Peer-led interventions to prevent tobacco, alcohol and/or drug use among young people: What's the evidence?

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Peer-led interventions to
prevent tobacco, alcohol
and/or drug use among young
people: What's the evidence?
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What’s the evidence?
MacArthur G.J., Harrison S., Caldwell D.M.,
Hickman M., & Campbell R. (2016). Peer-led
interventions to prevent tobacco, alcohol
and/or drug use among young people aged
11-21 years: A systematic review and meta-
analysis. Addiction, 111(3), 391-407.
http://www.healthevidence.org/view-
article.aspx?a=peer-led-interventions-prevent-tobacco-
alcohol-drug-young-people-aged-11-21-29422

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Poll Question #3

Dr. Georgie MacArthur
National Institute for Health
Research Postdoctoral
Research Fellow, School of
Social and Community
Medicine, University of Bristol

Peer-led interventions reduce odds of
youth tobacco smoking, alcohol use, and
cannabis use
A. Strongly agree
B. Agree
C. Neutral
D. Disagree
E. Strongly disagree
17
Poll Question #4

The Review
• Peer-led interventions to prevent
tobacco, alcohol and/or drug use among
young people aged 11-21 years: a
systematic review and meta-analysis
Addiction (2015) 111;3: 391-407
doi: 10.1111/add.13224

Review Team
• Dr Georgie MacArthur
• Dr Sean Harrison
• Dr Deborah Caldwell
• Professor Matt Hickman
• Professor Rona Campbell
• School for Social and Community Medicine,
University of Bristol, England

Background & Introduction
• Initiation of substance use during adolescence
• Age of onset similar across h/i countries
• Overall downward trends in UK. Nevertheless:
24%
Drugs in past
year
8% regular smoking
35% ever smoked
34%
Drinking at
hazardous levels
>50%
Drinking in past
week
Fuller E. Health and Social Care Information Centre (2015); MacArthur et al, Journal of Public Health 2012; Public Health
England. Data intelligence summary (2016)

Background & Introduction
• Rank of UK among 36 European countries (2011):
o 5th for drug use
o 7th for binge drinking
Hibell B et al (2011). The 2011 ESPAD Report. Substance use
among students in 36 European countries. The Swedish Council
for Information on Alcohol and Other Drugs, Stockholm, Sweden.
Having had 5+ drinks on one occasion during past 30 days
(%) by gender.

Public Health Importance
Smoking
Alcohol
Drugs
Early smoking- trajectory
Cancers, CVD, stroke, chronic
respiratory disease, premature death
Violence, injury, accidents, sexual risk
behaviour
Cancers, CVD, liver disease & others
Mental health problems, vehicle risk,
risk of dependence later in life
• Range of negative consequences
• Short and long-term

Global Burden
• Burden rises in adolescence & young adulthood
• Age 15-19 yrs:
Alcohol + Drugs 7% health burden
• Age 20-24 yrs:
Alcohol + Drugs 10% total health burden
• Tobacco: Western Europe & African countries
• Alcohol: Eastern Europe, W Europe, N America, Australasia
• Cannabis: USA, Canada, Australia, NZ, Western Europe
Degenhardt L et al, Lancet Psychiatry 2016; 3: 251-64.
Pschubert

Interventions (excl. population level)
• Substantial body of literature
• Evidence in support of:
o Parenting interventions
o School-based interventions:
o Multi-component school-based programs for tobacco use (less clear
alcohol and drugs)
o Certain non-specific programmes e.g. social influences for alcohol
use
o Social norms (small but positive effect) - alcohol
o Programmes that improve personal and interpersonal skills and
address social influences for drug use
o Individual-level interventions: findings are mixed
Faggiano Cochrane Database Sys Rvws 2014; Stockings et al, Lancet 2016; Allen et al, Pediatrics 2016; Kuntsche & Kuntsche,
Clinical Psychology Review 2016; Foxcroft and Tsertsvadze, Perspectives in Public Health, 2012

Interventions
• Heterogeneous body of evidence
o Variation in participants, components, duration,
outcomes, follow up
o Differential effects by age & intensity
o Methodological and reporting issues
oRisk of bias
Scope for novel approaches

