Effectiveness of the Strengthening Families Programme in the UK at preventing substance misuse in 10-14 year-olds: a pragmatic randomised controlled trial.

OBJECTIVES: The Strengthening Families Programme 10-14 (SFP10-14) is a USA-developed universal group-based intervention aiming to prevent substance misuse by strengthening protective factors within the family. This study evaluated a proportionate universal implementation of the adapted UK version (SFP10-14UK) which brought together families identified as likely/not likely to experience/present challenges within a group setting. DESIGN: Pragmatic cluster-randomised controlled effectiveness trial, with families as the unit of randomisation and embedded process and economic evaluations. SETTING: The study took place in seven counties of Wales, UK. PARTICIPANTS: 715 families (919 parents/carers, 931 young people) were randomised. INTERVENTIONS: Families randomised to the intervention arm received the SFP10-14 comprising seven weekly sessions. Families in intervention and control arms received existing services as normal. OUTCOME MEASURES: Primary outcomes were the number of occasions young people reported drinking alcohol in the last 30 days; and drunkenness during the same period, dichotomised as 'never' and '1-2 times or more'. Secondary outcomes examined alcohol/tobacco/substance behaviours including: cannabis use; weekly smoking (validated by salivary cotinine measures); age of alcohol initiation; frequency of drinking >5 drinks in a row; frequency of different types of alcoholic drinks; alcohol-related problems. Retention: primary analysis included 746 young people (80.1%) (alcohol consumption) and 732 young people (78.6%) (drunkenness). RESULTS: There was no evidence of statistically significant between-group differences 2 years after randomisation for primary outcomes (young people's alcohol consumption in the last 30 days adjusted OR=1.11, 95% CI 0.72 to 1.71, p=0.646; drunkenness in the last 30 days adjusted OR=1.46, 95% CI 0.83 to 2.55, p=0.185). There were no statistically significant between-group differences for other substance use outcomes, or those relating to well-being/stress, and emotional/behavioural problems. CONCLUSIONS: Previous evidence of effectiveness was not replicated. Findings highlight the importance of evaluating interventions when they are adapted for new settings. TRIAL REGISTRATION NUMBER: ISRCTN63550893.Cite Now.

Diffusion of effects of the ASSIST school-based smoking prevention intervention to non-participating family members: a secondary analysis of a randomized controlled trial.

AIMS: To investigate whether effects of the ASSIST (A Stop Smoking In Schools Trial) school-based smoking prevention intervention diffused from students to the people they lived with. DESIGN: Secondary analysis of a cluster-randomized control trial (cRCT). SETTING: England and Wales. PARTICIPANTS: A total of 10 730 students aged 12-13 years in 59 schools assigned using stratified block randomization to the control (29 schools, 5372 students) or intervention (30 schools, 5358 students) condition. INTERVENTION AND COMPARATOR: The ASSIST intervention involves 2 days of off-site training of influential students to encourage their peers not to smoke during a 10-week period. The control group continued with their usual education. MEASUREMENTS: The outcomes were the proportion of students who self-reported living with a smoker and the smoking status of each resident family member/caregiver. Follow-up assessments were immediately after the intervention and at 1 and 2 years post-intervention. FINDINGS: The odds ratio (OR) for living with a smoker in the intervention compared with the control groups was 0.86 [95% confidence interval (CI) = 0.72, 1.03] immediately after the intervention, OR = 0.84 (95% CI = 0.72, 0.97) at a 1-year follow-up and OR = 0.86 (95% CI = 0.75, 0.99) at 2-year follow-up. In a three-tier multi-level model with data from all three follow-ups, student-reported smoking by fathers (OR = 0.90, 95% CI = 0.80, 1.00), brothers (OR = 0.78, 95% CI = 0.67, 0.92) and sisters (OR = 0.80, 95% CI = 0.69, 0.92) was lower in the intervention compared with control group. Subgroup analyses by baseline smoking status suggested that these effects were more consistent with prevention of uptake than prompting cessation. CONCLUSIONS: A Stop Smoking In Schools Trial (ASSIST) school-based smoking prevention intervention may have reduced the prevalence of smoking in people who lived with ASSIST-trained students. This indirect transmission is consistent with the predictions of diffusion of innovations theory which underpins the design of ASSIST.

Identifying Well-Connected Opinion Leaders for Informal Health Promotion: The Example of the ASSIST Smoking Prevention Program.

