Last updated April 2012
As discussed in Section 5.8, peer group influences have been identified in numerous studies as a significant factor in uptake of smoking.1–6 Consequently, peer influences on youth smoking have received considerable, and some would argue disproportionate, attention in tobacco control, both in terms of research and in terms of investment in interventions.
For a long time, 'peer pressure' or perceptions that 'smoking is cool' were touted by the average person as primary determinants of youth smoking. The evidence suggests that it is far less simple however, 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.
Nonetheless, the 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.
The theoretical roots of peer education approaches can be traced to Bandura's social learning theory, and to social inoculation theory.7 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.7 Social influence programs may foster social norms that reduce adolescent social motivation to commence smoking,8,9 and peer education strategies can complement and reinforce other health promotion approaches.10
'Diffusion of innovations'11 is another 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.12 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.12, 13
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,7 modelling of interpersonal skills,14 and fostering of peer mentors.15 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.13
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.8, 13, 16
Research by Allbutt and colleagues in Scotland17 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.
While the rationale for peer-led approaches has theoretical and intuitive appeal, isolating the effectiveness of peer initiatives is difficult, and the evidence to date is somewhat mixed.
The complex nature of adolescent health behaviours and their peer interactions, and the influences of the broader social milieu in which they live, makes it difficult to measure behavioural change that is directly attributable to peer education.7 Peer-based strategies are also sometimes embedded within broader programs–for example, the long-running Minnesota Smoking Prevention Program in the US used peer leaders to conduct many of its program activities.8 Significant reductions in smoking onset and prevalence have been attributed to this program,8 but it is not clear what proportion of this success is due to the peer education component alone.
In a meta-analysis of smoking prevention programs, Rooney and Murray concluded that peer or social type programs should be continued as part of smoking prevention efforts, but that the overall magnitude of effect is quite limited.18 They argue 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.
In a broader meta-analysis of adolescent drug prevention programs delivered in school settings, interactive programs and those led by peers addressing the social influences of drug use were among the more effective strategies.19
As with youth mass media and school-based interventions, the quality, design, expectations and evaluation deficiencies of programs sometimes make it difficult to ascertain whether peer education is flawed per se, or flawed in its delivery. In a review of the effectiveness of youth peer interventions generally, Walker20 identifies a number of reasons for intervention failure, 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 as argued by Starkey and colleagues,13 this can result in peer educators who may not be perceived as influential or credible by the target group. 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'.13,21 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.21 Interestingly, the researchers note that 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.13, 21
An independent economic evaluation of the ASSIST program has also been undertaken,22 deeming it to be 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 equates to approximately $72 Australian dollars). 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 2007/2008) across all UK schools, concluding that this could result in 20 400 fewer adolescent smokers for a cost of around £38 million (which equated to around $85 million Australian at the 2008 exchange rate). The authors go on to note that this represents a good investment when compared to National Health Service expenditure on treating lung cancer in one year alone of £260.8 million.
Peer-based education in Australia appears to be 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 has also been 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.23
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