Feasibility and acceptability of adding peer support to a school-based nurse-led smoking cessation intervention among male adolescents in Pakistan: a pilot cluster-randomized trial

Abstract

Reducing adolescent smoking is a global health priority. School-based, nurse-led interventions show promise, yet most studies have been conducted in Western and other high-income countries. This study assessed the feasibility and acceptability of a school-based, nurse-led smoking cessation intervention delivered with and without peer support in Pakistan. We conducted a pilot cluster-randomized trial in four public high schools in Karachi. A total of 160 adolescent male smokers (aged 15–19 years) were allocated by school to receive either a nurse-led-only or a nurse-led plus peer-supported smoking-cessation intervention. Primary outcomes included feasibility (recruitment yield, retention rates and intervention deliverability) and secondary acceptability (satisfaction ratings). Smoking-related outcomes were assessed as exploratory measures and included self-reported and carbon monoxide–verified 7-day point-prevalence abstinence, treatment-related quit attempts, and changes in daily cigarette consumption among non-quitters. Recruitment yield was 76.2%, and retention exceeded 80% at 3 months in both study arms. Session attendance and satisfaction were higher in the peer-supported condition. Exploratory assessments indicated higher proportions of abstinence, more frequent quit attempts, and greater reduction in daily cigarette smoking in the peer-supported arm at 1- and 3-month follow-up. Estimated school-level variability was low but imprecise due to the small number of clusters. Results support the feasibility and acceptability of delivering both nurse-led and peer-supported smoking cessation interventions in Pakistani high schools. Exploratory smoking-related outcomes suggest potential added value of peer support and provide preliminary parameters for planning a fully powered cluster-randomized trial to evaluate effectiveness. This study was registered retrospectively with the Thai Clinical Trials Registry (TCTR) under the Registration Number TCTR20250822005 (Announcement Date:22 August 2025).