Tobacco consumption causes considerable damage to public health. Smoking kills over 650,000 people each year in Europe. For young people, there are very serious health consequences of smoking. Those who begin to smoke at a young age are less likely to give up and likely to smoke more heavily than those who start smoking later in life. They are more likely to smoke for longer and to die early from smoking-related illnesses (1). Moreover, those who start to smoke at a young age have higher age-specific cancer rates for all types of tobacco-related cancers - someone who starts smoking at age 15 is three times more likely to die of cancer due to smoking than someone who starts in their mid-20s. 90% of all smokers began smoking by the age of 18 and there is evidence that smoking prevalence remains high amongst young people at a time when overall smoking rates are falling.
Exposure to second-hand smoke kills non-smokers and exacerbates illnesses. However, many children and young people continue to be exposed to second-hand smoke, which has serious health and equity implications. Children are particularly susceptible to second-hand smoke as their bodies are still developing, their bronchial tubes and lungs are smaller and their immune systems are less developed (4). They also take in more chemicals from tobacco smoke than adults as they breathe faster.
Against this background, the WHO Framework Convention on Tobacco Control (FCTC) Article 12 outlines the need to promote and strengthen public awareness of tobacco control issues including broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristics of tobacco consumption and exposure to tobacco smoke. To this end, it is vital to raise public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles. Educational and public awareness programmes can contribute greatly to the denormalisation of tobacco consumption in our societies.
It is in this context that the project Working with communities to reduce health inequalities: protecting children and young people from tobacco, which received funding from the European Union in the frame of the Public Health Programme, was developed and implemented. The project ran from 2008 to 2010. Its primary objective was to develop tools that could tackle (1) high smoking prevalence rates amongst young people and (2) exposure of children and young people to second-hand smoke. The project included a focus on children and young people from socially excluded and disadvantaged communities that have poor health indicators. This article reviews the content and outcomes of the project and highlights the policy recommendations that flow from it.
The Working with Communities project was led by Liverpool Primary Care Trust, involved partners from 15 EU Member States and delivered a series of integrated activities and interventions engaging local communities and peer groups (5). It assessed the effectiveness of these interventions and it culminated in the development and launch of a cross-cultural, community engagement tool-kit (6) as well as a series of policy recommendations. Six pilot interventions were carried out and evaluated during the project:
- Partners from Paris (France), Riga (Latvia) and Liverpool (UK) implemented pilot projects that focused on school-based, peer-to-peer interventions to raise awareness about tobacco-related issues and to tackle smoking behaviour amongst young people aged 11 to 15 years old (7).
- Partners from Veneto (Italy), Manisteria (Romania) and the Manchester (UK) implemented pilot projects that focused on engaging local communities in protecting children from exposure to second-hand smoke (8).
School-based peer-to-peer actions
Partners from Liverpool, Paris and Riga launched pilot projects focussing on tobacco-related, peer-to-peer interventions in a total of 15 schools. In each pilot intervention, trained peer advocates delivered tobacco control interventions, within classroom settings, to other - usually younger - children in their school.
Evidence from the evaluations of these pilots highlighted several consistent findings. First, it was clear that across all the interventions, the projects were very well received and feedback from schools, peer mentors and young people was very positive. Second, peer advocates were the main beneficiaries. Their in-depth involvement led to a deepening of their knowledge, shifted or reinforced their attitudes to smoking and encouraged some to attempt to change their smoking behaviour. It also boosted their self-esteem. Thirdly, targeted pupils also benefited from an increase in their knowledge about tobacco control issues.
For instance, in Riga, there were identifiable impacts from pre and post intervention, survey data amongst the target group in relation to (1) an increase in knowledge about smoking (2) attitudes to smoking - suggesting greater resistance to young people taking up smoking. Amongst peer advocates who were smokers, their involvement had increased their intentions to quit. In Liverpool,qualitative evaluation indicated that, for peer advocates, their involvement increased their knowledge about tobacco control issues, reinforced smokers intentions to quit and led to more discussion about smoking in their own homes. For the target pupils, survey data indicated that the project also raised awareness about smoking issues and the dangers of tobacco and led to some encouraging their parents to quit smoking or not to smoke at home. In Paris, feedback from the pilot project participants suggested that the intervention increased most pupils knowledge about tobacco and reinforced smokers intentions to stop smoking and non-smokers resistance to starting.
