Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating 1 a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)] 2 , a course for school staff in short motivational conversations 3 , school class-based teaching material 4 , an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students’ acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.

Background Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students’ smoking. Methods A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation. Results Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention. Conclusion This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved. Trial registration https://www.isrctn.com/ISRCTN16455577, date of registration 14/06/2018.

The smoking prevalence among vocational education and training (VET) students is high. This paper describes the development and feasibility test of a multicomponent intervention designed to promote non-smoking behaviour at VET schools. We applied the Behaviour Change Wheel (BCW) stages and the capability, opportunity, and motivation for behaviour (COM-B) model to develop the intervention components based on theory, evidence, and a thorough needs-assessment study. Moreover, we feasibility-tested the preliminary ideas. All in all, our study was based on the literature, survey data, fieldwork, workshops, and expert and stakeholder involvement. The final intervention programme targets VET students’ smoking behaviour at the school, class, and individual levels through (a) a comprehensive tobacco policy to limit the physical and social opportunities to smoke, supplemented with a two-day staff course in conversations about smoking and an edutainment session (a lecture that both educates and entertains) to support a smoke-free environment; (b) classroom curricular with teaching materials to increase knowledge and social support, along with a quit-and-win competition to increase motivation; and (c) the national Quitline adapted to VET students to increase access to cessation support. The BCW model enabled a systematic and comprehensive development of an intervention, which demonstrates relevant techniques and delivery options to have the potential to reduce smoking in VET schools.