DECIPHer-ASSIST: Reducing teenage smoking through a cost-effective prevention programme
Submitting InstitutionUniversity of Bristol
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
ASSIST (A Stop Smoking in School Trial) is reducing smoking rates among
teenagers by 22%. `DECIPHer' Impact Ltd was set up to rollout the ASSIST
programme which has been adopted widely in England and Wales with 26
licences being commissioned. The company has achieved £240K annual
turnover. As a result, an estimated 1674 young people have not taken up
smoking. The Lancet estimates that if ASSIST were implemented
across the UK, 40,000 teenagers a year would not start smoking.
ASSIST has been commended by the English and Welsh Governments and
recommended in National Institute for Health and Care Excellence (NICE)
Smoking kills nearly six million people a year and is forecast to kill
one billion people in the 21st century. Tobacco users who die
prematurely leave their families without income, increase the cost of
healthcare, and impede economic development. In the UK, smoking accounts
for nearly 20% of deaths and costs the NHS around £2.7 billion every year.
Children who start smoking before the age of 16 are twice as likely to
continue as adults (compared to those who start later). They are also more
likely to have respiratory illnesses, use alcohol and drugs, and be absent
from school compared to those who do not smoke.
Preventing young people from starting to smoke is a key element of
tobacco-control strategies. ASSIST is based on an American model where
opinion leaders in the gay community train others to promote better sexual
health choices. ASSIST adapted this model and trained and supported
influential Year 8 school students (aged 12-13) to support their friends
and classmates . These `peer supporters' have informal conversations
with other Year 8 students about the risks of smoking and the benefits of
ASSIST was a joint initiative of the Universities of Bristol and Cardiff.
In the major part of the research the intervention was further developed
and evaluated by a randomised controlled trial (RCT) funded by the Medical
Research Council . Rona Campbell from the University of Bristol led
this research jointly with Laurence Moore of Cardiff University. The RCT
followed young people for two years and found ASSIST was effective in
reducing smoking uptake by 22% over this period . The trial results
were published in The Lancet and estimated that if implemented
throughout the UK, the programme would prevent 40,000 young people taking
up smoking each year. The research also evaluated the delivery process to
help understand what made the programme successful. It found that ASSIST
was implemented with a high degree of fidelity and was acceptable to
schools and teachers, and to the young people who received it [4,5].
Further analysis also indicated that the ASSIST intervention was cost
More detailed follow-on research on the peer supporters found that those
who were asked to work informally, rather than under the supervision of
teaching staff, took the responsibility seriously and were effective at
passing on messages about not smoking to their peers . This is a
research finding of considerable significance that can be applied to other
The RCT fieldwork was carried out equally by Bristol and Cardiff
universities. The data analysis for the RCT was conducted in Bristol and
Bristol took the lead in publishing research from the RCT: eight of the
nine journal papers produced have a Bristol-based first author (Campbell,
Audrey, Starkey and Hollingworth) and in six of the nine papers Rona
Campbell is the senior (last-named) author. Jo Holliday was seconded to
Bristol from Cardiff for 9 months to work on the dissemination of ASSIST.
Bristol Research Team
Professor Rona Campbell
Dr Susanne Audrey-Research Associate
Dr Fenella Starkey-Trial-cordinator-Left 15th Sept 2007
Mrs Kathleen Cordall-Health Promotion Specialist-30th Sept 2002
Dr Rachel Hughes -Statistician
Professor William Hollingworth-Health Economist
Mr James Hawkins-Health Economist-11th April 2012
Dr Jo Holliday-Research Associate-8th Sept 2008-31st May 2010.
References to the research
 Audrey S, Cordall K, Moore L, Cohen D, Campbell R on behalf of ASSIST
(A Stop Smoking In Schools Trial). The development and implementation of a
peer-led intervention to prevent smoking among secondary school students
using their established social networks. Health Education Journal
2004. 63(3) 266-284. http://dx.doi.org/10.1177/001789690406300307
 Starkey F, Moore L, Campbell R, Sidaway M, Bloor M. and ASSIST (A
Stop Smoking in Schools Trial) Rationale, design and conduct of a
comprehensive evaluation of a school-based peer-led anti-smoking
intervention in the UK: the ASSIST cluster randomised trial
[ISRCTN55572965]. BMC Public Health 2005, 5:43 http://dx.doi.org/10.1186/1471-2458-5-43.
 Campbell R, Starkey F, Holliday J, Audrey S, Bloor M, Parry-Langdon
N, Hughes R, Moore L. An informal school-based peer-led intervention for
smoking prevention in adolescence (ASSIST): a cluster randomised trial
Lancet 2008; 371: 1595-1602. http://dx.doi.org/10.1016/S0140-6736(08)60692-3
 Audrey S, Holliday J, Campbell R. Commitment and compatibility:
Teacher perspectives on the implementation of a school-based, peer-led
smoking intervention. Health Education Journal. 2008;67: 74-90.
 Hollingworth W, Cohen D, Hawkins J, Hughes R, Moore L, Holliday J,
Audrey S, Starkey F, Campbell R. Reducing smoking in adolescents:
cost-effectiveness results from the cluster randomised ASSIST (A Stop
Smoking In Schools Trial). Nicotine and Tobacco Research 2012,
Grant (peer reviewed)
Moore L. Campbell R, (Co PIs), Bloor M, Parry Langdon N, Williams G.
Randomised controlled trial of a schools based, per led, smoking
intervention. Medical Research Council. 2001-2005, £1,428,087
Details of the impact
Impact on Policy
The research associated with the development and evaluation of ASSIST has
had a substantial impact on policy.
