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This report is divided into different sections. Chapter 1 contains the introduction to the review, the background, the justification for the review, planning, scope, and review questions. Chapter 2 presents the literature review discussing the prevalence of smoking in United Kingdom. The reasons why young people smoke, a study in behavioural change and the quality of interventions. Chapter 3 is the methodology section where discussions on search strategy, inclusion and exclusion criteria, outcomes considered, appraisal methodology, and review limitations. The findings of the study are in Chapter 4 and discussions in Chapter 5. While the conclusions and recommendations are summarised in Chapter 6.

The CRD (2008) states that health care decisions for individual patients and for public policy should be informed by the best available research evidence. Evidence is about the reality of what is true and not true (Raphael 2000). Evidence needs to be collected in order to justify the decisions health promoters make.  Furthermore, a critical appraisal of the evidence must be done to assess its validity and applicability to a particular health problem (Oliver et al 2001). In this regard, systematic reviews are increasingly used to assess the effectiveness of interventions in public health (The Cochrane Collaboration, 2005).

Systematic reviews provide a synthesis of research findings in a given area, thus presenting the results in a manageable and coherent manner (Perkins et al 2001). They contain explicit statement of objectives, materials and methods (Petticrew 2003). They identify the intervention for a specific problem and determine whether or not the intervention works. On the other hand, as pointed out by Perkins et al (2001), systematic reviews try to establish whether or not the research findings are consistent; or whether or not they can be generalised across target groups and settings.  In summary, following from CRD (2001) a systematic review is defined as:

“A review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research; and to extract and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used”. (CRD, 2001, p. 4)

Systematic reviews are seen as methods that eliminate the research bias and in turn improve the reliability of the research findings (Murlow, 1994). Petticrew (2003) summarises it in this way:

  • Systematic reviews aim to reduce uncertainty by strengthening the evidence base.
  • Systematic reviews contribute to resolve uncertainty when original research, reviews and editorials disagree.
  • Systematic reviews can be conducted in an effort to resolve conflicting evidence to answer questions where the answer is uncertain or to explain variation in practice.
  • Systematic review are needed to inform policy and decision-making about the organisation and delivery of health and social care, They are particularly useful when there is uncertainty regarding the potential benefits or harm of an intervention.

A systematic review is therefore essential before any decisions are made concerning whether interventions should be expanded, reduced, or maintained.

1.3 Background

Globally, public health professionals are concerned about the destructive effects of tobacco smoking (WHO 2006). Numerous medical articles claimed that it is the cause of cancer of the lip, tongue, and lung. Smoking has also been established as a factor in the development of coronary artery disease, bronchitis, emphysema, cancer of the larynx, oral cavity, cancer of the bladder and stomach, duodenal ulcer, and allergies (Edlin & Golantry 2009, p.396). 

Tobacco use is the leading cause of preventable death and of health inequalities. In 2007, more than 80,000 premature deaths in England were caused by smoking (The NHS Information Centre. 2009). Up to half the difference in life expectancy and wellbeing between the richest and the poorest is due to smoking (Jha et al. 2006). In England today, over a fifth of the adult population smokes – over 8 million people (The NHS Information Centre. 2009) and according to the Government’s strategy on Tobacco Control (DH 2010), around 250,000 people in England will start smoking this year {2010}. The vast majority of them will be below the age of 18 (Department of Health. 2009, page 21).

A focus on reducing tobacco use among young people is vital, since children can very rapidly develop an addiction to, and dependence on, tobacco (Petro. 2007, page 15). The smoking prevalence among 11–15-year-olds is down from 13% in 1996 to 6% in 2008. This is the lowest level since records began. However, each year some 250,000 people in England take up smoking and the vast majority of them are under the age of 18. (Hopkins et al. 2001, page 16)  Approximately 100,000 16-year-olds smoke (17%). Before the age of 11, very few children smoke, and most (if asked) are anti-smoking. (The Information Centre for health and social care 2009)

However, we know that the tobacco industry needs to recruit over 100,000 smokers each year to replace those who die or quit. Since very few adults over the age of 21 take up smoking, young people continue to represent a key market for the tobacco industry. (Department of Health. 2009, page 21).

