A qualitative evaluation of a novel intervention using insight into tobacco industry tactics to prevent the uptake of smoking in school-aged children

Of six secondary schools approached in the UK East Midlands region, two agreed to participate in the delivery and evaluation of Operation Smoke Storm. Whilst the schools that declined our invitation expressed interest in the Operation Smoke Storm resource itself, they cited time pressures as their reason for not being able to participate. The two participating schools had contrasting socio-demographic profiles. School 1 was located in a market town, serving a relatively affluent catchment area in the town and surrounding villages. School 2 was in a small town on the edge of a major urban area. In School 1, 6.1 % of students were eligible for free school meals (a frequently-used measure of deprivation [16]) and in School 2, 10.2 %. Nationally, approximately 16 % of pupils are eligible to receive free school meals, with the figure reaching 75 % in some schools [17], and thus the two schools may not be representative of those in particularly deprived areas.

The research team provided a brief training session to teachers which outlined how to access and navigate the Operation Smoke Storm resource, and described the planned research-related activities. In total, 585 Year 7 (aged 11-12) students received Operation Smoke Storm during their usual PSHE lessons (School 1: 347 students in 14 classes; School 2: 238 students in 8 classes). School 1 had shorter lessons (40 minutes per week) and so some teachers took more than three sessions to cover the material. In School 2 PSHE was taught for 1 hour per fortnight; here delivery took place over three lessons, but there were wider intervals between the sessions.

Parents of Year 7 students were sent a letter informing them about Operation Smoke Storm and the accompanying academic evaluation, approximately three weeks prior to its delivery. They were asked to return an opt-out slip if they did not want their child to participate in a focus group to evaluate the intervention. Following delivery of the first Operation Smoke Storm session, teachers briefly outlined the purpose of the focus groups to students, and those interested in taking part were asked to write their name, gender and class on a piece of paper and hand this to the teacher. Students were informed that participants would be selected at random should more volunteer than needed. Students from School 2 were randomly selected from the list of volunteers by the PSHE teaching lead, whereas in School 1, volunteers’ names were handed to the research team who randomly selected students to take part. We planned to conduct four focus groups in each school, two for each gender, with up to 12 students in each, in line with recommendations on focus group size [18, 19]. Research suggests that smoking behaviours and attitudes differ according to gender [20, 21], and thus gender-specific groups were used both to encourage honest discussion and to allow us to explore any potential differences according to gender.

Three separate semi-structured discussion guides were developed based on existing literature and the content of the intervention, and agreed through discussion within the research team: one for the focus groups with students, another for interviews with teachers and one for PSHE teaching leads. The student focus group and teacher interview guides covered views on the acceptability and perceived effectiveness of Operation Smoke Storm, and the interview guide for the PSHE teaching leads also sought information about how PSHE (and specifically the topic of smoking) is usually taught in the school, by whom, and using what resources. There is evidence that follow-up ‘booster’ sessions are useful to strengthen and maintain the effectiveness of an intervention, and additionally that a wider approach tackling individual as well as family, community and societal influences is more likely to succeed in preventing young people from taking up smoking [8]. Therefore, the topic guides also sought students’ and teachers’ opinions on the potential acceptability and effectiveness of different options for a booster session for delivery in Year 8 and a family component to be delivered alongside the Year 7 resource.

Before the commencement of focus groups and interviews, participants were informed that data would be anonymised, treated confidentially and that they were free to withdraw at any point. Following this, written informed consent was obtained. Focus group discussions took place in a private room in both schools during lesson time, were facilitated by JT or AT (both experienced in facilitating qualitative research) with MB, LS or LJ acting as observers, and lasted 35 minutes on average (range 27 to 50 minutes). Face-to-face interviews also took place in a private room at the respective schools (conducted by JT or AT), and telephone interviews were conducted in a private room at Nottingham City Hospital (by AT) and lasted 34 minutes on average (range 24 to 50 minutes). All discussions were digitally audio-recorded.

An external specialist transcription company transcribed interviews and focus group recordings clean verbatim. Transcripts were checked for accuracy (by JT and AT) and any potential identifiers were removed. Transcripts were assigned a unique code that identified the school (1 or 2) and focus group (male or female) or teacher number. Data were analysed using the framework approach [22, 23]. As an initial step to aid familiarisation, data from the first four focus groups and four teacher interviews were read several times by JT, AT and MB who independently summarised the data (using Microsoft Excel) and identified initial codes, themes and sub-themes in the data. This stage also enabled the researchers to ascertain whether there were any contradictory cases or any within- or between-group differences (according to school and gender). It was apparent that codes identified from both the focus groups and teacher interviews were similar (apart from teachers’ interview data identifying a theme specifically about preparation to deliver the resource) and thus data were analysed together. Codes, themes and sub-themes were subsequently discussed between the researchers resulting in an initial analytical framework. The framework was then applied and refined following analysis of the remaining transcripts which were divided between JT and AT. Data were then indexed according to the final framework using NVivo 10 software. Finally, transcripts were charted according to each theme to facilitate synthesis and interpretation. Data presented reflect the overall views of the participants from both schools.

