As discussed in Section 5.8, peer group influences have been identified as a significant factor in uptake of smoking.1-6
For a long time, ‘peer pressure’ or perceptions that ‘smoking is cool’ were thought to be primary determinants of smoking uptake among young people. However, the determinants of smoking uptake are complex, with peer influences interacting with and compounded by a host of other predictive factors, and the nature of peer influences on smoking changing over time and varying across social and cultural groupings. A 2017 New Zealand survey found that one in 10 students reported having encouraged smoking among their peers, while half reported discouraging their peers from smoking, highlighting the positive impact that young people can have on each other.7
Evidence associating peer influences with adolescent uptake of smoking is often relied upon as part of the rationale for peer-led and peer-based approaches to smoking prevention. More broadly, peer education approaches have also been applied to a range of other health and social behaviours, and have a strong theoretical underpinning as outlined below.
5.28.1 Peer education approaches to smoking among young people
The theoretical roots of peer education approaches can be traced to Bandura’s social learning theory, and to social inoculation theory.8 While peer education has been applied across a diverse range of settings and health issues, including smoking, the common elements relate to the ‘tapping into’ and utilisation of the existing social processes among young people to influence their health-related knowledge, attitudes, skills and behaviour.8 Social influence programs may foster social norms that reduce adolescent social motivation to commence smoking,9 10 and peer education strategies can complement and reinforce other health promotion approaches.11
‘Diffusion of innovations’12 is a theory that has been applied in peer education initiatives, and serves as a model for understanding how information, ideas and or behaviours spread throughout a community. Applied to health promotion, diffusion of innovation theory seeks to identify ‘natural and influential’ opinion leaders to endorse and support desired health behaviours.13 In this regard, it not just a matter of targeting any ‘peer’, but rather those who can act as opinion leaders to influence the views, attitudes or behaviour of others because of their already established and credible social standing with others.13, 14
Transtheoretical model is another theory that has been successfully applied in peer to peer education.15 Transtheoretical model is an intentional behaviour change model that focuses on individual decisions and has been used in smoking cessation programs more broadly. Rather than moving directly from smoking to quitting, or not smoking to smoking, this theory follows the understanding that individuals progress gradually through stages of change, and peer role models can be harnessed to help positively influence this progression.15 See Section 7.3.6 for more on Transtheoretical model/Stages of change.
The role of peer educators varies considerably across programs, and may include formal or informal counselling, information provision one-to-one or in a group, participation in interactive activities with peers, staffing of ‘hotlines’ and resource centres,8 modelling of interpersonal skills,16 and fostering of peer mentors.17 Some programs take a deliberately informal approach, seeking to tap into everyday communication within social groups and/or utilise existing peer ‘influencers’ as a vehicle for behaviour change.14
Young people involved in peer education may also serve as viable role models and opinion leaders, and help to project norms of acceptable and unacceptable health-related behaviours. 9, 14, 18
Research in Scotland19 found that older teenagers were adamant about not wanting younger teenagers to start smoking, and it is suggested that peer education approaches may capitalise upon this attitude.
5.28.2 Effectiveness of peer education interventions
In a 1996 meta-analysis of smoking prevention programs, the researchers concluded that peer or social type programs should be continued as part of smoking prevention efforts, but that the overall magnitude of effect can be limited.20 They argued that the impact of such programs may be improved if delivered early in the transition from elementary to middle school, if same-aged peers play a significant role in delivery of the program, and if they are part of a multi-component health program.