1.4 Rationale for the study

The problem of cigarette smoking and tobacco-related disease is not limited to the western world, there are 1.1 billion people worldwide, ages 15 and older who smoke and 300 million of them are residing in developed countries. Consequently, 4 million people die annually from tobacco-related disease or one death every 8 seconds.

The main reason given for the large increase in tobacco-related deaths is the fact that the delayed effects of cigarette smoking for those young adults over the past few decades will only emerge today (Boyle 2004, p.281). Hence, when there are large numbers of young adults smoking in one particular region, this will produce a large upsurge of tobacco-related deaths 50 years later. It has been estimated that during the second half of the century, 60 million premature deaths in developed countries will have been caused by smoking (Ammerman et al. 2000, p.94).

Children can be seriously harmed by smoking and they may suffer irritation of the eyes and throat, high blood pressures, respiratory and immunity problems, and pre-cancerous gene mutations. In addition, smoking at a very young age will increase the probability of using illegal drugs at a later stage (Elders 2004, p.15).

Smoking is also a public health priority (Siegel & Biener 2000, p.115) and a significant public health problem that has a number of documented effects on negative health status (Haldeman 2004, p.193).  Consequently, a number of public health practitioners begun to launch smoking prevention programs to counter the effect of tobacco smoking in adults and young children including anti-tobacco media campaigns, bans on smoking in public places, significant tax increase in tobacco products (Atun & Sheridan 2007, p.51). The 1998 Department of Health White Paper “Smoking Kills” finally placed tobacco as a serious health threat in the United Kingdom (Griffiths & Hunter 2007, p.134).

However, despite the growing use of anti-smoking campaigns, little is known about their effectiveness since these campaigns often have confusing results. For instance, an apparently successful campaign to reduced smoking initiation rates among adolescents in Vermont, New York, and Montana, failed to influence smoking behaviour among young people in southern California (Siegel & Beiner 2000, p.116). The problem in assessing the outcomes of smoking intervention according to Koop (2004, p.244), are the fact that some of these studies often has been designed poorly with defective methodologies and quality control.

Most individuals who choose to smoke begin this behaviour during adolescence, and peer influence is a known factor in the initiation of smoking behaviour (Chassin, Presson, Sherman, & Edwards, 1990. One prevention approach aimed at confronting multiple problems of adolescence has included the development of peer leadership programs on secondary school campuses throughout the country. Students in such programs are trained in self-awareness, communication skills, and techniques in assisting peers with specific problems encountered in adolescence (Markham et al 2008).                                   

Studies have shown that young people are more likely to start smoking when exposed to a peer group that includes regular smokers (Markham et al, 2008). A number of systematic reviews have been conducted recently, (Flay, 2007,Flay, 2008, Fletcher et al, 2008, Thomas and Perera, 2006) and summarised in a report on young people and smoking submitted to the Department of Health in February 2009 (Amos et al, 2009). In particular, the Amos et al report highlights Flay’s analysis of the potential long term effects of school-based interventions which concludes that they can have long term effects if they take the form of interactive social skills or social influences programmes (rather than just information giving), if they involve 15 or more sessions up to aged 14-15 and if they produce substantial short term effects (Flay in Amos et al, 2009). However, many schools-based interventions have not included these components and there remains some uncertainty about what forms of intervention are most successful, particularly in different types of communities and with different age-groups.

The UK Governments strategy (A Smokefree Future, 2009) aimed at reducing smoking prevalence also highlighted that peer interventions need to be condidered. Stating that the ASSIST programme conducted by Campbell et al, 2008 which involved a peer-led intervention in schools ‘is a promising approach to schools based prevention’.

1.5 Background to the Review

Despite the existence of a systematic review about the effectiveness of school-based interventions for smoking prevention, there are currently no reviews detailing on  ‘peer-led’ initiatives to reduce smoking initiation in young people. 

Aims of the study

This research aims at synthesising the current research evidence that examines the effectiveness of peer-led interventions and designed to prevent the initiation of smoking in children and young people.

  • To explore the effectiveness and the effective elements of peer-led interventions designed to prevent the uptake of smoking in children and young people.

Bament (2001) concluded that ‘the only commonality appears to be that it involves training groups of people to pass on information to others who are seen to be in the same peer group, so as to encourage the adoption of health promoting behaviour(s)’ (p. 1).

