1307020
research-article2025
PED32Supp. 110.1177/17579759241307020Original ArticleF. Cousson-Gélie et al.
Original Article
Study of the transferability of the P2P program: peer-to-peer action
to prevent smoking among vocational high school students
Florence Cousson-Gélie1,2 , Laetitia Marcucci-Hilaire3, Olivier Lareyre1,
Marie Cholley-Gomez1, Jordan Gueritat1, Emilie Charton4, Vincent Grasteau5,
Amélie Anota4, Mathieu Gourlan1,2 and Véronique Régnier Denois3
Abstract:
Objectives: In order to prevent people from taking up smoking on a daily basis, the P2P program has
been developed based on the Theory of Planned Behavior (TPB) and relying on the peer-to-peer
method. A cluster randomized controlled trial involving 1573 high school students in the Occitanie
region of France showed a reduction in the increase in daily smoking. Given the effectiveness observed,
the aim was to assess the transferability of P2P to two other French regions (Ile-de-France and
Auvergne).
Method: The RE-AIM (Recruitment, Effectiveness, Adoption, Implementation, Maintenance)
methodology was used. A total of 190 interviews were conducted with school referents, peer educators,
peer receivers and regional coordinators. A self-questionnaire (before and after the intervention)
assessed changes in daily smoking habits.
Results: P2P has been implemented faithfully in 29 vocational high schools, with adaptations to suit
different contexts and actors. The main obstacles were organizational (timetable and school career).
The levers are the support provided by prevention structures. Recruiting pairs of nurse referents and
improving the pedagogical guide, which is recognized as a support tool, will be necessary. In terms of
effectiveness, more than 3229 students in 10th Grade in vocational high schools were followed for
1 year. The prevalence rates of daily smoking changed by −1.6%, +2.9% and +0.7%, respectively,
showing no significant difference between these regions, with no difference in effect depending on the
place of implementation.
Discussion: The P2P program is transferable to other regions despite differences in how the
organizations and high schools involved operate, and differences in the characteristics of the high
school students targeted. It is also reproducible, maintaining a beneficial effect in preventing increased
daily smoking among vocational high school students.
Keywords: adolescents and youth, school setting, tobacco, education (including health education),
health promotion
1. Université Paul Valéry Montpellier 3, EPSYLON EA 4556, F34000, Montpellier, France.
2. Institut Régional du Cancer de Montpellier, Epidaure, Montpellier, France.
3. Institut PRESAGE, P2S UR4129, Univ de Lyon, UJM, St Etienne, France.
4. Department of Clinical Research and Innovation and Department of Human and Social Sciences, Centre Léon Bérard,
Lyon, France.
5. Fondation JDB Prevention Cancer, Espace Prévention Santé Anteia, Fontenay-Les-Briis, France.
Correspondence to: Florence Cousson-Gélie, Université Paul Valéry Montpellier 3, EPSYLON EA 4556, Route de
Mende, 34199 Montpellier Cedex 5, France. Email:
(This manuscript was submitted on 26 August 2024. Following anonymous peer review, it was accepted for publication
on 23 November 2024.)
Global Health Promotion 1757-9759; Vol 32(Supp. 1): 110–118; 1307020 Copyright © The Author(s) 2025, Reprints and permissions:
http://www.sagepub.co.uk/journalsPermissions.nav https://doi.
DOI: 10.1177/17579759241307020
org/10.
1177/17579759241307020 journals.sagepub.com/home/ghp
https://doi.org/
, F. Cousson-Gélie et al. 111
Introduction In addition to the peer-to-peer modality,
implementing and evaluating theory-based
Smoking remains the most common cause of interventions are recognized as an effective way of
avoidable death in France (1), as it is worldwide (2), improving health behaviors (16–18), particularly by
with the French National Cancer Institute estimating identifying the main target concepts and selecting
that almost a third of cancer deaths are linked to appropriate intervention techniques (19). Among
smoking (3). Nevertheless, recent studies indicate a these theories, the Theory of Planned Behavior
decline in smoking among teenagers (4–6), (TPB) is one of the most widely tested models of the
particularly via a trend toward the ‘denormalization’ factors influencing health-related behavior (20,21).
of cigarettes among younger generations (7). In This theory postulates that a person’s behavior is
20 years, the proportion of 17-year-olds who smoke determined largely by the perception of control over
has fallen from 41.1% to 15.6%, and the proportion the conduct and the intention to adopt it. Intention
of smokers has fallen faster among adolescents than is, in turn, explained by attitudes, subjective norms
among adults (−62% vs. −16%) (6,8). In addition, and perceived behavioral control. Concerning
several studies have shown that people aged between smoking behavior, although studies may vary
15 and 24 years have a lower risk of relapsing into according to the behavioral outcome (e.g., reduction
smoking (9,10). in smoking, cessation of smoking) or the type of
However, social inequalities in smoking during product (cigarettes only, medicines including
adolescence are still significant (6). For example, in tobacco), previous meta-analyses and reviews have
terms of parental employment status, young people reported the validity of TPB in these different
from working-class families smoke more frequently contexts (22,23). The TPB has been shown to be
(i.e., every day) than those from managerial families. effective in predicting the intention not to smoke or
Educational status is also a marker of behavioral
reduce smoking, as well as smoking behavior in
differentiation. At the age of 17 years, young people
adolescent smokers and non-smokers (18). When
who have left the school system (having dropped
the theoretical implementation level is considered, it
out, been on a civic service or in employment)
has been shown that the most theoretically anchored
experience a smaller drop in smoking and report
interventions favor an increase in subjective norms
three times as much daily smoking as high school
unfavorable to smoking (18).