Background and Rationale
• Role & impact of peers and social
networks on alcohol use
o Harnessing role or influences
o Novel intervention
o Peer-based models
+
+
+
+
+
+
+
+
+
+
+
+
+

Peers and substance use
• Peers play prominent role at this stage
• Association with substance-using peers
associated with young people’s use
o Influence of behaviour
o Selection of peers with similar behaviour
o Both mechanisms
o E.g. 6-fold greater likelihood of drinking with 4 vs 0 drinking
peers
Kelly et al, Addictive Behaviors, 2012; Ali and Dwyer , Addictive Behaviors, 2010

Peer-based approaches
• Delivery, facilitation, group work
• Part or all of intervention
• Same age / older peers
o Formal or informal settings
o Educational,
o Discursive, ‘diffusion’
‘The teaching or sharing of health information, values and behaviours by
members of similar age or status group’
(Sciacca J. Peer Facilitator Quarterly 1987;5: 4-6)

Peer-based approaches
• Credibility
• Learn from each other
• Shared cultural background
• Understand behaviour
• Positive role models

Evidence Base
• School-based health education
o n=7/11 (64%) peers at least as effective as adults
o n=9/11 (75%) more effective vs control (Mellanby, 2000)
• Peer-delivered health promotion interventions
o n=7/12 (58%) effective for ≥1 behavioural outcome
o n=5 with contradictory results (Harden, 2001)

Evidence Base
• Positive view from young people (Harden, 1999, 2001)
• Overall, evidence not clear
• Lack of methodological rigor
• No meta-analysis
• No recent evidence (published 1999-2001)

Aims and Methodology
• Identify and review the latest evidence
• Interventions targeting those in secondary and
tertiary education
• Searches:
o Medline, EMBASE, PsycINFO, Cinahl, ERIC, Cochrane
Library, AEI, BEI
o Grey literature
o Mixture of MESH and text words

Inclusion & Exclusion Criteria
Inclusion Exclusion
Randomised controlled trials Non-randomised studies
>6 weeks follow up Clinical or brief interventions
>50% aged 11-21 years Multi-component interventions
Peers involved in substantial
component of intervention
delivery
Targeting prescription or body-
enhancing drugs
No language or geographical restriction

Review focus
P Young people aged 11-21 years
I Interventions in any setting targeting alcohol, tobacco
and/ or drug use
Peers involved in substantial part of intervention
delivery
C Usual practice, no intervention
Teacher/ professional/ adult-led
O Tobacco use (including smokeless tobacco)
Alcohol use
Drug use (including cannabis, cocaine, ecstasy, glue,
gas, aerosol, solvents, magic mushrooms, crack,
ketamine, heroin, poppers, LSD, methamphetamine,
amphetamine)

Methodology & Analysis
Duplicate
screening
Duplicate data
extraction
Extracted/
calculated /
converted to OR
Adjusted for
clustering
(incl sensitivity)
Random effects
model
(fixed effects as
sensitivity)
Heterogeneity
(I2 and 2 test)
Funnel plot and
Egger Test
Duplicate Risk of
Bias (Cochrane
Tool)

Records identified through database searching
(n=1,387)
Medline (n=375)
Embase (n=361)
PsycINFO (n=130)
CINAHL (n=143)
ERIC (n=108)
Cochrane Library (n=265)
Grey literature (n=2)
Hand searching (n=3)
Records after duplicates removed
(n=796)
Records screened
(n=796)
Records excluded (n=726)
Full-text articles assessed for eligibility
(n=70) Full-text articles excluded (n=45):
Study design (n=16)
Lack of peer involvement (n=14)
Multiple components (n=4)
Publication type (n=2)
Ineligible outcomes (n=4)
Type of intervention (n=1)
Other (n=4)
Studies included in qualitative synthesis (n=25)
Unique studies
(n=17)
Studies included in quantitative synthesis
(n=14)
Tobacco (n=10)
Alcohol (n=6)
Cannabis (n=3)
Flow Diagram

Characteristics of Studies
• Over half (59%):
o Conducted in 1980s and 90s
o Conducted in USA
o Targeted young people aged 12-14 years
• Majority (82%) school-based
• ~Half (53%) targeted tobacco
o One quarter targeted all 3 substances

