The European Smoking Prevention Framework Approach (ESFA) study in six countries tested the effects of a comprehensive smoking prevention approach after 24 (T3; N = 10 751) and 30 months (T4; N = 9282). The programme targeted four levels, i.e. adolescents in schools, school policies, parents and the community. In Portugal, 12.4% of the T1 non-smokers in the control group had started smoking at T4 compared to 7.9% of the experimental group. Smoking onset in the experimental group was thus 36% lower. In Finland, 32.4% of the T1 non-smokers started smoking compared to 27.6% of the experimental group, implying a 15% lower onset in the experimental group. In Spain, 33.0% of the T1 non-smokers in the control group had started smoking, compared to 29.1% of the experimental group, implying a 12% lower onset. In The Netherlands, the ESFA programme was effective for non-native adolescents with 11.4% new weekly smokers compared to 19.9% in the control group. An opposite effect was found in native Dutch adolescents with 19.0% new weekly smokers in the comparison group compared to 24.0% new smokers in the experimental group. Future programmes should use more standardized ways to assess process evaluations and should assess which elements are responsible for behavioral effects.

The European Smoking Prevention Framework Approach (ESFA) resulted in a smoking prevention project for six European countries. It included activities on four levels: adolescents, schools, parents and out‐of‐school activities. Common goals and objectives were developed, but countries were also able to include additional objectives. National diversities required country‐specific methods. The most important common element was a school‐based programme consisting of at least five lessons paying attention to social influence processes and training in refusal skills. During the first year, significantly more smoking prevention activities were realized in experimental schools compared with control schools. Not all countries had the same number of lessons on resisting peer pressures. Significant cognitive changes were observed in Spain, resulting in more negative attitudes, increased self‐efficacy levels and a more negative intention towards smoking in the experimental group. Counter‐productive cognitive effects were observed in the UK. Significantly less onset of weekly smoking in experimental groups was found in Finland (4.7%) and Spain (3.1%). Counter‐productive effects were observed in Denmark and the UK. In conclusion, while having common objectives, the ESFA approach allowed for a great deal of diversity. Fundamental research using dismantling designs is needed to be able to detect the most effective elements of smoking prevention programmes for different age groups. Attention to parenting styles and practices is also needed.

Understanding the key factors that influence smoking behavior, especially during adolescence, has a meaningful impact on public health. This study examined the impact of parent modelling, peer influence and peer selection on adolescent smoking behavior in two Portuguese cohorts followed for three years. A questionnaire was delivered in classes and schools randomly selected, three times, one per year (cohort1: time1-7th, time2-8th, time3-9th; cohort2: time1-10th, time2-11th, time3-12th graders). The sample included a total of 656 students (402 younger [time1 Mage = 13.17, SD = 0.53, 63.7% girls;] and 254 older [time 1 Mage = 16.20, SD = 0.53, 65% girls]). Longitudinal data were examined through an autoregressive cross-lagged model (ARCL). The model explained 35% of the variance in smoking behavior at T3 for the global sample (4% for the younger and 58% for the older). Over time, in both cohorts, the percentage of never smokers decreased sharply and the percentage of regular smokers increased rapidly. We observed that participants in the older cohort had higher chances of smoking if their parents smoked. Nevertheless, we did not find a parental modelling effect in the longitudinal model. Peer influence and peer selection influenced smoking behavior. However, peer selection influenced the youngest group, both processes influenced the middle age group, and only peer influence influenced the oldest. Best friend and friends had a stronger impact on the younger while friends and same grade students had a stronger impact on the older. Prevention programs should regard these differences of interpersonal influences through adolescent development and specific strategies for different age groups should be considered.

Preventing smoking initiation among adolescents of lower socio-economic groups is crucial for the reduction of socio-economic inequalities in health. The aim of the present study was to examine whether effective smoking prevention interventions in Europe are equally effective among adolescents of low- and high-socio-economic status (SES). As part of the European Union-funded TEENAGE project, three school-based smoking prevention intervention studies in Europe were selected for secondary analyses: (i) a Dutch class competition intervention, (ii) the European Smoking Prevention Framework (ESFA) study and (iii) the A Stop Smoking in Schools Trial (ASSIST) intervention. All three studies differed in effectiveness by SES. The Dutch class competition study only had a significant effect among higher SES adolescents. The results for the ESFA study and ASSIST study were mixed and depended on which SES indicator was used. The conclusion of the study is that stratified analyses provide important insights in differential intervention effects for higher and lower socio-economic groups. Although findings from the different studies were mixed, interventions that use a social network approach in which youngsters are allowed to deliver the intervention themselves may be a successful strategy in targeting adolescents from lower socio-economic groups.