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We are honoured by the response of an impressive international panel of stakeholders of the smokefree class competition to our recent comment on this programme.1 It is true that one of us (PB) is involved in a local initiative developing a classroom contest, but this is an unimportant detail, not a central point of our 2006 paper. This modest project only intends to be an opportunity to think about this issue on a concrete basis. Rather, we expected Hanewinkel et al to use more convincing arguments and challenge the central points of our criticisms, namely that the evidence for the efficacy of the smokefree class competition is not established beyond the short term, and that this approach raises serious ethical issues. The Cochrane review summarises the situation when it concludes that: “incentives and competitions do not appear to enhance long term cessation rates, with early success tending to dissipate when the rewards are no longer offered.”2 We can understand that this conclusion is difficult to accept for the stakeholders of this programme. Hanewinkel et al do not reject our assertion that the central principle of this competition is to apply negative peer pressure on smokers. Rather, they cite two studies, from Switzerland and Wales, suggesting that bullying and violence were not higher in participating classes than in control classes. However, the Swiss study compared classes that chose to participate with classes that chose not to. Thus it is not clear whether these results are attributable to the competition itself or to selection bias. No reference is given for the study in Wales, which apparently is not a randomised trial either.
For a programme of this importance (600 000 participants and millions of euros every year), conducted for so many years, the absence of an in‐depth evaluation of its potential adverse effects is a serious shortcoming—in particular because negative peer pressure is applied on youthful smokers, who represent a more psychologically vulnerable group than non‐smokers. As for the other points, non‐voluntary cotinine tests were conducted in Switzerland until 2004, and we maintain that this competition lacks a sound basis in behaviour theory. Our hope is that this interesting exchange will raise renewed interest in the psychosocial and ethical issues in school prevention, and stimulate a commitment to seriously evaluate the positive and negative effects of the smokefree class competition.