Methods used to select opinion leaders for informal behavior change interventions vary, affecting the role they adopt and the outcomes of interventions. The development of successful identification methods requires evidence that these methods achieve their aims. This study explored whether the "whole community" nomination process used in the ASSIST smoking prevention program successfully identified "peer supporters" who were well placed within their school social networks to diffuse an antismoking message to their peers. Data were collected in the United Kingdom during A Stop Smoking in Schools Trial. Behavioral data were provided at baseline and post intervention by all students. Social network data were provided post intervention by students in four control and six intervention schools. Centrality measures calculated using UCINET demonstrate that the ASSIST nomination process successfully identified peer supporters who were more socially connected than others in their year and who had social connections across the entire year group including the program's target group. The results indicate that three simple questions can identify individuals who are held in high esteem by their year group and who also have the interpersonal networks required of opinion leaders to successfully disseminate smoke-free messages through their social networks. This approach could be used in other informal health promotion initiatives.

E-cigarette use and intentions to smoke among 10-11-year-old never-smokers in Wales.

BACKGROUND: E-cigarettes are seen by some as offering harm reduction potential, where used effectively as smoking cessation devices. However, there is emerging international evidence of growing use among young people, amid concerns that this may increase tobacco uptake. Few UK studies examine the prevalence of e-cigarette use in non-smoking children or associations with intentions to smoke. METHODS: A cross-sectional survey of year 6 (10-11-year-old) children in Wales. Approximately 1500 children completed questions on e-cigarette use, parental and peer smoking, and intentions to smoke. Logistic regression analyses among never smoking children, adjusted for school-level clustering, examined associations of smoking norms with e-cigarette use, and of e-cigarette use with intentions to smoke tobacco within the next 2 years. RESULTS: Approximately 6% of year 6 children, including 5% of never smokers, reported having used an e-cigarette. By comparison to children whose parents neither smoked nor used e-cigarettes, children were most likely to have used an e-cigarette if parents used both tobacco and e-cigarettes (OR=3.40; 95% CI 1.73 to 6.69). Having used an e-cigarette was associated with intentions to smoke (OR=3.21; 95% CI 1.66 to 6.23). While few children reported that they would smoke in 2 years' time, children who had used an e-cigarette were less likely to report that they definitely would not smoke tobacco in 2 years' time and were more likely to say that they might. CONCLUSIONS: E-cigarettes represent a new form of childhood experimentation with nicotine. Findings are consistent with a hypothesis that children use e-cigarettes to imitate parental and peer smoking behaviours, and that e-cigarette use is associated with weaker antismoking intentions.

Electronic-cigarette use among young people in Wales: evidence from two cross-sectional surveys.

OBJECTIVES: To examine the prevalence of electronic(e)-cigarette use, prevalence of e-cigarette and tobacco use by age, and associations of e-cigarette use with sociodemographic characteristics, tobacco and cannabis use among young people in Wales. DESIGN: Data from two nationally-representative cross-sectional surveys undertaken in 2013-2014. Logistic regression analyses, adjusting for school-level clustering, examined sociodemographic characteristics of e-cigarette use, and associations between e-cigarette use and smoking. SETTING: Primary and secondary schools in Wales. PARTICIPANTS: Primary-school children aged 10-11 (n=1601) and secondary-school students aged 11-16 (n=9055). RESULTS: Primary-school children were more likely to have used e-cigarettes (5.8%) than tobacco (1.6%). Ever use of e-cigarettes remained more prevalent than ever use of tobacco until age 14-15. Overall, 12.3% of secondary-school students (aged 11-16) reported ever using e-cigarettes, with no differences according to gender, ethnicity or family affluence. The percentage of 'never smokers' reporting having used e-cigarettes was 5.3% at age 10-11 to 8.0% at age 15-16. The proportion of children who had ever used an e-cigarette and reported currently smoking increased from 6.9% among 10-11 year olds to 39.2% in 15-16 year olds. Only 1.5% (n=125) of 11-16 year-olds, including 0.3% of never smokers, reported regular e-cigarette use (use at least once a month). Current weekly smokers were 100 times more likely than non-smokers to report regular e-cigarette use (relative risk ratio (RRR=121.15; 95% CI 57.56 to 254.97). Regular e-cigarette use was also more likely among those who had smoked cannabis (RRR 53.03; 95% CI 38.87 to 80.65). CONCLUSIONS: Many young people (including never-smokers) have tried e-cigarettes. However, regular use is less common, and is associated with tobacco cigarette use. Longitudinal research is needed to understand age-related trajectories of e-cigarette use and to understand the temporal nature of relationships between e-cigarette and tobacco use.

