A Process Evaluation of the Implementation of ASSIST in Scotland
Smoking rates in Scottish adolescents have declined in recent years, 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  .
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.
Age is an important factor in adolescent smoking with existing evidence highlighting the relationship between smoking prevalence and age of initiation. Preventing smoking uptake, particularly amongst young people, remains a public health priority.
This report presents findings from a process evaluation of the ASSIST pilot in Scotland. ASSIST is a licensed peer-led, school-based smoking prevention programme that encourages the dissemination of non-smoking norms by training S1 and S2 students to work as peer supporters. These students are trained to have informal conversations with other students about the risks of smoking and the benefits of not smoking.
ASSIST in Scotland
In 2013 the Scottish Government made a commitment to undertake a pilot of ASSIST in its national Tobacco Control Strategy. 
The ASSIST programme was delivered in three NHS Boards across Scotland: Greater Glasgow and Clyde; Lothian; and Tayside. All three areas followed the licensed DECIPHer-IMPACT programme but their delivery models, in terms of project management, staffing and number of schools they worked with, varied.
Aim and Research Design
The overall aim of the study was to evaluate the process of implementing ASSIST in Scotland.
In light of existing evidence demonstrating the effectiveness of ASSIST, this study focused on the acceptability and implementation of ASSIST to inform any potential future adoption in other areas of Scotland. A range of stakeholders (school staff, trainers and students) were consulted via in-depth interviews, paired interviews, mini focus groups and observation along with a before and after survey to gather data from students. To maximise available resources a two-tier design was used. Tier one included consultation with school leads and a pre and post student survey in 20 schools. Tier two involved six case study schools (two in each area, selected from the 20 tier one schools) where qualitative methods were used to observe peer supporter training and follow-up sessions and consult with peer supporters and other students.
The key findings and recommendations are summarised below.
- Overall the evaluation found that it was feasible and acceptable to deliver ASSIST in Scottish schools and that feedback was very positive. There was a high degree of fidelity to the licence programme with key elements maintained during implementation. School leads particulalry highlighted support for the peer education model and the small amount of school resources required for delivery. More broadly, feedback was overwhelmingly positive about the wider benefits of the peer support training, particularly in terms development of communication skills and dissemntination of anti smoking messages to the wider community through those who had undertaken the training
- The study identified various barriers and facilitators to the implementation of ASSIST. At the macro level they were: partnership working; budget; and culture. Partnerships in particular were key, and findings from the evaluation suggest that future delivery of ASSIST in new areas should ensure enough time is set aside to build relationships with key stakeholders (such as school leads, NHS and Local Authority staff) in advance of programme delivery.
- Very few changes were required to implement ASSIST in Scotland. There were some minor amendments suggested, such as the timing of delivery when implemented in S1 and how to include more content on e-cigarettes.
- This process evaluation was designed to look at acceptability and fidelity, not intervention effectiveness. However, from the data we have, it is clear that there is uncertainty regarding the extent of message diffusion between peer supporters and peers in their school year and any impact this may have on adolescents smoking prevalence. Findings from the student survey showed no significant change in self-reported smoking prevalence with 1.6% of pupils (n=33) reporting that they smoked one or more cigarettes per week increasing slightly to 1.8% (n=38) at follow-up. In addition, recall of any relevant conversations about smoking with a peer supporter was fewer than one in ten (9%). However, opportunities to have informal conversations about smoking with peers may now be limited due to the ongoing decline in adolescent smoking since ASSIST was first developed. It is also worth noting that some peer supporters felt apprehensive or awkward initiating conversations about smoking with their peers for fear of being judged or ridiculed, and this also may have contributed to the low recall of any conversations relevant to ASSIST.
- Data collected from the original ASSIST trial is now 13 years old. Our findings on the number of relevant conversations (in particular) do raise questions about any appropriate assessment of ASSIST in the future. A relevant future step would be an implementation trial (a Phase IV study) of ASSIST, using a similar methodology to the original RCT, to assess current effectiveness in the context of lowering smoking prevalence in the target age group.