students in general, technological or vocational
In order to prevent the onset of daily smoking,
education (43.5% vs. 13.3%). These results also
which is particularly important during high school
apply to apprentices compared with high school
years, especially in vocational training, we have
students (38.4% vs. 13.3%), with the drop in
consumption again being differentiated since it is developed a P2P peer prevention program based on
half as great for apprentices as for high school the TPB aimed at preventing daily smoking (24). A
students (−19% vs. −40%) (8). randomized controlled cluster trial was conducted
Among preventive or health education initiatives, over 2 years on 1573 high school students enrolled
peer-to-peer interventions are a potentially effective in the second year of vocational education or the
means of preventing addictive behavior and first year of a vocational training certificate (10). At
combating the use of psychoactive substances among the end of the follow-up, a significantly smaller
adolescents (11–13). A recent literature review increase in the proportion of daily smokers was
demonstrated the effectiveness of peer-based observed in the intervention group (7.1 percentage
interventions in promoting health behaviors (12). points) than in the control group (17.4 points),
Although the smoking behavior of other adolescents resulting in a difference of 9.9 points between the
can influence an adolescent’s tobacco consumption groups at the end of the study. The impact of P2P on
through peer pressure or choice (14), the influence of preventing daily smoking at 16 months [odds ratio
other young people can also be protective through (OR) = 0.33, 95% confidence interval (CI) = 0.20,
peer education. Peers have a high degree of credibility, 0.53] also appeared to be greater than the average
a shared cultural context and a good understanding impact of previous peer-led interventions to prevent
of the smoking behavior of their peers, which can smoking among adolescents (OR = 0.78, 95%
increase the acceptability and effectiveness of CI = 0.62, 0.99). In light of the effectiveness observed
prevention messages and actions (15). in this context, we deployed the P2P program in
IUHPE – Global Health Promotion Vol. 32, Supp. 1 2025
research-article2025
PED32Supp. 110.1177/17579759241307020Original ArticleF. Cousson-Gélie et al.
Original Article
Study of the transferability of the P2P program: peer-to-peer action
to prevent smoking among vocational high school students
Florence Cousson-Gélie1,2 , Laetitia Marcucci-Hilaire3, Olivier Lareyre1,
Marie Cholley-Gomez1, Jordan Gueritat1, Emilie Charton4, Vincent Grasteau5,
Amélie Anota4, Mathieu Gourlan1,2 and Véronique Régnier Denois3
Abstract:
Objectives: In order to prevent people from taking up smoking on a daily basis, the P2P program has
been developed based on the Theory of Planned Behavior (TPB) and relying on the peer-to-peer
method. A cluster randomized controlled trial involving 1573 high school students in the Occitanie
region of France showed a reduction in the increase in daily smoking. Given the effectiveness observed,
the aim was to assess the transferability of P2P to two other French regions (Ile-de-France and
Auvergne).
Method: The RE-AIM (Recruitment, Effectiveness, Adoption, Implementation, Maintenance)
methodology was used. A total of 190 interviews were conducted with school referents, peer educators,
peer receivers and regional coordinators. A self-questionnaire (before and after the intervention)
assessed changes in daily smoking habits.
Results: P2P has been implemented faithfully in 29 vocational high schools, with adaptations to suit
different contexts and actors. The main obstacles were organizational (timetable and school career).
The levers are the support provided by prevention structures. Recruiting pairs of nurse referents and
improving the pedagogical guide, which is recognized as a support tool, will be necessary. In terms of
effectiveness, more than 3229 students in 10th Grade in vocational high schools were followed for
1 year. The prevalence rates of daily smoking changed by −1.6%, +2.9% and +0.7%, respectively,
showing no significant difference between these regions, with no difference in effect depending on the
place of implementation.
Discussion: The P2P program is transferable to other regions despite differences in how the
organizations and high schools involved operate, and differences in the characteristics of the high
school students targeted. It is also reproducible, maintaining a beneficial effect in preventing increased
daily smoking among vocational high school students.
Keywords: adolescents and youth, school setting, tobacco, education (including health education),
health promotion
1. Université Paul Valéry Montpellier 3, EPSYLON EA 4556, F34000, Montpellier, France.
2. Institut Régional du Cancer de Montpellier, Epidaure, Montpellier, France.
3. Institut PRESAGE, P2S UR4129, Univ de Lyon, UJM, St Etienne, France.
4. Department of Clinical Research and Innovation and Department of Human and Social Sciences, Centre Léon Bérard,
Lyon, France.