Prevalence of smoking restrictions and child exposure to secondhand smoke in cars and homes: a repeated cross-sectional survey of children aged 10-11 years in Wales.

OBJECTIVE: Small increases in smoking restrictions in cars and homes were reported after legislation prohibiting smoking in public places. Few studies examine whether these changes continued in the longer term. This study examines changes in restrictions on smoking in cars and homes, and child exposure to secondhand smoke (SHS) in these locations, since 2008 postlegislation surveys in Wales. SETTING: State-maintained primary schools in Wales (n=75). PARTICIPANTS: Children aged 10-11 years (year 6) completed CHETS (CHild exposure to Environmental Tobacco Smoke) Wales surveys in 2007 (n=1612) and 2008 (n=1605). A replication survey (CHETS Wales 2) was conducted in 2014, including 1601 children. PRIMARY OUTCOME VARIABLE: Children's reports of whether smoking was allowed in their car or home and exposure to SHS in a car or home the previous day. RESULTS: The percentage of children who reported that smoking was allowed in their family vehicle fell from 18% to 9% in 2014 (OR=0.42; 95% CI 0.33 to 0.54). The percentage living in homes where smoking was allowed decreased from 37% to 26% (OR=0.30; 95% CI 0.20 to 0.43). Among children with a parent who smoked, one in five and one in two continued to report that smoking was allowed in their car and home. The percentage reporting SHS exposure in a car (OR=0.52; 95% CI 0.38 to 0.72) or home (OR=0.44; 95% CI 0.36 to 0.53) the previous day also fell. Children from poorer families remained less likely to report smoking restrictions. CONCLUSIONS: Smoking in cars and homes has continued to decline. Substantial numbers of children continue to report that smoking is allowed in cars and homes, particularly children from poorer families. A growing number of countries have legislated, or plan to legislate, banning smoking in cars carrying children. Attention is needed to the impact of legislation on child health and health inequalities, and reducing smoking in homes.

Preventing substance misuse: study protocol for a randomised controlled trial of the Strengthening Families Programme 10-14 UK (SFP 10-14 UK).

BACKGROUND: Prevention of alcohol, drug and tobacco misuse by young people is a key public health priority. There is a need to develop the evidence base through rigorous evaluations of innovative approaches to substance misuse prevention. The Strengthening Families Programme 10-14 is a universal family-based alcohol, drugs and tobacco prevention programme, which has achieved promising results in US trials, and which now requires cross-cultural assessment. This paper therefore describes the protocol for a randomised controlled trial of the UK version of the Strengthening Families Programme 10-14 (SFP 10-14 UK). METHODS/DESIGN: The trial comprises a pragmatic cluster randomised controlled effectiveness trial with families as the unit of randomisation, with embedded process and economic evaluations. Participating families will be randomised to one of two treatment groups - usual care with full access to existing services (control group), or usual care plus SFP 10-14 UK (intervention group). The trial has two primary outcomes - the number of occasions that young people report having drunk alcohol in the last 30 days, and drunkenness during the last 30 days, both dichotomised as 'never' and '1-2 times or more'. The main follow-up is at 2 years past baseline, and short-term and intermediate outcomes are also measured at 9 and 15 months. DISCUSSION: The results from this trial will provide evidence on the effectiveness and cost-effectiveness of an innovative universal family-based substance misuse prevention programme in a UK context. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63550893.

Socioeconomic inequalities in childhood exposure to secondhand smoke before and after smoke-free legislation in three UK countries.