A 2015 systematic review and meta-analysis examining the effectiveness of peer-led interventions found lower odds of weekly or monthly smoking compared to those in a control group.21 Schools were considered an appropriate setting for the interventions where peer leaders were able to deliver part or all of the anti-tobacco curriculum. However, there was no clear pattern, from the studies included, of factors associated with impact, e.g. duration of intervention or underlying theory. The authors speculated that peer-led interventions may resonate to a greater extent with young people due to greater perceived credibility of peers, than of adults or professionals, in part due to shared social status, cultural background and being embedded within the same social groups and communities. The authors noted however that in two interventions, there were reports of increased rates of smoking. This finding was observed among those with pro-smoking attitudes and who had a substantial proportion of tobacco-using friends. The authors suggested that interventions take into account peer norms and peer influences in young people’s friendship groups and social networks, and targeting preventive messages to different risk groups in order to maximise effectiveness.21
In a meta-analysis of school based drug prevention programs more broadly, those led by peers addressing the social influences of drug use were among the more effective strategies.22
In a 1999 brief report on common reasons why some peer education can fail to be effective, a number of reasons were identified, including a lack of clear aims and objectives, inconsistency between the project design and the external environment/constraints, inadequate appreciation of the fact that peer education is a complex and skilled process to manage, and inadequate training and support of peer educators.
The way in which influential and credible peers are selected can also be critical to the success of peer-led approaches. In school-based peer interventions, peer educators are most often self selected and/or selected by school staff, but this can result in peer educators who may not be perceived as influential or credible by the target group.14 The ASSIST intervention is an example of a UK program that sought to overcome this limitation, through the development of a peer nomination process to identify ‘influential students’.14 23 The intervention was evaluated in a randomised controlled trial and involved 10,730 students aged 12–13 years across 59 schools (30 intervention, 29 control). The nomination process resulted in a diverse mix of students being selected as ‘peer supporters’ in the intervention schools; these students were trained to utilise their informal contacts with peers to disseminate smokefree health promotion messages outside the classroom setting.23 While some students and staff expressed doubts about the suitability of some of the students recruited to be peer supporters, the likelihood of students becoming smokers was significantly lower in the intervention schools at two-year follow-up. 14, 23
An economic evaluation of the ASSIST program concluded that it was a cost-effective intervention that resulted in a 2.1% reduction in smoking prevalence at two-year follow-up, and delivered at a modest cost of £32 per student (based on cost of program delivery projected in 2008 pound equivalent, which equated to approximately $72 Australian dollars).24 The authors also projected the economic costs and health promotion impact of extending the intervention to all Year 8 students (based on student numbers in 2007–08) across all UK schools, concluding that this could result in 20,400 fewer adolescent smokers for a cost of about £38 million (which equated to around $85 million Australian at the 2008 exchange rate).
In other studies, social branding has been used as a novel approach for peer crowd segmentation at events to identify and engage high-risk groups of young people for tobacco prevention and cessation. In this approach, peer crowds are groups of young people who share common interests, values, and lifestyles both within and outside of one’s immediate peer group, for example, those who identify as ‘Hipsters’ or ‘Partiers’. Anti-tobacco messaging is then delivered through opinion leaders who are viewed as influential peer crowd members. Two interventions using this method have been conducted in the US. The first, COMMUNE,25 was an intervention designed to compete with tobacco industry marketing in social venues. It was tailored for the ‘Hipster’ peer crowd with messaging delivered via peer crowd opinion leaders. The second was HAVOC,26 an intervention developed for ‘Partiers’, utilising brand ambassadors and peer crowd opinion leaders. Both interventions were successful and in a follow up research paper seeking to understand how and why the two interventions were effective, researchers reported six main features that participants found valuable;27 fun, interactive social environment; a sense of belonging; subtle, non-judgmental messaging; peer crowd specific; delivery through opinion leaders; and promotion of brand individuality and recognition’. The inclusion of peer crowd opinion leaders in the interventions were seen as valuable for encouraging event attendance and helping to create an exclusive experience for event attendees by using their willingness to engage positively with other peer crowd members and taking a visible role in the intervention.27
In a smaller randomised trial, the prevention strategy Teens Against Tobacco Use was found to have substantial promise.28 Adult advisors recruited and trained high school and middle school students to develop and deliver tobacco prevention presentations to younger students in the school setting. Classrooms receiving the tobacco prevention presentation had significantly lower tobacco susceptibility scores than classrooms not receiving presentations (12% vs 17%, p<0.01), representing a 37% reduction in the odds of tobacco susceptibility.28
5.28.3 Peer-based smoking interventions in Australia
Peer-based education in Australia has traditionally been more commonly applied to drug education and sexual health issues than to smoking prevention or cessation. Historically in Australian tobacco control, there have been a few peer-based programs targeting smoking, such as the ‘Hot water kit’ peer education program developed by the Victorian Smoking and Health Program in the early 1990s; these days, issues relating to peer influence are more commonly embedded within broader school-based programs and resources.
