5.9.1 Individual risk and protective factors
Academic achievement
Research, including from Australia,1 has shown that smoking in adolescence is associated with lesser academic achievement.2-5 This relationship may be reciprocal, in that smoking can both precede and follow poor grades.6 Research has found that students who experience difficulties with their schoolwork are more likely to take up smoking.7-9 In turn, students who smoke are more likely to perform less well academically.7,10 Peer smoking, or smoking by both parents, further reinforces the association between low academic performance and the intention to smoke among adolescents.11
For those who have tried smoking by the start of high school, higher academic achievement during the secondary years has been found to be protective against future smoking and other problem behaviour.12
Academic engagement and educational aspirations
Research has found that students who show low school engagement are more likely to take up smoking.7,8 Furthermore, students who smoke have been found to be less likely to enrol into post-secondary education.7
A 2021 longitudinal Swedish study found that both the level of completed education and the type of further education was associated with smoking initiation,9 with young people who only obtained (or anticipate to obtain) a compulsory amount of schooling being especially vulnerable to smoking uptake.9 Similarly, Australian research examining Victorian school children aged between 12 and 15 years found that those who did not intend to complete Year 12 were more likely to smoke than students who expected to complete their schooling.13
Having high educational aspirations has been found to be a protective factor in the susceptibility to smoking in adolescence.14
Feelings of belonging and connectedness at school
Students who smoke are more likely to feel negatively towards school.7 Research from New South Wales has shown that having a negative attitude to school, measured by student perception of school environment and teacher support, was associated with higher levels of smoking.15 A 2023 study on social connectedness and smoking among school children found that, compared with students who did not smoke, students who did smoke had significantly lower scores in terms of connectedness to school, and support from teachers and school peers.16
Research has found that students who experience a sense of ‘burnout’ during high school, are more likely to take up smoking.7,8
Liking school has been shown to be a consistent protective factor in the susceptibility to smoking in adolescence.14 Moreover, students who experience feelings of connectedness and belonging at school have been found to be less likely to take up smoking.2
Research has found that the social environment of schools, including a focus on caring and inclusiveness and the quality of teacher–student relationships (based on both student and teacher reports) can influence student smoking rates. The potentially protective effect of student–teacher relationships on adolescent smoking behaviour was observed in a large longitudinal study in Northern Ireland, with students who reported a positive relationship with teachers almost half as likely to report daily smoking as those who reported a negative relationship.17
Truancy, suspensions, expulsions, or drop out
Students who smoke are more likely to miss school more often, and are more likely to drop out of school at an earlier age than students who do not smoke.7,10 National data from England on secondary school students has shown that truancy or exclusion from school (being suspended or expelled) is correlated with regular smoking.18
Students who smoke are also more likely to engage in school misbehaviour.5
Research from the UK has found schools that reported lower levels of truancy and achieved better than expected examination results on the basis of their socio-demographic profile had a lower student smoking prevalence. The authors of this study propose that higher degrees of school connectedness may have the potential to break the link between smoking and disadvantage.19
5.9.2 School tobacco policies
One of the single most inexpensive and effective actions a school can take to reduce smoking is to introduce and enforce a no-smoking policy for teachers, staff and students.20-25
Research has shown that having more students with no nicotine use protects against susceptibility to smoking in adolescence.14
In a 2017 review26 on the impact of school tobacco policies on adolescent smoking behaviour the researchers recommended that for policies to be successful schools should include all buildings and premises, not allow students to leave school premises, develop clear rules, ensure strict enforcement, apply the policies to all individuals, and complement with education, prevention, and counselling. Moreover, the researchers recommended that policy should be continuously assessed for impact and adapted to incorporate improvements.26
Inconsistent enforcement by staff members may lead adolescents to perceive the smoking ban as unfair (e.g. different sanctions applied to different adolescents) and adolescents may rebel against school authority when the rules are perceived to be inconsistent.26
Due to the importance of strict and consistent enforcement of school tobacco policies, a 2019 review27 set out to understand what determines staff enforcement of school tobacco policies. The review found that staff members feel more responsible, motivated and confident to enforce school tobacco policies when they feel that the school tobacco policies are part of the school staff’s professional role and duties, feel their contribution is leading to positive outcomes, and feel that they are able to deal with students’ responses.27
In Australia, all states and territories have smokefree laws for schools indoors, however, to date, only Victoria, Queensland, South Australia, Tasmania and the Northern Territory have smokefree laws that apply to school grounds, see Table 15.7.1 in Section 15.7.10 for more information on smokefree legislation across Australian states and territories.