BACKGROUND: Secondhand smoke (SHS) exposure is higher among lower socioeconomic status (SES) children. Legislation restricting smoking in public places has been associated with reduced childhood SHS exposure and increased smoke-free homes. This paper examines socioeconomic patterning in these changes. METHODS: Repeated cross-sectional survey of 10 867 schoolchildren in 304 primary schools in Scotland, Wales and Northern Ireland. Children provided saliva for cotinine assay, completing questionnaires before and 12 months after legislation. RESULTS: SHS exposure was highest, and private smoking restrictions least frequently reported, among lower SES children. Proportions of saliva samples containing <0.1 ng/ml (i.e. undetectable) cotinine increased from 31.0 to 41.0%. Although across the whole SES spectrum, there was no evidence of displacement of smoking into the home or increased SHS exposure, socioeconomic inequality in the likelihood of samples containing detectable levels of cotinine increased. Among children from the poorest families, 96.9% of post-legislation samples contained detectable cotinine, compared with 38.2% among the most affluent. Socioeconomic gradients at higher exposure levels remained unchanged. Among children from the poorest families, one in three samples contained >3 ng/ml cotinine. Smoking restrictions in homes and cars increased, although socioeconomic patterning remained. CONCLUSIONS: Urgent action is needed to reduce inequalities in SHS exposure. Such action should include emphasis on reducing smoking in cars and homes.

A longitudinal social network analysis of peer influence, peer selection, and smoking behavior among adolescents in British schools.

OBJECTIVE: Similarity in smoking behavior among adolescent friends could be caused by selection of friends on the basis of behavioral similarity, or by influence processes, where behavior is changed to be similar to that of friends. The main aim of the present study is to disentangle selection and influence processes and study changes over time in these processes using new methods of longitudinal social network analysis. METHODS: The sample consists of 1716 adolescents (mean age at baseline = 12.17 years, SD = .38) in 11 British schools participating in the control group of the ASSIST (A Stop Smoking in School Trial) study. The design was longitudinal with three observations at one-year intervals. At each observation, participants were asked to report on their smoking behavior and friendship networks. An actor-based model of friendship network and smoking behavior coevolution (a statistical model for the simultaneously occurring changes in friendship nominations and smoking) was analyzed, capable of modeling possible changes occurring between observations, allowing alternative influence and selection mechanisms to be investigated, and avoiding the violation of assumptions of statistical independence of observed data. RESULTS: Adolescent's tendency to select friends based on similar smoking behavior was found to be a stronger predictor of smoking behavior than friends' influence. The proportion of smoking behavior similarity explained by smoking-based selection of friends increased over time, whereas the proportion explained by influence of friends decreased. CONCLUSIONS: Smoking prevention should not solely focus on social influence but also consider selection processes and changes in both processes over time during adolescence.

Reducing smoking in adolescents: cost-effectiveness results from the cluster randomized ASSIST (A Stop Smoking In Schools Trial).

INTRODUCTION: School-based smoking prevention programmes can be effective, but evidence on cost-effectiveness is lacking. We conducted a cost-effectiveness analysis of a school-based "peer-led" intervention. METHODS: We evaluated the ASSIST (A Stop Smoking In Schools Trial) programme in a cluster randomized controlled trial. The ASSIST programme trained students to act as peer supporters during informal interactions to encourage their peers not to smoke. Fifty-nine secondary schools in England and Wales were randomized to receive the ASSIST programme or usual smoking education. Ten thousand seven hundred and thirty students aged 12-13 years attended participating schools. Previous work has demonstrated that the ASSIST programme achieved a 2.1% (95% CI = 0%-4.2%) reduction in smoking prevalence. We evaluated the public sector cost, prevalence of weekly smoking, and cost per additional student not smoking at 24 months. RESULTS: The ASSIST programme cost of £32 (95% CI = £29.70-£33.80) per student. The incremental cost per student not smoking at 2 years was £1,500 (95% CI = £669-£9,947). Students in intervention schools were less likely to believe that they would be a smoker at age 16 years (odds ratio [OR] = 0.80; 95% CI = 0.66-0.96). CONCLUSIONS: A peer-led intervention reduced smoking among adolescents at a modest cost. The intervention is cost-effective under realistic assumptions regarding the extent to which reductions in adolescent smoking lead to lower smoking prevalence and/or earlier smoking cessation in adulthood. The annual cost of extending the intervention to Year 8 students in all U.K. schools would be in the region of £38 million and could result in 20,400 fewer adolescent smokers.

Socioeconomic patterning in changes in child exposure to secondhand smoke after implementation of smoke-free legislation in Wales.

