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

烟草是世界上可避免的健康状况不佳和过早死亡的主要原因。世界上约80%的吸烟者生活在中低收入国家。我们的项目重点关注中国、印度尼西亚和菲律宾这三个亚洲中等收入国家，这三个国家的吸烟率很高，预计还会上升或保持稳定。因为大多数人在青少年时期开始吸烟，所以防止青少年吸烟是至关重要的。这是具有挑战性的，但英国的研究表明，一项名为“学校戒烟试验”（ASSIST）的干预措施是有效的。ASSIST是不寻常的，因为它不涉及正规的健康教育。该项目招募12-13岁的学生，这些学生在他们的学年组中有影响力，作为“同伴支持者”，通过非正式的谈话，在他们的朋友圈中传播有关吸烟的风险和不吸烟的好处的信息。因为ASSIST被证明是有效的，它在英国被广泛采用。ASSIST的成本相对较低，因此可能适用于低收入和中等收入国家，但其非正式的同伴支持模式可能使其在拥有更正式或等级森严的学校系统的国家不太容易被接受。因此，我们的项目将评估：(1)ASSIST是否可以成功地适应并转移到这三个国家中的一个或多个国家（这些国家本身具有文化多样性）；(2)在未来进行一项大型研究（就像在英国发生的那样）以测试它是否能在一个或多个国家防止吸烟的发生有多容易。我们的研究团队是在2019年初进行的一个较小的项目中形成的，当时格拉斯哥大学的研究人员联系了国际国家合作伙伴，看看他们是否对这个研究领域感兴趣，并开始与政策制定者、学校工作人员和学生讨论这个想法。这项工作表明每个国家都对ASSIST模式感兴趣，我们的项目将以这种势头为基础。为此，我们将在每个国家继续就是否以及如何调整ASSIST进行磋商，使其在文化上和当代青少年中都是适当的，但仍保留其关键要素。一家具有培训培训人员经验的英国非营利公司（由培训人员培训同行支持者）将在每个国家举办培训培训人员会议，并支持所需材料的翻译。每个国家将招募10所中学参与这项研究；将随机选择六所作为干预学校（他们将进行ASSIST），作为比较，四所作为对照学校（照常进行，不进行ASSIST）。在干预学校里，ASSIST培训师会安排课程，让所有12-13岁的孩子完成一项调查，说出他们尊敬、认为是好领导和尊敬的人。得分最高的20%的学生将被邀请成为同伴支持者，参加为期两天的培训课程，以提高他们对吸烟危害和不吸烟益处的认识，并培养与朋友谈论吸烟的技巧和信心。接下来的10周，他们将在培训师的支持下，在学校里扮演同伴支持者的角色。在每个国家，研究人员将在ASSIST之前和完成后的7个月对所有10所学校的整个学年组进行调查。这些措施将包括吸烟测量（这样干预学校和控制学校的吸烟率就可以进行比较）和友谊网络（帮助了解同伴支持者的位置）。研究人员将观察培训课程，并与培训师、学生、员工和干预学校的家长进行访谈和讨论，以了解ASSIST在实践中是如何起作用（或不起作用）的。他们还将收集有关ASSIST费用的数据。如果研究表明：ASSIST是可接受和可行的；学校可以支持这项研究；政策制定者表示有兴趣在一个或多个国家为干预提供支持，下一步将是一个更大的项目，有更多的学校来适当地测试它是否有效。

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.