Within the European Commission health promotion activity and smoking prevention activity takes place at several levels. While the majority of the preventive work on smoking is channelled through the Europe against Cancer programme, this is integrated within an overall prevention strategy laid down in the Treaty of the European Union, where specific Public Health objectives are identified. The following areas are described here: an overview of European Commission activity in the area of tobacco control and the key activities, achievements and plans of the Europe against Cancer programme.
Tobacco control activities within the European Commission
Community action is focused on encouraging cooperation between
member states, and on promoting coordination of their policies
and programmes. This takes place within the principle of subsidiarity
outlined in the Maastricht Treaty, which means that the Community
supports actions whose objectives cannot be sufficiently achieved
by a Member State alone. Projects are assessed according to whether
complementary national activity has significant benefits for the
Community as a whole, whether the action will contribute towards
the development of best practice and whether community cohesion
is enhanced. The Commission will, in future, give priority funding
to projects in the field of cancer prevention which are on a large
scale, and involve governmental and non-governmental organisations.
Cooperative arrangements between members states will also be supported.
An audit of the health protection aspects of policy developed in all European Commission policy areas is undertaken by the commission annually. Internal procedures have been put in place to ensure that adequate coordination and consultation occurs during policy development on their likely effects on health.
Legislative action has also been taken: warnings on cigarette packets have been harmonised throughout the community, as have rules on the tar content of cigarettes. The Council of Health Ministers has adopted a non-binding resolution towards the reduction of smoking in public places and the Commission supports a ban on the advertising of tobacco products. Expenditure on support for tobacco production has been reduced, and a fund to support research into less toxic forms of tobacco and prevention activities has been established by placing a 1% levy on producers.
The Europe against Cancer Programme
Reducing tobacco consumption is a priority target within this
programme and smoking is dealt with as a leading topic within
cancer education in schools. Europe against Cancer supports the
dissemination of successful programmes throughout member states,
the "Smoking and You" video pack being a notable example.
Currently, a young people's version of the Cancer Code is under
development, with smoking reduction as its first recommendation.
It will be disseminated throughout member states for use in anti-smoking
and cancer prevention campaigns.
Europe against Cancer has based its programme on the following: promoting the European Cancer Code; supporting legislative action at European level; and encouraging the exchange of experience and programmes, especially those on public information and school health education, between member States. During the period 1996-2000, a third action plan will build on these achievements and seek to increase the capacity of health professionals and authorities to tackle the problem of cancer. Action in the following areas needs to be stepped up: information campaigns on tobacco, especially those aimed at risk groups; the protection of non smokers; the further development of existing networks; support for the implementation of the most effective preventive methods; education for teachers and those who work with young people; closer involvement with WHO campaigns; upward mobilisation of tobacco prices within the community; support for a cost of living index which excludes tobacco; and the evaluation of anti-tobacco policies, especially restrictions on advertising.
The European Network on Young People and Tobacco is a good example of the kind of cross national collaborative project that the Commission is keen to support: it is not a project that could be successfully completed by a national state alone; it aims to gather and disseminate good practice from throughout the community and to enhance co-operation between member states. By bringing groups together in conferences like these, existing strategies can be enhanced and new ideas on prevention developed.
Background
In 1990, when a series of conferences on smoking was held,
a number of key people in the field of tobacco control informally
developed the idea to establish a European wide communication
network on young people and tobacco. ASH Scotland took the idea
forward, secured funding for the project from Europe against Cancer
and offered administrative and management support in the their
offices in Edinburgh. The key aims of the network are:
The project thus acts as a contact point for people in the field and as a dissemination point for examples of good practice.
A Steering Group of experts from throughout Europe were appointed to oversee the strategic direction of the project, and a project coordinator and administrative assistant were appointed to operate the project.
Current activity
In the two year pilot phase of the project (ends December
1995) considerable progress has been made. Firstly, key contacts
were identified in each country, whose role is to keep the network
abreast of developments in the field in their country. The profile
of the project has been developed through attendance at key conferences
like Empoli and Frascati, and by articles published in key publications.