 CHAPTER: 2 Literature Review

2.1 Prevalence of Smoking

Many people have been dying of smoking related illnesses in the UK every year. The government put up the White Paper Smoking Kills Campaign in 1998 which saw the drop from 29% to 21% between 1998 and 2008.(NHS Statistics 2009).  

The campaign sought to reduce exposure to second hand smoke, offer education and communication to the public, reduce the availability and supply of cheap tobacco, give support for smoking cessation, reduce the promotion of tobacco and regulate tobacco(WHO 2006).

The main target group should be the young since statistics show that an estimated 250000people will start smoking and topping that list will be those below 18years(West,2009). Currently over 8 million people smoke.

2.2 International smoking trends

Smoking rates have declined in the UK over the last decade though the prevalence rate is still high. Australia stands at 14% (McCathy et al(2009),Canada 18%(CGSS 1991) while California which has had comprehensive tobacco control strategies for the longest time has a smoking prevalence rate of 12%. This just shows that it is possible to even lower the UK levels further down.

2.3 Reasons for Smoking

Social and environmental factors are to blame for the onset of many people starting to smoke. Teenagers will argue that it is a status symbol and a way to get accepted into a clique of the ‘cool’ crowd while others will say that they smoke when bored or only when drinking. Whatever the reason, the bottom line is that smoking does more harm than good with each puff.(Spijkerman 2005).

3.4 Personal influences

Most people believe that smoking helps in social settings or just find it enjoyable to do,(Wiltshire et al 2005). Non-smokers find it hard to believe that smoking helps some people relax and remain calm by taking the edge off the smokers (Higgins 2005). The younger people may use smoking as a sign of rebelling from their parents, schools or family. People who have low self esteem or those that have had traumatic childhoods are also at a higher level of vulnerability to smoking.

Smoking may also be used by young girls as a way of appearing to be much older than they really are by creating an ‘adult social identity’. In boys, smoking is seen as a way of looking popular and gives the boys confidence to face the opposite sex (Stanton et al 1993).

 Most of the smokers do not know of the addictiveness and health damaging properties of tobacco and there is a notion that it is almost impossible to quit smoking (Dudas 2005).

Smoking is also associated with other drug abuses like alcoholism and drug use (Best 2000).

2.5 Social influences

The family has a big role to play when it comes to the influences it has on children. Many young smokers say that they were influenced to start smoking by their parents or elder siblings who they have all along observed smoking.  A survey done showed that 59% of those surveyed lived in households where at least one person smoked. Thus smoking by parents, siblings and friends and peers are all important predictors of tobacco use (Barman 2004). Regular smoking increase from 3% (living in households where nobody smoked) to 21% in households with three or more smokers lived (NHS 2009, Statistics).

The more easier it is to get cigarettes the higher the numbers will be for first time smokers. There should be legislation controlling the availability and ease of accessing tobacco especially to the young people in order to reduce the numbers of those starting to smoke. Surveys conducted in the UK show that regular smokers aged between 12- 15 years buy their cigarettes from the newsagents or sweetshops (Forster et al). Just under a quarter of 12 to 15-year-old current regular and occasional smokers in England reported that they found it difficult to buy cigarettes from a shop (Information Centre for Health and Social Care 2007).

 According to the 2008 NHS survey results, children under the age of 16 are buying their cigarettes from shops (44%) and vending machines (10%) despite the law prohibiting the sales of cigarettes to minors. However, the most common sources of cigarettes according to the result are other people such as friends (58%), siblings (10%), and parents themselves (6%).

The government should make it impossible for the young people to buy cigarettes from shops to reduce the number of buyers. Shop owners should be encouraged to refuse to sell to any young person any tobacco product. Strict monitoring of vending machines selling cigarettes will also minimize the number of youngsters attempting to make any purchase; this is done by the National Association of Cigarette Machine Operators (NHS 2009, pg 27).

2.6 Environmental

The media is also to blame for portraying smoking as a good thing to do. All the heroes and beautiful women in movies smoke at some point and the young people are just like sponges, absorbing any new trends. The wealthier youth are also less likely to take up smoking compared to those from lower economic backgrounds (Jarvis 1997).