Characteristics of studies II
• Weeks to years
• 2 to 36 sessions
• Curriculum to
conversations
• Same age & older
peers
• Teachers &
facilitators
• Refusal
• Consequences
• Norms
• Videos
• Communication
• Scenarios, role play
• Advertising
• Peer pressure
• Resisting influences

Role & selection of peers
• Led classes, boosters, group sessions,
activities, role-play, conversations
• Selected by classmates, recruited by
teachers, volunteers
• Training: range 1 hr to 9-month course

Study
Sequence
generation
Allocation
concealment
Blinding
(participants)
Blinding
(outcome
assessment)
Incomplete
outcome
data
Selective
reporting Other
Albrecht, 2006 + ? - ? - ? +
Armstrong, 1991 ? ? + + ? ? -
Bobrowski, 2014 ? ? - ? + ? ?
Botvin, 2001 ? ? ? ? - -
Campbell, 2008 + + + ? + + +
Elder, 1993 ? ? - ? + ? +
Ellickson, 1990 ? ? - ? + ? +
Fromme, 2004 ? ? - ? ? ? +
Lotrean, 2010 + ? - ? + ? +
Luna-Adame, 2013 ? ? - ? ? + +
Murray, 1987 ? ? - ? - ? ?
Perry, 1989 ? ? - ? + ? +
Rosenblum, 2008 ? ? - ? ? - -
Severson, 1991 ? ? - ? - ? +
Telch, 1990 ? ? - ? ? - ?
Valente, 2007 ? ? - - ? ? +
Wilhelmsen, 1994 ? ? - ? ? + +
Risk of Bias
Cochrane Handbook for Systematic Reviews of Interventions: handbook.Cochrane.org

Findings: Tobacco
N=13,706
220 schools
OR 0.78, 95% CI 0.62-
0.99
p=0.04
I2 = 41%, 2 15.2, p=0.086
I-V Overall (I-squared = 40.7%, p = 0.086)
Campbell
Valente
Elder
Severson
D+L Overall
Lotrean
Armstrong
Telch
Luna-Adame
Botvin
Ellickson
Author
2001
2007
1988
1985
2006
1981
1984
2013
1984
1984
Date
0.79 (0.67, 0.93)
0.67 (0.46, 0.97)
0.79 (0.54, 1.17)
0.57 (0.36, 0.88)
1.13 (0.75, 1.69)
0.78 (0.62, 0.99)
0.45 (0.19, 1.04)
0.87 (0.61, 1.23)
0.26 (0.03, 2.24)
3.49 (0.70, 17.45)
0.33 (0.08, 1.32)
1.20 (0.60, 2.41)
ES (95% CI)
0.79 (0.67, 0.93)
0.67 (0.46, 0.97)
0.79 (0.54, 1.17)
0.57 (0.36, 0.88)
1.13 (0.75, 1.69)
0.78 (0.62, 0.99)
0.45 (0.19, 1.04)
0.87 (0.61, 1.23)
0.26 (0.03, 2.24)
3.49 (0.70, 17.45)
0.33 (0.08, 1.32)
1.20 (0.60, 2.41)
ES (95% CI)
1.01 .1 1 10
Odds Ratio

Findings: Alcohol
N=1,699
66 schools
1 university
OR 0.80, 95% CI 0.65-
0.99
p=0.04
I2 = 15%, 2 5.9, p=0.321
.
.
Overall (I-squared = 14.5%, p = 0.321)
Subtotal (I-squared = 0.0%, p = 0.685)
Botvin
Valente
Unadjusted
Wilhelmsen
Study
Perry
Subtotal (I-squared = 0.0%, p = 0.514)
Fromme
Adjusted
Ellickson
1984
2007
1992
Date
1986
2004
1984
0.80 (0.65, 0.99)
1.03 (0.74, 1.45)
0.88 (0.32, 2.39)
0.59 (0.40, 0.88)
0.92 (0.58, 1.47)
ES (95% CI)
0.67 (0.46, 0.98)
0.70 (0.56, 0.88)
0.98 (0.63, 1.51)
1.12 (0.66, 1.91)
0.80 (0.65, 0.99)
1.03 (0.74, 1.45)
0.88 (0.32, 2.39)
0.59 (0.40, 0.88)
0.92 (0.58, 1.47)
ES (95% CI)
0.67 (0.46, 0.98)
0.70 (0.56, 0.88)
0.98 (0.63, 1.51)
1.12 (0.66, 1.91)
1.01 .1 1 10
Odds Ratio