- In February 2010, the UK government published `A Smokefree Future',
its White Paper on tobacco control. It outlines future policy and
focuses on the use of evidence-based policies in three areas, the first
of which is `To stop the inflow of young people recruited as smokers'
[a]. The review of evidence into smoking and young people which informed
this White Paper identified ASSIST as a `potentially important
- ASSIST has been cited as an example of good practice in another
Government White Paper, Healthy Lives, Brighter Futures: The
Strategy for Children and Young People's Health [c].
- It was also flagged as an example of an effective preventative
strategy aimed at young people in the NHS Stop Smoking Services:
Service and Monitoring Guidance [d].
- Guidance published by NICE, `School-based Interventions to Prevent
Smoking',[e] which was informed by four separate reviews [f, g],
has a specific recommendation on peer-led initiatives. It states that
those commissioning health care should `consider offering
evidence-based, peer-led interventions aimed at preventing the uptake of
smoking such as the ASSIST (A Stop Smoking in School Trial) programme'
and refers the reader to the main trial results published in The
- The Tobacco Action Plan for Wales, published in February 2012,
has, as one of four strategic action areas, `reducing the uptake of
tobacco use, especially amongst children and young people.' It restates
the Welsh Government's continuing commitment to providing the ASSIST
programme to 40 to 50 schools per year, focussing on areas of
Implementation of ASSIST
The research intervention was faithfully translated into a practical
model that can be implemented by national, regional and local bodies with
health and education responsibilities. The major vehicle for dissemination
has been DECIPHer (the Centre for the Development and Evaluation of
Complex Interventions for Public Health Improvement), the UKCRC (UK
Clinical Research Collaboration) Public Health Research Centre of
Excellence jointly established by the universities of Bristol, Cardiff and
In order to ensure effective support for the implementation of ASSIST and
to maintain its integrity, the universities of Bristol and Cardiff created
DECIPHer Impact Ltd, a `not for profit' company, limited by guarantee
which aims to maximise the translation and impact of evidence-based public
health improvement research and expertise. Its first product is ASSIST,
which is trade-marked as the DECIPHer-ASSIST smoking prevention programme.
Licences are sold by the company and purchasers receive DECIPHer-ASSIST
materials, training, support and ongoing quality assurance. This ensures
that DECIPHer-ASSIST is implemented in a high quality way and maximises
the likelihood that the effects found in the RCT are reproduced in real
There has been substantial demand for DECIPHer-ASSIST from local
healthcare purchasers [i]. To date 25 health bodies in England and the
Channel Islands have been issued with licences costing up to £34K each. A
more substantial licence has also been issued covering the whole of Wales,
where ASSIST is being implemented at a rate of 40-50 schools per annum.
Company turnover in the year ending July 2013 was £240K [i]. In its recent
tobacco control policy the Scottish government committed to pilot ASSIST
and discussions are ongoing with state and educational institutions in
France and Germany about implementing ASSIST.[i] To date over 350 UK
schools have been involved in the programme and over 150 staff from former
primary care trusts and local authorities have been trained to deliver the
Impact on teenagers
The use of ASSIST is growing every year. In the academic year 2012/2013
over 25,000 Year 8 students (via more than 4,500 peer supporters)
were involved in DECIPHer-ASSIST. By summer 2013 more than 60,000 Year 8
students and over 11,000 peer supporters were involved in DECIPHer-ASSIST,
resulting in 1674 fewer teenagers taking up smoking.[i]
Recognition of the impact on health
In 2011 DECIPHer-IMPACT was the overall winner of the Bristol Health
Partners Health Innovation Award [j] which recognises outstanding health
innovation achievements. In 2013 DECIPHer- IMPACT won the Innovation in
Healthcare Award as part of Cardiff University's Innovation and Impact
Sources to corroborate the impact
[a] Department of Health (2010) A smokefree future: A comprehensive
tobacco control strategy for England. White Paper (p 31).This
substantiates that the research associated with ASSIST has had an impact
[b] Amos A and Hastings G, Angus K, Bostock Y, Fidler J. (2009). A review
of young people and smoking in England. Public Health Research Consortium.
(p97) This is a review cited in [a] which further substantiates the impact
[c] Department of Health (2009) Healthy lives, brighter futures: The
strategy for children and young people's health (p 59). Substantiates the
impact on policy.
[d] Melanie Chambers (2009) NHS Stop Smoking Services: Service and
monitoring guidance (p 69). Substantiates the impact on policy.
[e] National Institute for Health and Clinical Excellence (2010) NICE
public health guidance 23: School-based interventions to prevent smoking
(p10). Available at:
. Substantiates the impact on policy.
[f] Bauld L, Brandling J, Templeton J (2009) Facilitators and barriers to
the delivery of school- based interventions to prevent the uptake of
smoking among children: A systematic review of qualitative research
. Substantiates the impact on policy.
[g] Uthman O, Yahaya I, Pennant M, Bayliss S, Aveyard P, Jit M, Barton P,
Meads C, Chen Y. (2009) School-based interventions to prevent the uptake
of smoking among children and young people: effectiveness review Available
Substantiates the impact on policy.
[h] Welsh Government (2012) Welsh Government: Tobacco Control Action Plan
for Wales (pp 7,15-16). Available at:
Substantiates the impact on policy.
[i] Michael Day, Chief Executive Officer, DECIPHer Impact Ltd, (2013)
Personal communication. For verification of the impact on teenagers
including details regarding DECIPHer Impact Ltd, licence sales and the
reach of the intervention.
[j] DECIPHer IMPACT- Winners of the BRIG-H 2011 award for Innovation!
and Cardiff University's Innovation in Health Care Award 2013 available
http://www.innovation-network.org.uk/innovation-awards/innovation-in-healthcare-award-1.aspx Evidence of recognition
of the impact on health and commerce.