2.7 Level of Perception on the Danger of Smoking

A study done by the University of Michigan (2008, pg338), found out that most people do not know of the dangers of smoking and what degree of harm that tobacco can have on an individual. 74% of those interviewed believed that smoking a packet a day could have no harm on them, while another 39% thought that smoking was harmless. Despite the growing number of illnesses that tobacco can cause in the human body, it still is sad to imagine that people can be that ignorant of their health and general wellbeing. The perceived risk of smoking currently stands at 23%, still very low.

Generally, an increase in the perceived risk of any product leads to a decrease in the demand and consumption of the same product (Department of Health and Human Services 2008, pg 60).

2.8 Peer Education

Numerous studies done throughout the United States , UK, Australia and through Europe have found that most of the young people seek advice from their colleagues and friends . Most of the counsellors availed in schools are not approached by the students targeted who instead seek opinions and advice from their colleagues. Research results have indicated that it’s easier to train peer counsellors within the student community who will in turn pass the right advice to their colleagues. This has been done in a number of institutions with good results.

Management of these institutions should come up with ways of training the ‘cool’ kids in schools to handle certain common issues that have the highest recurrence rates within these institutions. Many other students in need will always in one way or another get to talk to one of the trained peer counsellors who will in turn offer professional help to the needy students. Ignoring this fact will mean that the institutions will have a whole counselling department that does not do much for the students. Prevention programs targeting young people need to be directed at peers to strengthen (or immunise) students against harmful influences.

 Numerous studies have demonstrated that peers influence youth health behaviours with regard to sexuality, violence and substance abuse and in making wise and appropriate decisions (Wills, 2004).

2.9 Defining peer education

So what is peer education? The young people often have cliques that they form in schools which are basically groups of people sharing some character in common, this may include but is not limited to; sportsmen, cheerleaders, the A students, etc.

Counsellors may find it almost impossible to penetrate these groups of students especially because young people do not like discussing their issues. This has necessitated the education of young people in groups. Peer education is often used to effect changes in knowledge, attitudes, beliefs, and behaviours at the individual level. However, peer education may also create change at the group or societal level by modifying norms and stimulating collective action that contributes to changes in policies and programs (Bament 2001).

Research has been recommended to help develop new programs in the delivery of information to the adolescents in schools on the identification of essential elements of tobacco use cessation programs in schools (Glynn, Anderson & Schwartz, 1999).

2.10 Understanding Behavioural Change

Behavioural interventions are aimed at either; influencing a new behaviour, stopping something from ongoing, preventing a harmful behaviour or modifying an existing behaviour (Darnton 2008 p.23)

(Leininger, 2000) explains that complex interventions are often guided by a theory and useful in predicting outcomes and failures of the intervention. In order to deal with health-related concerns, such as smoking,many traditional approaches to providing health promotion interventionshas been used within the logical/rationale model (Leininger, 2000). The underlying assumption of this modelis that once people are informed of health-promoting activities,they will embrace this information and alter their behaviours.More recently, theories have addressed health beliefs and attitudesas precursors of behaviours. The health belief model, e.g. attemptsto explain and predict health behaviour based on a complex interplayof beliefs, values and cues to action (Rosenstock, 1990). Othersocial theorists, e.g. Bandura have focused on the smokers'perceived positive outcomes of smoking (Bandura, 1985),e.g. using smoking to cope with daily pressures. The Theoryof Reasoned Action (Ajzen and Fisher, 1993) identifies healthbeliefs, personal factors and social influences as variablesaffecting smoking behaviour (Michell and Amos,1997).

For some time, the goal of health promotion when dealing withindividuals who were practicing unhealthy behaviours was to helpmove people from a state of chronically unhealthy behaviour tostable healthier behaviour. However, individuals do not shifttheir behaviour in such a dramatic fashion (Prochaska, 1994).The Transtheoretical Model of Change is an integrative, comprehensivemodel of change (Prochaska etal., 1994). It describes five stages of change adult smoker’smove through as they achieve smoking cessation.

Past Department of Health smoking/tobacco marketing activity has drawn from the Prochaska Stages of change model to inform both the targeting of campaigns and the nature of timing of content (DH 2008). However, while simple to understand and apply (West 2007), many studies have identified some significant issues and limitations with the model. The definition of the different stages is arbitrary, with no supporting evidence of why each stage starts and finishes when it does. West 2009 also suggests that up to fifty percent of quit attempts involve no forethought or planning presenting the theory that preparation is irrelevant. 

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