5.29 School-based interventions

Last updated April 2012 

School-based interventions have been the traditional cornerstone of efforts to prevent the adoption of health-compromising behaviours by young people, including smoking. Lynagh and colleagues1 identify some of the major premises underlying the use of schools to promote health:

  • children spend a large proportion of their waking life 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.

The most common types of school-based smoking prevention methods are described in Table An evaluation summary of the approaches is presented in the following section.

Table 5.29.1
School-based intervention methods relating to youth smoking



Information-giving curricula3

Present information about smoking, including health risks of tobacco use, and the prevalence and incidence of smoking.

Social theory based

Social competence curricula based on Bandura's Social Learning Theory,4 Social Influence Approaches based on McGuire's Persuasive Communications' Theory,5 and Evans's Theory of Psychological Inoculation.6 Programs may be underpinned by one or a combination of these approaches.

Multi-modal programs

The methods combine curricular approaches with wider initiatives within and beyond the school, including programs for parents, schools, or communities and initiatives to change school policies about tobacco, or state policies about the taxation, sale, availability and use of tobacco. This is congruent with a health promoting schools approach that is considered 'best practice'.7

Source: Thomas and Perrera 20062

5.29.1 Are school-based programs effective?

There is very mixed evidence regarding the effectiveness of school-based smoking interventions, both from individual studies and various reviews of the evidence.2, 8,9,10,11,12 In addition, few studies have evaluated their long-term impact.13, 14 Several reviews concluded that school-based smoking prevention programs are relatively ineffective,11, 13 but a more recent (2009) critique of the various reviews and meta-analyses conducted to date contested this conclusion.12 Flay contends that the differing methodologies and methodological limitations of past reviews have led to conclusions of ineffectiveness, and notes also the difficulty of strictly 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.12

From his comprehensive 'review of reviews', Flay concludes that school-based interventions can produce significant and practical effects in both the short term and long term.12 This does not apply to all programs clearly, and Flay's review found certain elements were critical for long-term effectiveness, including interactive social influences or social skills programs, a duration of 15 or more sessions including some up to at least ninth grade, and substantial short-term effects.12

Various other reviews have also sought to distil which intervention elements are associated with program effectiveness. A meta-analysis undertaken by Tobler and colleagues found that programs with interactive learning strategies were significantly more effective than non-interactive programs.15 Other reviews found that interventions based on social reinforcement, developmental stages and social norm orientations have been more effective in modifying attitudes and behaviour than programs that focus on more rational information delivery.16,14, 17 Programs only providing information have limited, if any, effect2 and are generally viewed as dated and too narrow a form of health education.

The timing of interventions in relation to child age and development can also be pertinent in terms of effectiveness. 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.18 This corresponds to the age at which smoking experimentation is typically observed. In an intervention targeting 5th and 6th grade students Crone and colleagues found that treatment had limited effects during elementary school but in secondary school (one year later) significant effects on smoking and behavioural determinants were seen.19 The intervention group had a higher intention not to smoke and started to smoke less often than the control group.19

One of the criticisms of some interventions is that they have been designed and initially piloted as 'research projects', which may not be so effective when implemented in 'real life conditions' within schools.16 In seeking to explain the disappointing evaluation of two multifaceted school-based programs in the UK that were modelled on a successfully trialled program in the US, Nutbeam and colleagues20 also queried the efficacy of school interventions in real life settings.

There is some evidence of a synergistic effect on smoking behaviour from the dovetailing of school programs with mass media and other interventions targeting young people.21 An Australian example of this is the Western Australia Smarter than Smoking projecti, which has an active schools component (including teacher and school activity resources, school grants, smarter than smoking sports, arts sponsored activities for school students, and so on) complementing mass media and other strategies.22 As noted by Flay,23 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.

As summarised in the US Surgeon General's 2000 report on reducing tobacco use, school-based programs are more effective when coupled with community-based initiatives that involve mass media and other techniques.24 A 2006 Cochrane review similarly concluded that school-based interventions that are multi-modal and complemented by broader community campaigns and strategies are more likely to have a positive effect.2 However the review also went on to note that such interventions are relatively rare in practice and in the literature.2 A well-known exception is the successful and often cited smoking interventions in North Karelia25 and Minnesota,26 which both reported positive long-term outcomes for school-based programs that were complemented by broader community campaigns.

