Situation: The public health nurse and the school nurse plan health education on oral hygiene and tobacco use for Grade 6 pupils of a public elementary school. Before the tobacco lessons, the nurses survey the pupils and run a practice scenario in which a classmate, acting as a friend, keeps urging each pupil to take a cigarette. The results: Believe that smoking is harmful: 92% Intend never to smoke: 88% Took the cigarette when the classmate kept urging: 60% Which teaching method should the nurses MAINLY use?

Knowledge and attitudes (92% believe smoking is harmful) and intention (88% intend never to smoke) are already high, yet 60% gave in under repeated pressure. The gap lies between intention and a skill: refusing under peer pressure. Role play lets pupils rehearse the words and actions of refusal in a safe setting until they can use them. Values clarification and group discussion work on attitudes that are already favorable, and a former smoker's talk offers a model but no practice.

The survey results reveal a classic intention–behavior gap: pupils already hold strong negative beliefs about smoking and most say they do not plan to smoke, yet a majority still accepted a cigarette when pressured repeatedly. This means the nurses should not spend more time trying to change knowledge or attitudes. Instead, the main teaching method must target the missing link—behavioral skill practice for refusing offers under social pressure.

Why role play is the priority

In this scenario, 92% believe smoking is harmful and 88% intend never to smoke. These are already high numbers. However, 60% took the cigarette when a peer kept urging them. The problem is not what pupils know or believe; it is what they can actually do in the moment. Role play directly rehearses the verbal and nonverbal refusal behaviors needed to resist repeated peer offers.

Refusal under pressure is a performance skill, not just a decision. A pupil may know smoking is bad and may want to say no, but without practiced responses, repeated urging can override intention. Role play provides a safe setting to practice words, tone, eye contact, body language, and alternative actions—such as walking away or changing the subject—until the response becomes automatic.

Key point! When knowledge and attitude scores are already high but behavior still fails, the educational gap is a skill deficit, not a knowledge deficit. Teach and rehearse the skill.

How the evidence supports skills-based refusal training

The provided studies consistently show that teaching refusal skills—often through role play, modeling, rehearsal, and feedback—is more effective than purely informational or attitude-focused approaches for adolescent substance use prevention.

One study compared peer pressure resistance training with a normative education approach and found that resistance skill training was the active strategy for reducing cigarette, alcohol, and marijuana use onset ^[1]. This aligns with the scenario: the pupils do not need more information about norms or harms; they need the actual skill to refuse when someone keeps offering.

Another study directly compared social skills training with didactic training and no training. The social skills training group showed significantly greater increases in assertiveness for resisting peer pressure related to risk behaviors . This supports choosing an active rehearsal method over a talk or discussion.

A third study described refusal skills training that used role-plays built from real situations, following a sequence of rationale, modeling, rehearsal, feedback, and reinforcement . The pupils in the scenario would benefit from exactly this structure: see a model refusal, practice it, receive feedback, and repeat.

A fourth study examined the mediating role of refusal skills in preventing adolescent alcohol misuse and found that refusal skills serve as a key mechanism through which prevention programs reduce substance use . This reinforces that the nurses should focus on building the skill itself, not just strengthening the intention.

Why the other options are less appropriate

Option	What it targets	Why it is not the main method here
1. Values clarification	Attitudes and beliefs	Attitudes are already favorable; 92% believe smoking is harmful
3. Talk by a former smoker	Modeling and motivation	Provides a model but no active practice of refusal behavior
4. Group discussion on harms	Knowledge and perceived risk	Knowledge is already high; discussion does not rehearse the actual refusal skill

Watch out! Do not confuse a good role model with skill rehearsal. A former smoker’s story may inspire, but it does not let pupils practice saying no under pressure. The gap shown by the 60% acceptance rate is behavioral, so the teaching method must involve active practice.

The most defensible choice is therefore role play of refusing repeated offers from a peer. It directly addresses the identified deficit—the inability to translate intention into refusal behavior when confronted with persistent social pressure—and is consistent with the evidence that refusal skills training improves adolescent resistance to substance use offers ^[1].