All of this has contributed to the development of the project's database where 158 initiatives are detailed. Most contacts have been in the U.K., Germany, France, Spain and Belgium, particularly with programme managers and those who work directly with young people. Currently, 576 individuals and organisations have been contacted, 241 of whom have responded positively. Researchers and youth organisations will be targeted in the next phase.
Of the initiatives collected on the database, intervention programmes (125) outnumber research programmes (33). Smokebuster Clubs (26) and training manuals (28) are the two main groups of intervention programmes. "Interaction", the newsletter of the network, is the main disseminating tool and several editions have been published. Future dissemination ideas include Directories of contact individuals and initiatives, as well as exchange visits and "twinning" of contacts.
Future targets include more intensive marketing to increase the uptake of the network among researchers, refining the classification system, developing national networks on young people and tobacco, setting up an advisory group on terminology, and evaluating the pilot phase of the work.
Smoking has considerable impact on the health of families, children and young people. Annually in Scotland, 10,600 people die from smoking related diseases and £77 million are spent on in-patient treatment for smoking related illnesses. Government policy to reduce smoking as a top priority is outlined in two documents: 'Scotland's Health - A Challenge to us all' and 'Health Education in Scotland'. Government targets to reduce smoking aim at a 20% reduction between the years 1986 and 2000 in the prevalence of smoking in the age group 12-24, and a 20% reduction in the same period in the 25-65 age group. Some progress is being made towards the target for the older age group, but the figures from 1992 indicate no change for the younger age group.
A coordinated and strategic approach is currently being taken in Scotland, based on a national strategy produced by the Health Education Board for Scotland (HEBS). Tobacco taxation will be increased at 3% per year thus increasing the price of tobacco products and thereby reducing consumption. The Children and Young Persons' Protection from Tobacco Act 1991, has strengthened the law on tobacco sales to young people and stopped the practice of selling cigarettes singly or in unpackaged small quantities. The Health Education Board for Scotland has run a series of advertisements on smoking backed up by a helpline - Smokeline- which has attracted over 275,000 calls since October 1992. Evaluation research after 12 months suggested that 24% of callers had successfully given up smoking. A further 63% had attempted to quit, reduced their consumption of cigarettes or moved to a low tar brand. This is very encouraging, especially as so many young people call 'Smokeline'. Services for employers and materials for schools are developed by HEBS in conjunction with the voluntary sector.
Within schools, smoking is covered in curriculum guidelines for the 5-14 age group issued by the Scottish Office Education Department. A new initiative - HELP - Health Education for Living Project, has just been launched by the Education Department. This is a curriculum framework for health education to assist schools in evaluating and developing their health education programmes.
The National Health Service contributes to initiatives through health promotion programmes within key settings like the workplace and schools. By 1993, the target of a smokefree health service was achieved, with all government health agencies having policies in place to restrict smoking. In the workplace, smoking is restricted according to government directives which require employers to make arrangements to protect non-smokers from smoke.
Progressively stronger warnings have been put on cigarette packets. In the U.K. these are the largest in the European Union. Advertising, promotion and sponsorship of tobacco are controlled by voluntary agreements with the tobacco industry. These agreements are sufficiently flexible to respond to particular concerns and take prompt action on loopholes. For example, in response to concern about increasing the protection of young people from exposure to advertisements, a new agreement was made which removed adverts from the vicinity of schools and secured the removal of permanent shop front advertising for all tobacco products by the end of 1996.
A Code of Practice issued by the Scottish Office in 1992 stated that non-smoking should be the norm in all public places. Encouraging progress has been made and smokefree public places have increased substantially, as have bans on public transport.
In summary, the strategy in place in Scotland and the U.K. combines a number of measures, which recognises the contribution that all sectors of the community can make to tackling smoking. Conferences like this one make a particular contribution to devising new and innovative ways to combat smoking amongst the young by creating the opportunity for formal and informal exchanges of ideas and initiatives.