Peer influence was also used as a communication approach as part of the Western Australian Smarter than Smoking media project targeting adolescents. The project produced a series of advertisements that sought to tap into the peer influence psyche, with vignettes, for example, featuring young people reflecting on the lack of money or fitness of peers who smoke. Campaign evaluation data collected from a sample of young people aged 14–15 years between 1999 and 2005 found a significant strengthening in young people’s agreement with statements relating to the cost and effects on fitness of smoking.29
For information on adolescent-focused e-cigarette prevention programs in schools see Section 18.10.7.
Relevant news and research
For recent news items and research on this topic, click here. (Last updated April 2022)
1. Conrad K, Flay B, and Hill D. Why children start smoking cigarettes: Predictors of onset. British Journal of Addiction, 1992; 87(12):1711–24. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.1992.tb02684.x
2. Wang M, Fitzhugh E, Westerfield R, and Eddy J. Family and peer influences on smoking behaviour among American adolescents: An age trend. Journal of Adolescent Health, 1995; 16:200-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7779829
3. Tyas S and Pederson L. Psychosocial factors related to adolescent smoking: A critical review of the literature. Tobacco Control, 1999; 7(4):409–20. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/7/4/409
4. Seo D-C, Torabi MR, and Weaver AE. Factors influencing openness to future smoking among nonsmoking adolescents. Journal of School Health, 2008; 78(6):328–36. Available from: https://pubmed.ncbi.nlm.nih.gov/18489466/
5. Simons-Morton B and Farhat T. Recent findings on peer group influences on adolescent smoking. Journal of Primary Prevention, 2010; 31(4):191-208. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20614184
6. Vitória PD, Salgueiro MF, Silva SA, and de Vries H. Social influence, intention to smoke, and adolescent smoking behaviour longitudinal relations. British Journal of Health Psychology, 2011; 16(4):779-98. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.2044-8287.2010.02014.x/full
7. Marsh L, Iosua E, McGee R, and White J. New Zealand adolescents' discouragement of smoking among their peers. Australian and New Zealand Journal of Public Health, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28749572
8. Milburn K. A critical review of peer education with young people with special reference to sexual health. Health Education Research, 1995; 10(4):407–20. Available from: http://her.oxfordjournals.org/cgi/reprint/10/4/407
9. Perry C. Reaching youths before they begin. ARHP Clinical Proceedings, 1996; October:20-1.
10. Donaldson SI, Graham JW, and Hansen WB. Testing the generalizability of intervening mechanism theories: Understanding the effects of adolescent drug use prevention interventions. Journal of Behavioral Medicine, 1994; 17:195-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8035452
11. Wood L. Preventing teenage smoking what works best: A review of international behavioural interventions relevant to efforts to reduce smoking among young people. Adelaide, Australia: SA Smoking and Health Project, 1999.