5. Fondation JDB Prevention Cancer, Espace Prévention Santé Anteia, Fontenay-Les-Briis, France.
Correspondence to: Florence Cousson-Gélie, Université Paul Valéry Montpellier 3, EPSYLON EA 4556, Route de
Mende, 34199 Montpellier Cedex 5, France. Email:
(This manuscript was submitted on 26 August 2024. Following anonymous peer review, it was accepted for publication
on 23 November 2024.)
Global Health Promotion 1757-9759; Vol 32(Supp. 1): 110–118; 1307020 Copyright © The Author(s) 2025, Reprints and permissions:
http://www.sagepub.co.uk/journalsPermissions.nav https://doi.
DOI: 10.1177/17579759241307020
org/10.
1177/17579759241307020 journals.sagepub.com/home/ghp
https://doi.org/
, F. Cousson-Gélie et al. 111
Introduction In addition to the peer-to-peer modality,
implementing and evaluating theory-based
Smoking remains the most common cause of interventions are recognized as an effective way of
avoidable death in France (1), as it is worldwide (2), improving health behaviors (16–18), particularly by
with the French National Cancer Institute estimating identifying the main target concepts and selecting
that almost a third of cancer deaths are linked to appropriate intervention techniques (19). Among
smoking (3). Nevertheless, recent studies indicate a these theories, the Theory of Planned Behavior
decline in smoking among teenagers (4–6), (TPB) is one of the most widely tested models of the
particularly via a trend toward the ‘denormalization’ factors influencing health-related behavior (20,21).
of cigarettes among younger generations (7). In This theory postulates that a person’s behavior is
20 years, the proportion of 17-year-olds who smoke determined largely by the perception of control over
has fallen from 41.1% to 15.6%, and the proportion the conduct and the intention to adopt it. Intention
of smokers has fallen faster among adolescents than is, in turn, explained by attitudes, subjective norms
among adults (−62% vs. −16%) (6,8). In addition, and perceived behavioral control. Concerning
several studies have shown that people aged between smoking behavior, although studies may vary
15 and 24 years have a lower risk of relapsing into according to the behavioral outcome (e.g., reduction
smoking (9,10). in smoking, cessation of smoking) or the type of
However, social inequalities in smoking during product (cigarettes only, medicines including
adolescence are still significant (6). For example, in tobacco), previous meta-analyses and reviews have
terms of parental employment status, young people reported the validity of TPB in these different
from working-class families smoke more frequently contexts (22,23). The TPB has been shown to be
(i.e., every day) than those from managerial families. effective in predicting the intention not to smoke or
Educational status is also a marker of behavioral
reduce smoking, as well as smoking behavior in
differentiation. At the age of 17 years, young people
adolescent smokers and non-smokers (18). When
who have left the school system (having dropped
the theoretical implementation level is considered, it
out, been on a civic service or in employment)
has been shown that the most theoretically anchored
experience a smaller drop in smoking and report
interventions favor an increase in subjective norms
three times as much daily smoking as high school
unfavorable to smoking (18).
students in general, technological or vocational
In order to prevent the onset of daily smoking,
education (43.5% vs. 13.3%). These results also
which is particularly important during high school
apply to apprentices compared with high school
years, especially in vocational training, we have
students (38.4% vs. 13.3%), with the drop in
consumption again being differentiated since it is developed a P2P peer prevention program based on
half as great for apprentices as for high school the TPB aimed at preventing daily smoking (24). A
students (−19% vs. −40%) (8). randomized controlled cluster trial was conducted
Among preventive or health education initiatives, over 2 years on 1573 high school students enrolled
peer-to-peer interventions are a potentially effective in the second year of vocational education or the
means of preventing addictive behavior and first year of a vocational training certificate (10). At
combating the use of psychoactive substances among the end of the follow-up, a significantly smaller
adolescents (11–13). A recent literature review increase in the proportion of daily smokers was
demonstrated the effectiveness of peer-based observed in the intervention group (7.1 percentage
interventions in promoting health behaviors (12). points) than in the control group (17.4 points),
Although the smoking behavior of other adolescents resulting in a difference of 9.9 points between the
can influence an adolescent’s tobacco consumption groups at the end of the study. The impact of P2P on
through peer pressure or choice (14), the influence of preventing daily smoking at 16 months [odds ratio
other young people can also be protective through (OR) = 0.33, 95% confidence interval (CI) = 0.20,
peer education. Peers have a high degree of credibility, 0.53] also appeared to be greater than the average
a shared cultural context and a good understanding impact of previous peer-led interventions to prevent
of the smoking behavior of their peers, which can smoking among adolescents (OR = 0.78, 95%
increase the acceptability and effectiveness of CI = 0.62, 0.99). In light of the effectiveness observed
prevention messages and actions (15). in this context, we deployed the P2P program in
IUHPE – Global Health Promotion Vol. 32, Supp. 1 2025