- There was general agreement (from school leads and students) that the ASSIST model (ie peer to peer message diffusion) could and should be applied to other risk taking behaviours such as alcohol or drugs. Currently and previously there have been other versions of ASSIST (focusing on sexual health, physical activity, healthy eating, binge drinking and drug prevention). School staff and stakeholders were also interested in how the ASSIST model could address multiple behaviours in one intervention, but this will be far more challenging to deliver. Investigating how/if the ASSIST model could be developed to address more than one risk behaviour is an important area for further research.
Overall, this process evaluation has demonstrated that it is feasible and acceptable to deliver the ASSIST programme in Scottish schools. Despite slight differences in the age of young people participating compared to the original programme in England and Wales, and some organisational and socio-demographic variation between the three participating areas in Scotland (Glasgow, Lothian and Tayside), the programme was delivered to a high degree of fidelity.
Three different delivery models were piloted in the participating areas. This did not impact on fidelity or acceptability. There are learning points from them to apply to other areas that may implement ASSIST in Scotland. Feedback was overwhelmingly positive regarding the wider benefits of taking part in ASSIST for peer supporters ( i.e. personal and communication skills) but also for the school and communities, via message diffusion to wider social networks.
Our findings show less certainty regarding the extent of message diffusion and any impact this may have had on adolescent smoking. Student survey results showed no significant change in self-reported smoking prevalence between baseline and follow-up and conversation recall with a peer supporter was low at 9%. There are caveats around the interpretation of these results which were not the main focus of this process evaluation. It is also important that the current context (where regular smoking prevalence is 2% overall in 13 year olds in Scotland  ) is taken into account. Now may be the time to consider whether, 13 years on from the original RCT, an implementation trial of ASSIST is warranted to determine if it is still effective and cost effective. It may still have an important role to play, particularly in more deprived areas where youth smoking uptake starts in the early teens and where community smoking rates and norms have shown little change in recent years.
Specific (although more minor) adaptations to the existing ASSIST programme should also be considered. In particular: the utility of paper diaries; whether four week follow-ups are required; and how content on electronic cigarettes can be included in a way that makes clear the important distinctions between vaping and smoking.
Further consideration is also merited regarding the best school year for any delivery of the programme in Scotland i.e. S1 or S2. Findings from the process evaluation gave no clear guidance over one year or the other. However, considering the very low rates of smoking amongst young people in their very early teens today, and the relevance of peer groups being formed when the programme is delivered, S2 may be more appropriate.
This process evaluation has demonstrated that it is feasible and acceptable to deliver the ASSIST programme in Scottish schools, although questions remain about the extent of message diffusion. Further consideration is required to assess whether delivery of ASSIST still offers a suitable return on investment and what role it may play in schools in areas of deprivation where smoking rates are higher.
Flay, B.R, Hu, F.B, and Richardson, J. (1998) Psychosocial predictors of different stages of cigarette smoking among high school students. Preventive Medicine, 27 (5), pp. A9-A18.
Hopkinson, N.S, Lester-George, A, Arnott, D, Ormiston-Smith, N, and Cox, A.(.3.). (2014) Child uptake of smoking by area across the uk. Thorax, 69 (9), pp. 873-875.
Leventhal, H, and Cleary, P.D. (1980) The smoking problem: A review of the research and theory in behavioral risk modification. Psychological Bulletin, 88 (2), pp. 370-405.
Mowery, P.D, Farrelly, M.C, Haviland, M.L, Gable, J.M, and Wells, H.E. (2004) Progression to established smoking among US youths. American Journal of Public Health, 94 (2), pp. 331-337.
How to access background or source data
The data collected for this social research publication:
☐ are available in more detail through Scottish Neighbourhood Statistics
☐ are available via an alternative route
☒ may be made available on request, subject to consideration of legal and ethical factors. Please contact email@example.com for further information.
☐ cannot be made available by Scottish Government for further analysis as Scottish Government is not the data controller.
Email: James Niven