Both schools reported that it was their usual practice to cover the topic of smoking within the Year 7 PSHE curriculum, including the dangers of smoking and how to resist peer pressure to smoke; School 2 also included the influence of celebrity and role model smoking in their teaching. Operation Smoke Storm replaced these lessons. Although most of the teachers had no prior training or experience in teaching students about smoking (the majority were newly-qualified), after looking over the resource most felt confident about delivering Operation Smoke Storm. The ‘off-the-shelf’ nature of the resource, and that background knowledge about the topic or lengthy preparation time was not required, appealed to most teachers (Table 2, quote a). Some teachers spent more time preparing for the lessons than others, for instance by doing further independent research into the topic. Being given an appropriate amount of information and a training session prior to using the resource were seen to be important, and these helped to put a few teachers who were less confident at ease (Table 2, quote b).

Teachers at School 1, where lessons were 40 minutes in length, found it very challenging to fit everything in, reporting specifically that there was insufficient time for class discussion to consolidate learning (Table 2, quote c). One teacher suggested that it would have been helpful to have been given more guidance on how to split the sessions up to enable delivery in lessons of varying length. Furthermore, teachers would have liked the functionality to easily navigate back and forth to recap if required, or skip sections to fit their lesson lengths (Table 2, quotes d and e).

A few students expressed concern to their teachers about family members who smoked and teachers’ confidence in dealing with these concerns varied. Some felt their skill as a teacher and the school procedures aided them through the process, but a lack of background knowledge and issues such as not knowing whether they gave the correct advice to students were raised by less confident teachers. They suggested that the provision of guidance on steering discussions, advice to give students, and signposts to background information on the topic would be helpful to counter this (Table 2, quote f).

Although many students mentioned that they knew a little bit about the harms of smoking and cigarette ingredients before beginning Operation Smoke Storm, the resource seemed to add more depth to their awareness (Table 3, quote a). For instance, students mentioned that they learnt new information about what is in a cigarette, such as chemicals also found in rat poison and petrol. Some students reported thinking, having learnt about cigarette ingredients and the health effects of tobacco use, that smoking was worse than they previously thought. A few students also reported having learnt about the nature of the tobacco industry, such as its focus on profits (Table 3, quote b), and how they target young people (Table 3, quote c).

Some students stated that participation in Operation Smoke Storm strengthened or maintained their aversion to smoking (Table 3, quote d) and felt it would for other young people too. However, a minority of students thought the resource may trigger thoughts about smoking amongst those who had not considered it previously.

Students enjoyed the interactive nature of Operation Smoke Storm, which they reported was different to the usual format of their PSHE lessons. Generally, teachers felt the resource was appropriate for the age group and allowed all students to actively participate in the lessons (Table 4, quote a). Students mentioned that they liked the secret agent theme and teachers felt this was important in capturing the students’ interest and reported that the storyline engaged them throughout. However, a couple of teachers reported that their class did not relate well to the storyline but that this did not impact upon their engagement in the lessons.

Having a variety of activities to take part in seemed to maintain students’ engagement and they enjoyed learning from peers in group work and the creative freedom they had when putting together group presentations (Table 4, quote b). One activity required students to recall facts from a previous lesson and some students found this difficult. Teachers suggested including a plenary session or providing teacher answer sheets would be useful ways to counteract the problem.

Some teachers highlighted that aspects of the resource could be improved to better cater for lower-ability students who struggled with remembering facts (Table 4, quote c) and felt that some differentiation in the activities could be beneficial. However, they acknowledged that the absence of differentiation did not impede students’ ability to engage with the resource.

Both students and teachers supported the idea of a ‘booster’ session delivered a year later when students are in Year 8 (aged 12-13 years) to reinforce learning about how the tobacco industry targets young people. In general, teachers felt that a classroom session would work better than a homework activity, and they suggested the booster should include a reminder of Operation Smoke Storm followed by a progressive activity to cater for students’ growing maturity (Table 5, quote a). Students were asked to consider the acceptability and potential effectiveness of playing a game (either paper-based, such as a board game, or an electronic game on a computer, tablet or mobile telephone) or producing their own short film, where the example of Cut Films [24] was presented to students in focus groups; both options were well received by students and they suggested that an anti-smoking message delivered by peers of their own age might be effective (Table 5, quote b). However, though teachers liked the ideas they felt that both would be difficult to deliver in school for logistical reasons, such as not having enough equipment (tablets, computers or video recorders) or space (computer rooms) to accommodate all classes at the same time (Table 5, quote c). Regardless of the content of a booster session, teachers were again in favour of a teacher-led ‘off the shelf’ resource similar to Operation Smoke Storm.

Students and teachers were also asked to think about the most effective ways to engage families in discussions around the anti-smoking message. In particular, participants were asked to comment on the idea of a take-home booklet containing information and activities for parents and guardians to complete with their child. In principle, students felt that this would be a good way of involving their families in their learning but opinion was mixed in terms of whether their parents would read it. Some also questioned whether their parents would have time to complete the activities (Table 5, quote d). Teachers expressed the importance of parental engagement in the students’ learning, but from prior experience stressed that this remained a challenge. Thus teachers were generally in favour of a booklet (Table 5, quote e), as long as it was carefully worded so as not to offend parents who themselves smoke.