Background to HBSC survey
The first HBSC survey was undertaken in 1983 and included
three countries - England, Finland and Norway. Further surveys
followed in 1985/6, 1989/90 and 1993/4. Over the years, many more
countries have participated, with 24 taking part in the latest
survey. In Europe, these countries were - Belgium (French speaking
and Flemish speaking communities), Denmark, Finland, France, Germany,
N. Ireland, Scotland, Spain, Sweden and Wales. Many countries
outwith the European Union (E.U.) are also part of the survey,
but are not included in the following discussion.
Each country subscribes to the HBSC protocol which stipulates that the sample is nationally or regionally representative, that the survey is school based, that the age groups surveyed are 11.5 years, 13.5 years and 15.5 years, with a sample of approximately 1300 per group and that the survey is conducted every four years at the same time of year in each country.
In self complete questionnaires, young people are asked about their health behaviour, health indicators, socio-economic indicators, family factors, their relationships with their peers, school, and themselves as individuals. Smoking is included in the health indicators section, where three questions are asked:
These questions have been constant since the beginning of the study.
Data on smoking from the 1993/4 survey
This presentation focuses on data from the 1993/4 survey.
It covers data from E.U. countries, for 11 year olds and 15 year
olds indicating those who had 'ever smoked' and the weekly and
daily smoking of 15 year olds. In comparing figures for 'ever
smoked' between 11 and 15 year olds, the increase with age is
obvious. At 11 years old, the range of experimentation for boys
is 17% to 41%, while for girls is 7% to 24%. In 10 out of 11 countries,
boys are more likely to have tried smoking than girls at age 11.
By age 15, the range for boys is 55% to 81% and for girls it is 49% to 77%. In 8 out of 11 countries, girls have higher rates of experimentation than boys. Sweden and Finland have the highest rates amongst boys and girls. By age 15, regular smoking is a feature: within the E.U. countries the range of weekly smoking for boys is 14% to 32%, for girls 18% to 29%. Finland has the second highest prevalence of weekly smoking among boys, while Sweden has dropped to second lowest among the boys. This latter observation leads us to conclude that 'ever smoked' is not a consistent predictor of current smoking across countries. For weekly smoking, 8 countries have higher rates amongst the girls than the boys. In terms of daily smoking, the range among boys is 10% to 25% of boys, and 12% to 22% of girls. Girls are in the majority as daily smokers. The U.K. has the highest rates of smoking among girls, where 1 in 5 smoke daily.
So, why are Finland and Sweden so different in the transition from experimenting with smoking to regular smoking, and what is the explanation for the higher smoking rates among girls in the majority of countries in the E.U.?
To answer these, further research is required into smoking culture in different countries and into how factors like availability, price, advertising, and the image of smoking impact on the process of experimentation through to establishing a smoking habit. An explanation for the shift towards more women smoking may lie in exploring how the smoking epidemic progresses. The U.K. and other Western European countries are thought to be at stage five, where the rates of male and female smoking are similar. Higher rates among women are indicative of a later stage in the epidemic. Eastern European countries are at stage 2 or stage 3 indicated by higher rates among males. In future surveys, it might be expected that the rates in E. Europe will move towards the Western European picture. Eastern European countries are therefore a major health promotion challenge if this stage is to be averted.
Value and limitations of cross-national data
Such data provides a context within which to view the extent
of the problem of young people and smoking . It is also possible
with several consecutive surveys to gain a picture of the trends
in smoking, and compare these between countries. It has been found
across countries that children who smoke are more socially integrated
and a strong link has been found between school alienation and
smoking. In terms of socio-economic position and smoking, in the
U.K, it has been found that there is no gradient of smoking by
father's occupation. There are, however, strong gradients with
the amount of money that children have to spend. The amount of
spending money is inversely related to family affluence and high
social class. Cross national data, then, helps explain both similarities
and differences between countries.
Cross national data does, however, have limitations. 'League tables' must be used with caution and the effects of small differences in age and stage of school year, for example, must be taken into account. Data indicating a 'good' position may divert attention from the problem at policy making level. Negative press coverage can distract from the health promotion effort, and undermine the need to understand smoking in young people.