Not only is effectiveness of school-based programs affected by the quality of the intervention content and delivery, and the degree of supporting strategies in the broader school and community, but emerging research also suggests that other individual traits of students can affect the extent to which they are responsive to smoking prevention interventions. For instance, in a smoking prevention trial conducted in China, adolescents at risk for developing depression were found to process social information differently from low-risk peers: specifically, the program was less effective with adolescents with high levels of depressive symptoms, and their perceptions of smoking prevalence among friends was more resistant to change.27 The authors concluded that adolescents more at risk of depression may be more sensitive to social influences associated with smoking prevalence, and that individual disposition traits such as this need to be taken into account in developing prevention programs.27 Another study by Wang and colleagues looked at the association between depressed mood and smoking uptake among a cohort of students (n=563) exposed to two school-based smoking prevention interventions. Follow-up data on depressed mood and smoking were collected from the students from Grade 6 through to age 19 years. Depressed mood was found to be associated with smoking uptake.28

It has been argued by some that at best, existing school-based interventions appear to be able to delay the onset of smoking,29,30 rather than prevent it. As discussed above, one of the most comprehensive and recent reviews of the evidence refutes this and contends that some interventions have been shown to be effective in deterring smoking uptake.12 Moreover, even if interventions do only delay onset, while prevention is obviously the preferred outcome, delayed onset is still a positive public health outcome because mortality is lower and quitting rates are higher among smokers who commence smoking at a later age.10,30 A recent study by Jit and colleagues found that an intervention that delays smoking initiation without decreasing smoking prevalence at age 18 years may reduce adult smoking prevalence by 0.13–.032% and all-cause mortality by 0.09% over the lifetime of the sample.31

5.29.2 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 5.29.2), with information on many of these programs easily accessible online. These programs vary in their delivery technique, content and target group, but many cover similar topics. Jointly developed initiatives such as 'The critics' choice' (see Table 5.29.2), which have been used by a number of states and territories, are an example of more strategic and cost-effective approaches.

Table 5.29.2
Examples of school-based interventions in Australia



Target group


The critics' choice

Encourages students to watch, critique and discuss 12 anti-smoking television advertisements from all over the world. Classroom worksheets included.
Free resource.

Upper primary and lower secondary

South Australia, New South Wales, Queensland, Western Australia, Tasmania, Victoria, the Australian Capital Territory

TOBACCO–the truth is out there

Prevention activities mapped to the South Australian Curriculum Standards and Accountability Framework.

Middle school

South Australia

Drug education K–12 teacher support package

A teacher resource with a range of student activities, covering topics such as passive smoking, health effects and harms of smoking, recognising pressures to smoke and coping strategies, prevalence of smoking, strategies to quit smoking, tobacco and the law, tobacco and pregnancy, personal intentions and behaviours towards smoking. http://www.decd.sa.gov.au/drugstrategy/pages/resources/supportpackages/?reFlag=1


South Australia

School drug education and road aware

Teacher education, curriculum support, drug information for parents, support for school policies, support for parents and community participation in developing and implementing drug education programs, policies and protocols. Includes information on the effects of tobacco, terms and definitions relating to tobacco, patterns and prevalence of use, models to understand usage, usage by adolescents, theory and principles of intervention and strategies for responding.

All years

Western Australia

Cigarette smoke is 'poison'

Provides strategies and tools that can be used to prevent the uptake of tobacco smoking among young people and encourages schools to provide a supportive environment for those who want to quit smoking.

Primary and secondary schools


Healing time stages 2 and 3 drug education resources for Aboriginal students

Developed to address the drug education needs of all students, particularly Aboriginal students, in primary school. Support learning outcomes identified in the New South Wales Personal Development, Health and Physical Education and English K–6 syllabuses. Each manual contains six lessons and two Dreamtime stories with Stage 2 focusing on passive smoking and Stage 3 on the effects of smoking, reasons not to smoke and advocacy skills.

Specifically Aboriginal but suits all K–6 students

New South Wales

Smoke free schools

Guidelines & support materials for schools including classroom lesson materials for students. Outlines guidelines for the prevention and management of smoking tobacco.

Middle school years



A smoking prevention resource, supporting the New South Wales Personal Development, Health and Physical Education K–6 and Years 7–10 syllabuses.

Stage 3 (Years 5–6) and Stage 4 (Years 7–8)

New South Wales

KEEP LEFT Youth smoking cessation guides for school nurses

A resource for school staff (particularly school nurses and others who work with students who smoke) to assist them in cutting down or quitting tobacco smoking.

Identified smokers years x to x

South Australia, Western Australia

Smarter than smoking school-based resources and programs1

Classroom resources including Keeping Ahead of the Pack (a smoking prevention resource for use with lower secondary school students) and an Ideas Kit for Upper Primary School.
Smart School Grants: Schools can apply to Healthway for up to $3000 to implement smoking prevention initiatives in their school.

Different year group strategies, but mainly years 5–7 and 8–10.

