control school staff. We will also gather data on intervention costs and determine policymaker interest in providing (financial) support for the intervention. We will determine whether pre-set progression criteria are met and a larger scale trial justified in one or more of these countries.

PRIMARY RESEARCH-RELATED IMPACTS
Adolescents will benefit from:
Participating in an intervention with the potential to reduce smoking uptake and so improve long-term health outcomes;
Participating in a large research project which may be of interest and provide learning opportunities (e.g. the science of/personal feedback from, exhaled carbon monoxide measures);
Wider personal and transferable skills (e.g. self-confidence/team-work) available to those who become peer supporters.

If, as suggested by new evidence from the original UK ASSIST trial, there are 'spillover' effects, there may be benefits to parents, wider family members or 'inoculation' among wider friendship groups.

Academics will benefit from:
Increased understandings of: peer-based interventions; intervention transferability; social network analyses; and exhaled carbon monoxide, to be communicated via peer-reviewed international journal papers and international, national and local presentations;
Availability of cross-country research data (in national repositories) for secondary analyses;
Capacity-strengthening (partner country institutions) in trial-based evaluation research, quantitative and qualitative methods and (all involved institutions) international multi-site projects.

The public, young people and other stakeholders will be consulted to help develop the project and ensure the intervention is a good fit for context and acceptable to those involved. Engagement events and communications will ensure appropriate involvement of the public and other stakeholders.

SCHOOL SYSTEM IMPACTS
Schools/school staff will benefit from:
Participating in a novel (for their country, in its informal, peer supporter model), evidence-based intervention which might increase smoking-related knowledge and, potentially, reduce smoking uptake among students;
Exposure to non-traditional approaches to student engagement and learning emphasising peers rather than teachers;
Student peer supporters, particularly 'lower achievers" may become more engaged in school;
Participating in well-governed evaluation research providing ideas for learning and strengthening links with academic researchers, providing potential for future knowledge exchange or research involvement.

POLICY IMPACTS
Local and national health and educational policy-makers and non-Governmental organisations will benefit from:
Research relating to a novel, evidence-based intervention which might reduce smoking uptake in countries where (very) high smoking rates have been identified as a significant public health issue;
Potential identification of a relatively low-cost intervention (crucial in resource-poor settings) which it may eventually be possible to apply to other health-risk behaviours which are rising in their countries;
Capacity strengthening around use of exhaled carbon monoxide to motivate smoking cessation and identify those exposed to high carbon monoxide levels from air pollution;
Networking around a possible scale-up or larger trial of the intervention (dependent on the results of this feasibility study).

Scoping work (see Case for Support) has already identified and engaged with a number of these (e.g. China Tobacco Control Association; School Health Institute of Beijing; Indonesian Ministry of Education; Indonesian Public Health Promoter and Educator Association; Philippines Department of Education - see further examples in Letters of Support). The project would build on and extend these relationships.

ECONOMIC AND SOCIETAL IMPACTS
If shown to be effective in a future trial and rolled out, this intervention could have long term impacts on individual health, quality of life, and work life. This could, in turn, impact the economies of our partner countries, particularly as part of a wider improved tobacco control strategy. Research capacity-strengthening could lead to better evaluation of services and interventions and increased success in winning research funding.