5.9.3 School-based smoking interventions
School-based interventions were traditionally a key focus of efforts to prevent young people adopting unhealthy behaviours including smoking.28 Some of the major premises underlying the use of schools to promote health include the following:
- Children spend a large proportion of their time in school, including during the developmental years when health-risk behaviours are often formed.
- Schools are recognised places of learning, and have structures and systems into which ‘health education’ can be integrated.
- The school environment, and the messages and cues it communicates, can influence student attitudes and behaviours by either reinforcing or undermining what is taught in the classroom.
- Schools provide a prime access point as nearly all young people attend school, including disadvantaged and ‘at risk’ groups.
- Schools also provide access to important secondary target groups such as parents, families and the broader community.28
The most common types of school-based smoking prevention methods are described in Table 5.9.1.29
5.9.4 School-based smoking interventions in Australia
All states and territories in Australia have developed, or have access to, some form of school-based smoking prevention activity (see Table 5.9.2). These programs vary in their delivery technique, content and target group, but many cover similar topics. The State Government of Victoria has had comprehensive Smoke Free Schools Tobacco Prevention and Management Guidelines for Victorian Schools in place since 2009,35 and Tasmania,36 South Australia,37 and the Northern Territory38 have highlighted the need for similar school tobacco prevention programs in their tobacco action plans.
5.9.5 Are school-based smoking interventions effective?
A number of comprehensive reviews have concluded that school-based programs are effective at preventing and reducing tobacco use among young people.39-43
Older studies reported mixed evidence regarding the effectiveness of school-based smoking interventions, both from individual studies and various reviews of the evidence.29,44-47 However, a critique of these reviews argued that the differing methodologies and methodological limitations of past reviews led to conclusions of ineffectiveness, and notes the difficulty of comparing the vast variety of programs that have been implemented in schools, which can differ considerably in theoretical framework, target age group, program content, method of delivery, duration, type of school environment and so on.47
Across multiple systematic reviews and meta-analyses, evidence has shown that school-based programs are effective at preventing and reducing tobacco use among young people. A 2013 Cochrane review42 of 49 randomised controlled trials (RCTs) and a 2015 review43 of 50 RCTs both reported no significant effects at one year or less, but identified longer-term benefits, including a 12% reduction in smoking onset.43 Other meta-analyses have also found significant effects: a 2021 meta-analysis41 of 23 RCTs reported a significant reduction in smoking, and a 2025 review and meta-analysis40 of 20 studies in low- and middle-income countries found 24% lower odds of tobacco use among intervention participants. In contrast to the earlier reviews that showed significant longer term impact but no short term impacts, a 2025 review and meta-analysis39 of six RCTs reported substantial short-term effects at six months, however these effects diminished over longer follow-up periods.
Information on effectiveness for many Australian interventions is not readily available. Exceptions are interventions that have received research grant funding. An Australian study investigated the impact of the Drug Education in Victorian Schools (DEVS) program on tobacco smoking after three years and found intervention students smoked fewer cigarettes and experienced less smoking related harm, than the control groups.48 Australian research on the effectiveness of the personality-targeted prevention program PreVenture for adolescent tobacco use found students from participating schools were less likely to report recent tobacco use and intentions to use tobacco in the future over the three-year follow-up period, compared to control schools.48,49
5.9.6 Making school-based interventions more effective
A substantial body of research has identified factors that may influence the effectiveness of school-based smoking prevention programs, spanning the relevance of program content, the timing and intensity of delivery, the underlying theoretical frameworks employed, and the ways in which programs are delivered and integrated within broader school contexts.
Theoretical framework
As summarised in the US Surgeon General’s 201250 report on preventing tobacco use among youth and young adults, school-based programs are more effective when they are a part of coordinated, multicomponent interventions that combine mass media campaigns, tax and price increases, and state-wide or community-wide strengthening of smokefree policies.2 An Australian example of this was the Western Australia Smarter than Smoking project, which had an active schools component (including teacher and school activity resources, school grants, smarter than smoking sports, and arts sponsored activities for school students) complementing mass media and other strategies.51 As noted by researchers,52 it is often difficult for multimodal interventions to disentangle the relative impact of school curricula-based, school-wide environmental change, parent training, mass media and community-wide interventions.
