Development and evaluation of an intervention providing insight into the tobacco industry to prevent smoking uptake: a mixed-methods study

Abstract

Background: Smokers who start smoking at an early age are less likely to quit and more likely to die from their habit. Evidence from the US Truth® campaign suggests that interventions focusing on tobacco industry practices and ethics may be effective in preventing smoking uptake. Objectives: In an exploratory study, to develop, pilot and provide preliminary evidence of the acceptability and effectiveness of Operation Smoke Storm, a school-based intervention based on the premise of the Truth® campaign, to prevent smoking uptake. Design: Mixed-methods, non-randomised controlled study. Component 1 was delivered to Year 7 students, and student focus groups and teacher interviews were conducted to refine the lessons and to develop components 2 and 3. The revised Year 7 lessons and accompanying family booklet were delivered to new Year 7 students 1 year later in one school only; Year 8 students in both schools received the booster session. Setting and participants: Students in Years 7–8 (aged 11–13 years) in two UK schools. Intervention: A three-component intervention comprising (1) three 50-minute classroom-based sessions in Year 7 in which students acted as secret agents to uncover industry practices through videos, quizzes, discussions and presentations; (2) an accompanying family booklet containing activities designed to stimulate discussions about smoking between parents and students; and (3) a 1-hour interactive classroom-based booster session for Year 8 students, in which students learnt about tobacco marketing strategies from the perspectives of an industry executive, a marketing company and a health campaigner. Main outcome measures: Odds ratios to compare the self-reported prevalence of ever smoking and susceptibility to smoking in Year 8 students after the delivery of the booster session in study schools compared with students in local control schools. Qualitative data on acceptability of the intervention. Results: The combined prevalence of ever smoking and susceptibility increased from 18.2% in Year 7 to 33.8% in Year 8. After adjusting for confounders there was no significant difference in the odds of a Year 8 student in an intervention school being an ever smoker or susceptible never smoker compared with controls [adjusted odds ratio (aOR) 1.28, 95% confidence interval (CI) 0.83 to 1.97; p = 0.263] and no significant difference in the odds of ever smoking (aOR 0.82, 95% CI 0.42 to 1.58; p = 0.549). Students mostly enjoyed the intervention and acquired new knowledge that appeared to strengthen their aversion to smoking. Teachers liked the ‘off-the-shelf’ nature of the resource, although they highlighted differences by academic ability in the extent to which students understood the messages being presented. Use of the family component was low but it was received positively by those parents who did engage with it. Limitations: Logistical difficulties meant that students’ responses in Year 7 and Year 8 could not be linked; however, baseline smoking behaviours differed little between intervention and control schools, and analyses were adjusted for confounders measured at follow-up. Conclusions: Operation Smoke Storm is an acceptable resource for delivering smoking-prevention education but it does not appear to have reduced smoking and susceptibility. Future work: The lack of a strong signal for potential effectiveness, considered alongside logistical difficulties in recruiting and working with schools, suggests that a fully powered cluster randomised trial of the intervention is not warranted. Funding: The National Institute for Health Research (NIHR) Public Health Research programme.