Key policy lessons emerging from the school-based, peer-to-peer project experience related to procedures for engaging schools, the age and smoking status of peer advocates and the scope and scale of interventions. In terms of engaging schools in such interventions, the project highlighted that securing collaboration from schools for peer-to-peer interventions is a labour intensive activity and some schools can be difficult to engage. This can frustrate efforts to include all schools within an area. Importantly, the experience of the pilot interventions suggests that interventions could be more cost-effective, simpler to initiate and more widespread if peer-to-peer and tobacco control activities were built into school curricula. In this way, the potentially labour intensive activity of “selling the idea” to schools could be avoided. That does not mean that schools would not need support to deliver effective interventions but it does mean that they would already be prepared and geared up to participate.
The project clearly suggests that the age and smoking status of peer advocates can influence the effectiveness of peer-to-peer interventions. Lessons from the pilots indicate that peer advocates should be older than the pupils that they engage with. Peer advocates are more likely to work effectively in a class-based environment with younger children. Equally, younger pupils are more likely to respect and give their attention to older pupils.
The use of peer advocates who may be smokers is more contentious. There is an argument for involving peer advocates who smoke - as they may be motivated to stop smoking. However, the pilot experience suggests that if peer advocates smoke, it risks undermining the credibility of interventions. On balance, therefore, it is preferable that peer advocates should be pupils who have stopped smoking or who never smoked. At a minimum, however, if smokers do become peer advocates, it is important that they are not put into a position where they may mislead pupil beneficiaries about their smoking status. For instance, peer advocates indicating that they are not smokers, campaigning against smoking but then being seen smoking by others would be counter-productive.
For interventions to be able to generate change in knowledge, attitudes and behaviour, it is important that they are not simply one-off actions. Peer-to-peer interventions in classrooms will be more effective if they are extended over several sessions.
Community Engagement Actions
Partners from Manchester (UK), the Veneto Region (Italy) and Manastirea (Romania) realised pilot interventions, which centred around engaging communities in protecting children from exposure to second-hand smoke. Each community engagement pilot utilised community-based advocacy methods to deliver tobacco control interventions to protect children and young people from second-hand smoke. Each drew on differing traditions, cultural contexts and available resources to devise the most appropriate method to engage local communities and to achieve its goals.
In Wythenshawe, Manchester (UK), civil society partners and health professionals worked alongside local community volunteers to engage with residents and parents from across the community. The Healthy Smoke-free Families initiative engaged both children and parents to make their families smoke-free. In Manastirea (Romania), an established group of community activists received tobacco control training and led a series of second-hand smoke actions within the local community. The community group aimed to bring about lasting improvements in the community by working together to identify the health and social problems. In Veneto Region (Italy), primary school teachers worked alongside local health professionals to engage with primary school children and their parents. The intervention targeted secondary school pupils aged 12-13, endeavouring to improve life skills in an attempt to reduce vulnerability to social pressure, while at the same time involving family, school and peers.
Evidence from evaluations of these pilots indicates that these community-based interventions increased the number and proportion of households with children in the community that are smoke-free - leading to children and young people becoming more protected from exposure to second-hand smoke and raised knowledge amongst parents about the dangers of second-hand smoke and influenced their attitudes to it.
For instance, in Manchester, 1151 households in Wythenshawe signed up to the initiative during the one year project period and declared their homes smoke-free. Of these, 558 people from smoking households, including 471 smoking households with over 1400 children declared their homes smoke-free. 413 families made a behaviour change - in homes where previously smoking did take place, following the intervention, smoking was no longer allowed. In Manastirea, the intervention had a positive impact on knowledge, attitudes and behaviour. In particular, there is evidence that it affected the incidence of smoking indoors. Survey data indicated that the number of respondents who declared that in their home someone smokes every day decreased, and fewer smokers smoked in front of children. Also, the percent of respondents who stated that smoking was not allowed indoors at all when children or young people are in their house rose after the intervention. In Adria (Veneto region) 283 families signed up to its Smoke Free Homesinitiative. 32% of these were smoking households where smoking took place indoors. These families signed their commitment to maintain, in future, their homes as smoke free. Evidence from survey data also suggests that the intervention has made a difference to parents’ knowledge and awareness of the impact of second-hand smoke on children. In particular, it raised awareness about the risk of children suffering from ear and respiratory infections. It also increased knowledge about the risk of cardiovascular disease for adults exposed to second-hand smoke.
Key policy lessons deriving from the community engagement tobacco control interventions related to the importance of generating genuine community involvement, ensuring adaptability to local circumstances and adopting a sustained and innovative approach. The project reinforced understanding that genuine and substantive community involvement is crucial to effective interventions that seek to shift community-wide perceptions, attitudes and behaviour around tobacco control. The experience points to community involvement being built in from the beginning - including in the design and delivery of the intervention and the approach to be adopted. This is more likely to build a sense of ownership of the intervention and enhance prospects of success.