In a 2013 Cochrane review, the researchers concluded that combined social competence and social influences interventions at all time points (See Table 5.9.1 above for a description of these theoretical concepts), and social competence interventions at longest follow-up prevented smoking uptake compared with controls; social influence interventions did not appear to reduce uptake compared with controls.42 In a 2015 systematic review and meta-analysis by the same researchers, the review concluded that only social competence and combined social competence/social influence showed statistically significant results (7 trials, OR 0.59 (95% CI 0.41 to 0.85)). Social competence curricula include interventions that help adolescents refuse offers to smoke by improving their general social competence and personal and social skills. This type of intervention teaches problem solving, decision making, cognitive skills to resist personal or media influences, ways to increase self-control and self-esteem, coping strategies for stress, and assertiveness skills. Information-only, social influences and multimodal curricula were not found to be effective.43
Relevant and targeted content
Young people tend to disassociate themselves from the long-term health effects of smoking,53 as they lack personal salience to their lives in the here and now. Focusing on the shorter-term consequences of smoking is far more relevant to young people than longer term health effects,54,55 and is a finding reiterated in focus group research with adolescents in Australia.53,56
Researchers have also highlighted the need for programs to take into account context-specific factors40 and the needs of different cultures and minorities,57 as it is not easy to adopt and adapt programs for use in contexts different from those in which they were tested, especially in other cultures and countries, and great care must be taken to implement with integrity and monitor implementation and outcomes.47 Other research has also suggested taking into account individual disposition traits,58 and personality types when developing prevention programs.49
Evidence suggests that the most critical window of opportunity for prevention programs in school settings appears to be in the late primary to early secondary school years.59 In an intervention targeting 5th and 6th grade students, treatment had limited effects during elementary school but in secondary school (one year later) significant effects on smoking and behavioural determinants were seen.60 The intervention group had a higher intention not to smoke and started to smoke less often than the control group.60
Duration and intensity of the program
A 2021 meta-analysis of randomised controlled trials examining the effects of smoking prevention programs for young adolescents found that the effects of high-intensity (seven or more sessions with each session lasting between 45 and 60 minutes) programs were statistically significant, while low-intensity programs did not show a meaningful or reliable effect on smoking behaviour.41
Shorter interventions appeared to offer practical advantages, suggesting that brief yet engaging programs that incorporate targeted behavioural change techniques, such as providing information on emotional consequences and strategies for reducing negative emotions, may optimise effectiveness. However, evidence regarding long-term prevention of tobacco use remains less clear, and further research is needed to determine optimal intervention duration and intensity for sustained effectiveness.40
A 2013 Cochrane review found there was no evidence that delivering extra sessions makes the intervention more effective.42 A later 2015 Cochrane review confirmed booster sessions did not increased effectiveness.43
Appropriate delivery
Programs with interactive elements appear to be significantly more effective than non-interactive programs.61,62 Having trained, rather than non-trained, adult43 instructors delivering the program positively affects program implementation.62,63 Specifically, training to address how to deliver controversial topics, and training that leaves instructors feeling adequately supported to deliver the program.63 Having the program conducted by teachers or educators has been shown to be effective, when compared to health-related persons (including professionals or students studying health-related majors) or peers.41,42
In a 2021 meta-analysis on the effects of smoking prevention programs for young adolescents, programs were found to be most effective when conducted by a trained teacher. The author argues that a close bond between a young adolescent and his or her teacher is considered an important protective factor, therefore, school-based programs conducted by teachers with whom students may have a close bond can have positive effects on the prevention or reduction of smoking behaviour among students.41
Integrated programs
The UK National Institute for Health and Clinical Excellence recommends that information on the health impacts of smoking and its social, legal and behavioural aspects be integrated into the broader curriculum in areas such as biology, economics, mathematics, chemistry, geography or media studies.64 It is unhelpful to treat each health issue independently, as there are underlying determinants, issues and skills relevant across health behaviour areas. The clustering of tobacco use with other risk behaviour is well documented (see Section 5.5).45,65,66 Researchers also argue that coupling smoking with other health issues is beneficial because on its own, it is often ranked below other topics in terms of teacher priority.65 Teachers may be more prepared to devote curriculum time to more comprehensive rather than single issue programs.45
Furthermore, school contexts that matched the intervention with their own promoted values were more likely to enable successful implementation.63
Researchers have recommended that programs have built-in methods of updating material,67 particularly as smoking runs the risk of being viewed as a ‘tired’ issue; innovative and creative ways to address it are important.68
Barriers to effective implementation
In a 2017 systematic review, barriers to implementation of tobacco and substance use interventions within secondary school settings included: heavy workloads, budget cuts and lack of resources or support for teachers. In particular, education providers within the school setting often did not fully understand the scale and complexity of the implementation requirements, which would lead to low fidelity in carrying out the intervention as intended.63
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References
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