INTRODUCTION: Secondhand smoke (SHS) exposure is higher among children from lower socioeconomic status (SES) households. Legislation banning smoking in public places has been linked with reduced SHS exposure in children. However, socioeconomic patterning in responses to legislation has been little explored. METHODS: A total of 3,083 children aged 10-11 years, within 75 Welsh primary schools, completed questionnaires either before legislation or 1 year later. Saliva samples were provided by 2,787 of these children for cotinine assay. Regression analyses assessed socioeconomic differences in SHS exposure, and associations of legislation with exposure among children from low, medium, and high SES households. Changes in parental smoking in the home, car-based exposure, and perceived norms were assessed. RESULTS: SHS exposure was highest among children from lower SES households. The likelihood of providing a sample containing an undetectable level of cotinine increased significantly after legislation among children from high [relative risk ratio (RRR) = 1.44, 95% CI = 1.04-2.00] and medium SES households (RRR = 1.66, 95% CI = 1.20-2.30), while exposure among children from lower SES households remained unchanged. Parental smoking in the home, car-based SHS exposure, and perceived smoking prevalence were highest among children from low SES households. Parental smoking in the home and children's estimates of adult smoking prevalence declined only among children from higher SES households. CONCLUSIONS: Post-legislation reductions in SHS exposure were limited to children from higher SES households. Children from lower SES households continue to have high levels of exposure, particularly in homes and cars, and to perceive that smoking is the norm among adults.

The relative importance of different measures of peer smoking on adolescent smoking behavior: cross-sectional and longitudinal analyses of a large British cohort.

PURPOSE: To examine the relative importance of smoking behavior of best friends, boyfriends/girlfriends, the wider friendship group, and school year group smoking prevalence as correlates and predictors of smoking behavior (peer influence). The article also aims to assess the relative extent to which smoking behavior is associated with changes in smoking among peers who are selected to be friends (selective association). METHODS: Using two waves of data collected from 4,145 year 8 (12-13 years) and year 9 (13-14 years) students in 29 schools, logistic regression models estimated the cross-sectional association between four year 8 peer influence variables and weekly and occasional smoking, and the extent to which these peer influence variables and three selective association variables were predictors of weekly smoking in year 9. RESULTS: The smoking behavior of best friend, boyfriend/girlfriend, the wider friendship group, and school year group prevalence were cross-sectionally associated with higher odds of weekly and occasional smoking. In longitudinal multivariate influence models, only the smoking behavior of boyfriend/girlfriend and the wider friendship group were associated with weekly smoking. Weekly smoking was associated with maintaining or changing to having smokers among best friends, boyfriends/girlfriends, and the wider friendship group. In models including all variables, only selective association effects were observed. CONCLUSIONS: Although univariate analyses indicate an association of friends', peer group, and year group smoking with current and subsequent smoking behavior, multivariate longitudinal analyses indicate that simple peer influence models do not completely explain adolescent smoking and that a more complex interrelationship exists between smoking, peer's smoking and peer socialization.

Changes in child exposure to secondhand smoke after implementation of smoke-free legislation in Wales: a repeated cross-sectional study.

BACKGROUND: Smoke-free legislation was introduced in Wales in April 2007. In response to concerns regarding potential displacement of smoking into the home following legislation, this study assessed changes in secondhand smoke (SHS) exposure amongst non-smoking children. METHODS: Approximately 1,750 year 6 (aged 10-11) children from 75 Welsh primary schools were included in cross-sectional surveys immediately pre-legislation and one year later. Participants completed self-report questionnaires and provided saliva samples for cotinine assay. Regression analyses assessed the impact of legislation on children's SHS exposure at the population level, and amongst subgroups defined by parental figures who smoke within the home. RESULTS: Geometric mean salivary cotinine concentrations were 0.17 ng/ml (95% CI 0.15,0.20) pre-legislation and 0.15 ng/ml (95% CI 0.13,0.17), post-legislation, although this change was not statistically significant. Significant movement was however observed from the middle (0.10-0.50 ng/ml) to lower tertile, though not from the higher end (>0.51 ng/ml) to the middle. Reported exposure to SHS was greatest within the home. Home-based exposure did not change significantly post-legislation. Reported exposure in cafés or restaurants, buses and trains, and indoor leisure facilities fell significantly. The proportion of children reporting that parent figures smoked in the home declined (P = 0.03), with children with no parent figures who smoke in the home significantly more likely to provide saliva with cotinine concentrations of <0.10 ng/ml post-legislation. Amongst children with no parent figures who smoke in the home, the likelihood of 'not knowing' or 'never' being in a place where people were smoking increased post-legislation. CONCLUSION: Smoke-free legislation in Wales did not increase SHS exposure in homes of children aged 10-11. Reported SHS exposure in public places fell significantly. The home remained the main source of children's SHS exposure. The legislation was associated with an unexpected reduction in cotinine levels among children with lower SHS exposure pre-legislation. The findings indicate positive rather than harmful effects of legislation on children's SHS exposure, but highlight the need for further action to protect those children most exposed to SHS.