12. Rogers EM, Diffusion of innovations. 4th ed New York: The Free Press; 1995.
13. Kelly JA. Popular opinion leaders and HIV prevention peer education: Resolving discrepant findings, and implications for the development of effective community programmes. AIDS Care, 2004; 16(2):139-50. Available from: http://www.tandfonline.com/doi/pdf/10.1080/09540120410001640986
14. Starkey F, Audrey S, Holliday J, Moore L, and Campbell R. Identifying influential young people to undertake effective peer-led health promotion: The example of A Stop Smoking In Schools Trial (ASSIST). Health Education Research, 2009; 24(6):977–88. Available from: http://her.oxfordjournals.org/cgi/content/abstract/24/6/977?etoc
15. Bilgiç N and Günay T. Evaluation of effectiveness of peer education on smoking behavior among high school students. Saudi Medical Journal, 2018; 39(1):74-80. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885124/
16. Black D, Tobler N, and Sciacca J. Peer helping/involvement; an efficacious way to meet the challenge of reducing alcohol, tobacco and other drug use among youth? Journal of School Health, 1998; 68(3):87–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9608448
17. Straus MB, Violence in the lives of adolescents. New York: W.W. Norton and Company; 1994.
18. Kassirer A and Griffiths J. The effectiveness of 'the responsible sexuality program': A brief high school sexual education intervention. Journal of Sex Education Therapy, 1997; 22:5-11. Available from: http://her.oxfordjournals.org/content/17/4/471.full
19. Allbutt H, Amos A, and Cunningham-Burley S. The social image of smoking among young people in Scotland. Health Education Research, 1995; 10:443-54. Available from: http://her.oxfordjournals.org/content/10/4/443.abstract
20. Rooney B and Murray D. A meta-analysis of smoking prevention programs after adjustment for errors in the unit. Health Education Quarterly, 1996; 23:48-64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8822401
21. MacArthur GJ, Harrison S, Caldwell DM, Hickman M, and Campbell R. Peer-led interventions to prevent tobacco, alcohol and/or drug use among young people aged 11-21 years: A systematic review and meta-analysis. Addiction, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26518976
22. Tobler NS, Roona MR, Ochshorn P, Marshall DG, Streke AV, et al. School-based adolescent drug prevention programs: 1998 meta-analysis. Journal of Primary Prevention, 2000; 20:275-336.
23. Campbell R, Starkey F, Holliday J, Audrey S, Bloor M, et al. An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster randomised trial. The Lancet, 2008; 371:1595-602. Available from: http://www.sciencedirect.com/science/article/pii/S0140673608606923
24. Hollingworth W, Cohen D, Hawkins J, Hughes RA, Moore LAR, et al. Reducing smoking in adolescents: Cost-effectiveness results from the cluster randomized ASSIST (A Stop Smoking In Schools Trial). Nicotine & Tobacco Research, 2012; 14(2):161-8. Available from: http://ntr.oxfordjournals.org/content/14/2/161.short
25. Ling PM, Lee YO, Hong J, Neilands TB, Jordan JW, et al. Social branding to decrease smoking among young adults in bars. American Journal of Public Health, 2014; 104(4):751-60. Available from: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2013.301666
26. Fallin A, Neilands TB, Jordan JW, Hong JS, and Ling PM. Wreaking "havoc" on smoking: Social branding to reach young adult "partiers" in oklahoma. American Journal of Preventive Medicine, 2015; 48(1 Suppl 1):S78-85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25528713
27. Toledo G, McQuoid J, and Ling PM. "It's not too aggressive": Key features of social branding anti-Tobacco interventions for high-risk young adults. Health Promotion Practice, 2020:1524839920910372. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32111139
28. Brown LD, Bandiera FC, and Harrell MB. Cluster randomized trial of teens against Tobacco use: Youth empowerment for Tobacco control in El Paso, Texas. American Journal of Preventive Medicine, 2019; 57(5):592-600. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31564599
29. Mitchell J, Rosenberg M, and Wood L. Adolescents with attitude ... Changes in views about smoking over time. Health Promotion Journal of Australia, 2008; 19(2):109–12. Available from: http://www.unboundmedicine.com/medline/ebm/record/18647123/full_citation/Adolescents_with_attitude_____changes_in_views_about_smoking_over_time_