The Public Health Interventions Advisory Committee (PHIAC) took account of a number of factors and issues when developing the recommendations.
3.1 PHIAC noted that no single intervention or programme can prevent children and young people from taking up smoking. Rather, it requires a comprehensive approach embracing individual, social, community and societal issues. PHIAC also noted that different elements of a comprehensive approach may act synergistically. For example, activities targeting young people in schools may also have an effect on parents' smoking habits. Likewise, if parents are encouraged and supported to quit smoking, this will affect their children's attitudes and behaviour in relation to smoking.
3.2 Many of the studies reviewed were not carried out in the UK. This is important to note, as the UK context differs in many respects from the US, Australia and other parts of Europe (for example, in terms of health and education systems).
3.3 The last decade (and the last 3 years, in particular) has seen major changes in the UK in relation to tobacco control. This includes the introduction of smokefree public places, a ban on tobacco advertising, and mass-media messages and services focused on helping people to quit smoking. In turn, this has led to a more favourable climate for interventions aiming to discourage children and young people from taking up smoking.
3.4 PHIAC acknowledged that it is difficult to interpret research literature in the current UK context because of the many tobacco control policy measures that have been introduced in the past decade. Changes in national policies and programmes can make it difficult to detect and interpret differences between control and intervention groups, especially when trying to compare them to earlier studies.
3.5 PHIAC noted that smoking is dangerous at any age. However, it also noted that the earlier someone starts, the more likely they are to smoke for longer – and to die earlier from a related condition or disease. As the risk of disease relates to the overall length of time someone smokes, PHIAC considered that delaying the onset of smoking is worthwhile (in addition to preventing uptake altogether). Furthermore, it noted that young people who take up smoking later in life are also more likely to stop smoking (Breslau and Peterson 1996; Khuder et al. 1999; Park et al. 2004).
3.6 On the basis of the economic modelling, PHIAC concluded that school-based smoking prevention programmes – whether they prevent or delay the uptake of smoking – are likely to be cost effective.
3.7 The evidence was mixed on when it is best to start delivering school-based smoking prevention interventions. However, it was clear that smoking prevalence among schoolchildren increases with age. In light of this, PHIAC considered prevention efforts would be most effective if they began in primary school and continued throughout the school 'career'.
3.8 There is good UK evidence that one particular peer-led approach can prevent children and young people from taking up smoking. This was drawn from a randomised controlled evaluation of the ASSIST programme and has been used as the basis of recommendation 3. PHIAC noted the need for further UK-based research on peer-led interventions for schools and other educational establishments.
3.9 PHIAC recognised that schools and further education colleges vary considerably in terms of their catchment area, geographic location and type. The implementation of these recommendations will need to reflect this diversity.
3.10 PHIAC noted that children and young people may experiment with smoking, taking up and dropping the habit intermittently, before becoming regular tobacco users. In practice, this means that the boundary between smoking prevention and cessation work may be unclear. PHIAC believes that preventing children and young people from smoking as adults may involve both prevention and cessation activities (even though smoking cessation is outside the scope of this guidance). On this basis, it has recommended that smokefree policies for schools and other educational settings should include efforts to promote local NHS stop smoking services (to both students and staff).
3.11 Policies on how schools and other educational establishments operate are under review and often change. Where relevant, the recommendations in this guidance link to current national policy and the national curriculum. PHIAC recognised that this context may change, but is confident that the guidance will continue to be relevant to all schools.