Findings: Alcohol II
• 6 studies, fewer participants
• Meta-analysis of unadjusted estimates
only null effect
• Sensitivity analysis (excl 1 study)
null effect

Findings: Cannabis
N=976
38 schools
OR 0.70, 95% CI 0.50-
0.97
p=0.034
I2 = 0%, 2 1.0, p=0.605
Overall
Unadjusted
Adjusted
Valente
Botvin
Subtotal
Ellickson
Subtotal
Study
2007
1984
1984
Date
0.70 (0.50, 0.97)
0.69 (0.47, 1.02)
0.24 (0.03, 2.22)
0.79 (0.40, 1.56)
0.79 (0.40, 1.56)
0.67 (0.46, 0.98)
ES (95% CI)
0.70 (0.50, 0.97)
0.69 (0.47, 1.02)
0.24 (0.03, 2.22)
0.79 (0.40, 1.56)
0.79 (0.40, 1.56)
0.67 (0.46, 0.98)
ES (95% CI)
1.01 .1 1 10
Odds Ratio

Adverse effects
• 2 studies
• Enhanced tobacco / alcohol use among higher-
risk groups
o Peer leaders identified via social network
nominations
o Higher use among those with existing networks of
substance-using peers (Valente, 2007)
o Higher prevalence of smoking & pro-smoking
attitudes among baseline smokers in peer-led arm
(Ellickson, 1990)

Study Summary
• Multiple databases
• Three behaviours
• Quantified effect for
1st time
• Low quality of evidence
& risk of bias
• Insufficient data to
compare across risk
groups or by
gender/ethnicity/SES
• Cultural norms of 1980s
and 90s

Summary
• Corroborate and strengthen evidence
• Peer-led interventions can reduce tobacco,
alcohol and possibly cannabis use in young
people
o Peers embedded in social groups
o Share social, cultural norms & background
o Credibility
o Possible benefits to peer leaders themselves
• Scope for more extensive trial and
implementation e.g. school-based curriculum for tobacco

Implications & Conclusions
• Poor quality evidence
• Potential for adverse consequences
o Cultural, social and peer norms
o Targeting of messages in different risk groups
o Wider influences of behaviour
• Need for robust, rigorously conducted studies
o Longer follow up
o Process evaluations

Acknowledgements
• Georgie MacArthur is supported by a National Institute for Health Research
(NIHR) post-doctoral fellowship (PDF-2013-06-026). The views expressed are
those of the author(s) and not necessarily those of the NHS, the National
Institute for Health Research or the Department of Health.
• Sean Harrison (Wellcome Trust PhD programme in Molecular, Genetic and
Lifecourse Epidemiology, grant number 102432/Z/13/Z)
• Deborah Caldwell (Medical Research Council population health scientist award
(G0902118))
• Rona Campbell and Matt Hickman are members of the UKCRC Public Health
Centre of Excellence at Bristol, Cardiff and Swansea (DECIPHer) and the NIHR
School for Public Health Research
The work was undertaken with the support of The Centre for the Development and
Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a
UKCRC Public Health Research Centre of Excellence. Joint funding
(MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, Economic
and Social Research Council, Medical Research Council, the Welsh Government and the
Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is
gratefully acknowledged.

Questions?
Georgie.Macarthur@Bristol.ac.uk

Peer-led interventions reduce odds of
youth tobacco smoking, alcohol use, and
cannabis use
A. Strongly agree
B. Agree
C. Neutral
D. Disagree
51
Poll Question #5

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C. Neutral
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Peer-led interventions to prevent tobacco, alcohol and/or drug use among young people: What's the evidence?

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Peer-led interventions to prevent tobacco, alcohol and/or drug use among young people: What's the evidence?