Identifying influential young people to undertake effective peer-led health promotion: the example of A Stop Smoking In Schools Trial (ASSIST).

The objective of the study was to develop and evaluate an effective whole-community approach to identifying a diverse group of influential young people to effectively diffuse health promotion messages among their peers. A peer nomination questionnaire, developed through extensive piloting work, was completed by 10 730 Year 8 students (aged 12-13 years) in 59 schools (30 intervention, 29 control) as part of a cluster randomized controlled trial. Influential students identified in 30 intervention schools were trained to disseminate smoke-free health promotion messages through informal contacts with peers. This approach successfully identified, recruited and retained a diverse group of students, broadly representative of their year group, to undertake the role of 'peer supporter'. Although students and staff expressed doubts about the suitability of some young people recruited as peer supporters, the intervention achieved a 22% reduction in the odds of being a regular smoker in intervention compared with control schools [odds ratio 0.78 (95% CI 0.64-0.96)]. Carefully designed and developed peer-led interventions have potential for delivering effective smoking prevention among adolescents. Paying close attention to the way in which peer educators are identified, and involving young people themselves in this process, may be the key to increasing the effectiveness of peer education.

Meeting the challenges of implementing process evaluation within randomized controlled trials: the example of ASSIST (A Stop Smoking in Schools Trial).

It is increasingly argued that the effectiveness of health promotion interventions should be measured to inform policy and practice. The randomized controlled trial (RCT) continues to be regarded as the 'gold standard' of health services research but health promotion practitioners have raised concerns about the RCT's appropriateness for evaluating their work. A preferred model is currently the pragmatic trial, measuring effectiveness under 'routine' conditions, incorporating a process evaluation to examine context, implementation and receipt. This model was chosen by A Stop Smoking in Schools Trial (ASSIST) to evaluate an intervention in which influential Year 8 students (12-13 years old) were trained to encourage non-smoking behaviour through informal conversations with their peers. Outcome data show that the intervention was effective in reducing smoking levels in intervention schools compared with control schools. In this paper we describe the extensive process evaluation embedded within the trial and, rather than focusing on resultant data, we consider the potential for such detailed examination of process to affect the intervention's delivery, receipt and outcome evaluation. We describe how some acknowledged challenges were addressed within ASSIST, which have relevance for future similar trials: Hawthorne effects, overlapping roles within the team and distinguishing between the intervention and its evaluation.

It's good to talk: adolescent perspectives of an informal, peer-led intervention to reduce smoking.

Although peer education has enjoyed considerable popularity as a health promotion approach with young people, there is mixed evidence about its effectiveness. Furthermore, accounts of what young people actually do as peer educators are scarce, especially in informal settings. In this paper, we examine the activities of the young people recruited as 'peer supporters' for A Stop Smoking in Schools Trial (ASSIST) which involved 10,730 students at baseline in 59 secondary schools in south-east Wales and the west of England. Influential Year 8 students, nominated by their peers, were trained to intervene informally to reduce smoking levels in their year group. The ASSIST peer nomination procedure was successful in recruiting and retaining peer supporters of both genders with a wide range of abilities. Outcome data at 1-year follow-up indicate that the risk of students who were occasional or experimental smokers at baseline going on to report weekly smoking at 1-year follow-up was 18.2% lower in intervention schools. This promising result was supported by analysis of salivary cotinine. Qualitative data from the process evaluation indicate that the majority of peer supporters adopted a pragmatic approach, concentrating their attentions on friends and peers whom they felt could be persuaded not to take up smoking, rather than those they considered to be already 'addicted' or who were members of smoking cliques. ASSIST demonstrated that a variety of school-based peer educators, who are asked to work informally rather than under the supervision of teaching staff, will engage with the task they have been asked to undertake and can be effective in diffusing health-promotion messages. Given the serious concerns about young people's smoking behaviour, we argue that this approach is worth pursuing and could be adapted for other health promotion messages.