Western Australia

As noted in the literature, evaluation of school-based smoking interventions is generally patchy, and information on effectiveness is not readily available for many Australian interventions. Exceptions are interventions that have received research grant funding. For example, a randomised controlled trial of the Smoking Cessation for Youth Project found that the project was successful in both reducing regular cigarette smoking (five days per week or more) and preventing greater uptake of cigarette smoking in students who had not smoked.32 Another Australian study targeting high school students was not as successful, and while the intervention improved smoking knowledge, it had no success in improving smoking behaviour.18

5.29.3 Making school-based interventions more effective

Despite the mixed evidence of effectiveness to date, school settings do have the potential to influence the health-related beliefs, attitudes, knowledge and behaviour of young people in relation to smoking, and are an important complement to other tobacco-control measures.

Effectiveness would be enhanced if school-based interventions were more strategically based around the evidence of factors influencing smoking uptake. For example, the increasing recognition of the importance of the social context of smoking supports programs that explore and address social influences, particularly programs that allow students to explore these issues themselves, either individually or in groups.33 School programs have effectively helped to impart awareness of the long-term health effects of smoking, but young people tend to disassociate themselves from these consequences,34 as they lack personal salience to their lives in the here and now. Similarly, focusing on the shorter term consequences of smoking is far more relevant to young people than longer term health effects,35,36 a finding reiterated repeatedly in focus group research with adolescents in Australia.34,37 Programs also need to be adaptable to the needs and culture of different minorities to resonate with these groups.14 Findings from the National Youth Tobacco Prevention Research Project suggest that there is potential for smoking to be incorporated into teaching as a 'factual study' of a social change phenomenon,34 rather than being confined to the health curriculum.

There is considerable scope also to improve the content, design and delivery of behaviourally based interventions in schools to enhance their relevance, appeal and effectiveness with young people.20,38 Classroom-based activities and lessons need to be framed around current and evidence-based pedagogy and not outdated health education or didactic learning approaches. This is reflected in the factors identified by Cuijpers as integral to effective school-based drug prevention programs more broadly, which seem congruent with findings regarding smoking-specific school-based programs. The effective ingredients include:39

  • interactive delivery methods
  • use of the social influence model
  • components on norms, commitment not to use, and intentions not to use
  • community components
  • use of peer leaders rather than relying totally on adult providers
  • inclusion of training and practice in the use of refusal and other life skills.

A novel cluster randomised controlled trial found considerable success in the ASSIST program, training peer supporters to undertake informal conversations about smoking with other students outside the classroom setting. Schools that were randomised to the trial intervention had lower odds of smoking at all three follow-up periods, with a significant risk reduction at one year that diminished to a non-significant reduction at two years.40 The use of peer led interventions and the ASSIST program are now being more widely encouraged.41 Young people today are exposed both in and out of school to a range of stimulating mediums and activities that set a high benchmark in terms of interest and creativity. Thus programs should have built-in methods of updating material42. Smoking in particular runs the risk of being viewed as a 'tired' issue, and so innovative and creative ways to address it need to be found.38 Programs need to be sustained until the school leaving age through 'booster' components such as health fairs or guest speakers in order to retain pertinence.41, 43

Moreover, teachers and school curricula often struggle within a crowded timetable to accommodate the silo approach to health risk factors (that is to say, lessons focused on tobacco only). 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.41 It is artificial always 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 indeed well documented10,16,44 (see Section 5.5). Reid also argues 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.16 Others concur that teachers may be more prepared to devote valuable curriculum time to more comprehensive rather than single issue programs.10

5.29.4 School policies

One of the single most inexpensive actions a school can take to reduce smoking is to introduce and enforce a no-smoking policy.45,46 An analysis of smoking and policy at 55 schools demonstrated an association between policy strength, policy enforcement and the prevalence of smoking among pupils.47 In a study of factors from the school and community environment that affect youth smoking, Lovato and colleagues found that students were less likely to smoke if they attended a school with a focus on tobacco prevention , stronger policies prohibiting tobacco use and fewer students smoking on the peripheries than in schools without these characteristics.48 Thus bans on smoking in schools need to be diligently enforced to have most impact on adolescent smoking rates.49 In Australia, although all states and territories have had smokefree school buildings under workplace laws since 1988, some have been slow to extend this to all school grounds. Western Australia's Department of Education and Training only extended its policy to all outside areas in 2005,50 and the Northern Territory still allows smoking in designated areas on school grounds under the proviso that it is out of sight of children.51 In Victoria, the Smoke-free Schools – Tobacco Prevention and Management Guidelines recommend that schools operate as non-smoking environments.52


i http://www.smarterthansmoking.org.au/

Recent news and research

For recent news items and research on this topic, click here (Last updated March 2018)  


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