A process evaluation of the implementation of ASSIST in Scotland
Report on the ASSIST pilot programme, which promotes non-smoking in schools.
Chapter 1: Introduction and Background
This report presents findings from a process evaluation of the delivery of ASSIST (A Stop Smoking in Schools Trial) in three pilot areas across Scotland. This first chapter describes the policy context in which ASSIST was delivered, as well as a brief history of the ASSIST programme and the delivery models used in each of the three pilot sites. Research aims, objectives, method, sample, ethics/research permissions and the analytical approach adopted are the focus of Chapter 2. Results are presented in Chapters 3-5 with discussion and conclusions the focus of Chapter 6.
1.1 Policy Context
Smoking rates in Scottish adolescents have declined in recent years (Figure 1), particularly in the 15 year old cohort, with 30% of boys and girls smoking regularly (defined as smoking at least one cigarette per week) in 1996 compared to just 7% in 2015.
Figure 1: SALSUS regular smoking prevalence trend data 1982 - 2015[3]
However, it is estimated that between 2010 and 2011 a total of 207,000 young people aged 11-15 started smoking in the UK. The estimated number of children who start to smoke daily in the UK is: 463 in England, 55 in Scotland, 30 in Wales and 19 in Northern Ireland (Hopkinson et al 2014). This will have a significant impact on future health and life expectancy. Young people can become rapidly addicted to cigarettes and up to 2011 it was estimated that most young smokers in the UK were tobacco dependent before they leave school; nearly 40% before the age of 16 (Dunstan and Robinson 2012).
Age is an important factor in adolescent smoking with existing evidence highlighting the relationship between smoking prevalence and age of initiation. For example, smokers who start at an early age tend to smoke more cigarettes per day in adulthood, smoke for longer, are less likely to quit and are more likely to die from smoking-attributable causes. (Flay et al 1998; Leventhal and Cleary 1980; Mowery et al 2004).
For these reasons, preventing smoking uptake, particularly amongst young people, remains a public health priority.
1.2 ASSIST
ASSIST is a peer-led, school-based smoking prevention programme that encourages the dissemination of non-smoking norms by training S1 (aged 12 to 13 years) and S2 (aged 13 to 14 years) students to work as peer supporters. Peer supporters are trained to have informal conversations with other students about the risks of smoking and the benefits of being smoke-free (Audrey et al 2004). The programme consists of seven sessions, delivered over a 14 week cycle by external trainers (who have to attend a three day training course to deliver the programme, discussed further in 4.2.1). Table 1 summarises the key elements of ASSIST.
Table 1: Essential elements of ASSIST
| Peer nomination |
Conducted in school, the entire year group is brought together to complete a peer nomination questionnaire. Students are asked to nominate students in their year who they look up to, respect and view as good leaders. This takes around 20 minutes and trainers then rank the number of nominations to produce a list of students in the year with the most nominations (this has to be 18% to ensure adequate coverage) who are then invited to become a peer supporter. Care is taken not to mention smoking as this may influence nominations. |
|---|---|
| Peer recruitment |
Conducted in school, usually consisting of one class period lasting around 30-40 minutes. Students with a high number of nominations are invited to attend the peer recruitment meeting where they are introduced to ASSIST and the peer supporter role which includes two days of training away from school. They are given information about the benefits of taking part and invited to participate, but it is made clear that it is their decision whether to take part or not. Consent forms for parent/carer to sign are sent home. |
| Peer supporter training |
Conducted in a venue away from school (e.g. hotel, community venue). The aim is to promote learning around the risks of smoking and the advantages of being smoke-free in an informal and supportive environment. Training is delivered through games, role play and group work. Once trained, peer supporters are asked to have informal conversations with peers over a 10 week period and record these in a diary. |
| Follow-up sessions x 4 |
After training peer supporters meet with ASSIST trainers 4 times over the 10 week cycle in school, usually during class time lasting around 30-40 minutes. This is an opportunity for peer supporters to share their experiences, discuss any problems and raise questions to help consolidate their skills and knowledge and encourage them to have informal conversations. It also enables trainers to monitor progress and check diaries. |
The ASSIST model is different to previous school-based prevention programmes which systematic reviews have shown to be largely ineffective (Thomas Roger et al 2013). ASSIST was previously evaluated via a large cluster randomised trial of 59 schools in South Wales and Avon, England. Results from this trial showed that ASSIST was effective and cost effective at reducing smoking prevalence in young people (Campbell et al 2008), (Hollingworth et al 2012). This led to the wider roll out of ASSIST in parts of England and Wales and pilot expansions of the ASSIST programme to include healthy eating and physical activity (AHEAD) (Bell et al 2014). With current research underway looking at physical activity in young women (PLAN A) (Sebire et al 2016), drug prevention (ASSIST + FRANK) and sexual health (STASH)[4]. In a 2013 systematic review of policies and interventions to reduce socio-economic inequalities in adolescent smoking, ASSIST was identified as having a positive equity impact and reduced smoking inequalities in school children (Amos et al 2013).
In 2010, ASSIST became a licensed programme and a not-for-profit company, DECIPHer-IMPACT, was established to provide training, a detailed manual, ongoing support and quality assurance to maintain effective delivery of the programme[5]. An annual conference is held for trainers and interested parties (e.g. commissioners, researchers).
Until recently ASSIST had not been delivered in Scottish schools. This changed in 2013 when the Scottish Government pledged its commitment to smoking prevention in 'Creating a Tobacco Free Generation' (the national tobacco control strategy published in March 2013) which stated that:
"We will undertake a pilot of ASSIST, which will consider its suitability for Scotland and potential for further adaptation to other risk taking behaviour." (The Scottish Government 2013)
1.3 ASSIST in Scotland
In English and Welsh schools ASSIST is delivered to Year 8 students which is equivalent to S2 in Scottish schools. However the age composition is different. At the end of year 8 students are aged between 12-13, whereas S2 students are aged 13-14. This is important because the slightly older age range may result in students being less receptive to the programme. This presented three delivery options for Scotland. The first was to deliver to S1 students only. The advantage of this approach was that students would have been more comparable in terms of age (12-13), but as these students would just have started secondary school they may not have the established friendship groups which are an essential component of the ASSIST programme. The second delivery option was to target S2 students only who would have formed friendship groups, but who would be slightly older and the third option was to pilot in both S1 and S2 but target S1 in the third term or second half of the school year. This latter option was the agreed approach because it offered schools more delivery flexibility, which could have encouraged greater school participation. It also allowed delivery comparisons across the two years which could potentially generate useful learning for future delivery.
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