Whilst the different interventions adopted common principles, reflecting local cultures and norms was important in engaging with their respective communities. The three community engagement pilot projects reflect the reality of adapting interventions to diverse communities. In this context, it can be argued that careful consideration, informed by local knowledge, is essential to ensure that appropriate engagement methods are put in place. Evidence from the pilot projects also emphasised that the prospects of community engagement interventions are more likely to achieve successful outcomes if they are part of a sustained campaign that incorporates innovative and diverse actions across the targeted community.
Generic Programme Lessons
Assessment of the pilot interventions also flags up a series of generic lessons for both peer-to-peer and community engagement tobacco control interventions. These relate to the importance of integrating with broader tobacco control agendas, the wording of second-hand smoke messages, the type of intervention materials and the imperative of cost effectiveness. It also highlights the importance of continuing to build the evidence base for tobacco control actions.
It is very important to recognise that peer-to-peer and community engagement interventions should be part of wider tobacco control agendas that comprehensively seek to reduce smoking prevalence and minimise exposure to second-hand smoke. There is, therefore, a strong case for policy makers, at all levels, to adopt comprehensive tobacco control agendas that can denormalise smoking, cut smoking prevalence - through reducing uptake of smoking and increasing quits - and ensure protection from second-hand smoke for children, young people and adults alike. In this context, peer-to-peer and community engagement interventions must link with other local tobacco control and health strategies and initiatives.
Experience from the pilot projects and elsewhere indicates that messaging that is part of interventions to reduce children and young people’s exposure to second-hand smoke should not be anti-smoker but should emphasise that the aim is to protect “children and young people” from second-hand smoke. Equally, it should emphasise the dangers of children’s involuntary exposure to second-hand smoke - as opposed to what someone can or cannot do in their own home or vehicle and that messages should highlight the positive outcomes of being smoke-free. Materials should also be practical, evidence-based (or, if innovative, derive from a sound rationale), visual, inter-active and be tailored to specific groups.
Especially at a time when public sector budgets are under pressure, all tobacco control interventions will need to be affordable and cost effective. In this context, integrating such actions into school curricula, and into health professionals’ routine activities within local communities, can contribute significantly to affordability criteria and will support the sustainability of programmes.
The Working with Communities project has added to the evidence base about the effectiveness of and policy lessons for peer-to-peer and community engagement interventions. However, there continues to be a knowledge gap about the effectiveness of many youth-focused tobacco control actions. There is also a shortfall in knowledge about precisely what is happening and where in Europe and the extent that interventions that do take place meet good practice criteria. The lack of robust evidence, a comprehensive map and assessments of youth-focussed tobacco control programmes across Europe means policymakers are often ill prepared to make informed judgements about investments in youth-focussed tobacco control action. As a corollary, there is still enormous potential for identifying evidence and good practice that could lead to better youth-focussed tobacco control interventions. A stronger evidence base would lead to improved policy making and better programme and project delivery.
The lessons from the project experience outlined help to make the case for a series of key policy recommendations. Pertinent for European, national, regional and local policy-makers, these are:
Policy recommendation 1:
Tobacco control and peer-to-peer health promotion should be integrated into school curricula as a means of promoting youth engagement, raising awareness and influencing attitudes and behaviour to denormalise tobacco.
Policy recommendation 2:
Tobacco control interventions led and implemented by community-based advocates are an effective way to increase the number of smoke-free homes and vehicles and so protect children and young people from exposure to second-hand smoke. National, regional and local authorities should strongly support such interventions and build them into their strategic and action plans.
Policy recommendation 3:
Community engagement and peer-to-peer advocacy should be incorporated into comprehensive tobacco control strategies, if they are to maximise their impact and address health inequalities.
Policy recommendation 4:
Extensive knowledge of the dangers of tobacco and effective tobacco control measures should be incorporated into the training of health professionals and others who work with children, young people, parents and carers to ensure more continuous and consistent tobacco control advocacy.
Policy recommendation 5:
The Protecting Children and Young People from Tobacco Toolkit should be deployed to strengthen peer-to-peer and community engagement tobacco control interventions and to build the business case for them.
Policy recommendation 6:
Adopting the good practice lessons incorporated within the toolkit, the effectiveness of peer-to-peer and community engagement, tobacco control interventions should be further tested in a more extensive series of demonstration projects to build the evidence base.
Policy recommendation 7:
A comprehensive mapping and assessment of wider youth-focussed tobacco control interventions should be carried out to improve policy-making and enhance programme delivery.