Future plans of HBSC
It is hoped that the HBSC will continue to stimulate the establishment
of monitoring systems for youth smoking in European countries.
Countries like Norway that have participated in all the surveys
are able to identify trends in smoking patterns and in future
will be able to monitor the impact of preventive efforts. Deeper
understanding of young people's health will be developed through
refining the HBSC questionnaire and through using HBSC findings
to identify new questions and stimulate further research. In Scotland,
for example, there is already evidence of this happening. A study
being carried out at Edinburgh University is examining the impact
on smoking behaviour of the use of cigarettes as a fashion accessory
by models in magazines.
Introduction
Smoking is probably the most heavily researched public health
issue. In reducing prevalence we have seen a major public health
success, although there are tremendous variations between countries.
In the U.K., we are observing a move from successful prevention
to a plateau, where it has become more difficult to make inroads.
We have, in particular, failed to make inroads into young women's
smoking. For future success, we need to make the most of what
we already know, to undertake a radical analysis and get to the
roots of the problem.
The Analysis
The Smoking Career Analysis model is a useful tool in the
analysis of smoking particularly as it sheds light on the social
factors, environmental influences and socio-economic pressures
that influence smoking. It documents the progress of the smoker
through life and the influences on smoking behaviour, including
the socialisation of the individual and the settings in which
this takes place. Prevalence and incidence figures on smoking
can be attached to each stage in the smoking career. This model
also acknowledges the oscillating behaviour of those people trying
to stop smoking and the various attempts they make in the process
of doing so.
Socialisation is the most important factor in recruitment to smoking. Primary socialisation through the family, secondary socialisation, usually through the school, and anticipatory socialisation are the means by which a society's values are transmitted to new members of that society, influencing whether they do or do not take up smoking. Local community norms and family influences are likely to have greatest effect. By identifying such influences prevention strategies and their settings can be developed involving, for example, the mass media or community development methods.
Peer pressure has been a key element in our understanding of young people starting to smoke. By extension, it has been argued that equipping young people with the social and personal skills to resist this pressure is an effective preventive strategy. This, however, may be a naive view. Such an argument assumes that the individual does not want to be in the peer group, or if in the peer group, does not want to go along with its pressures and norms. The reality is entirely the reverse. If the individual does not want to smoke then having the skills to resist these are probably useful, but they are likely to be in the peer group in the first place because smoking satisfies a need, both in the individual and in the peer group. It may act as a refuge from a hostile adult environment, for example, or be a way of gaining status and respect and enhancing self esteem. In pursuit of our radical approach we need to take a fresh look at peer group pressure.
We also need to examine our assumptions about the influence of 'significant others'. Data from the Avon Prevalence study, carried out some years ago, includes information about the boyfriends and girlfriends of young smokers. 73% of young people who smoked more than 6 cigarettes, had a girlfriend or boyfriend who smoked. Assuming that they did so because of peer pressure may be misleading, as it is equally likely that 'like attracts like'. Another question in this survey asked whether the young people had boyfriends or girlfriends and related this to smoking status. Of those who had never smoked at age 11, 19% had a boyfriend or girlfriend and at age 16, 28% had. Of those who smoked, 50% at age 11 had a boyfriend or girlfriend and at 16, 59% had. The hypothesis that smokers may be more sociable in some way needs to be examined.
Environmental factors like having non-smoking public places, restricting access to cigarettes, and preventing sales to minors, undoubtedly have an impact by signalling the unacceptability of smoking. However, socio-economic factors in the environment have a profound impact. Unemployment and gender are key social factors related to the level of smoking, although this relationship is not necessarily direct in the case of young people. The variation in smoking levels between women reflect social factors, e.g. 43% of married and cohabiting women smoke, as opposed to 33% of single women and 33% of those who are divorced and separated. Unemployed women seeking work smoke at a rate of 38%, compared to 32% of those in employment. A survey undertaken in West Belfast, found that 75% of people living in houses that were cold and damp smoked, and that 80% of people who had not had a holiday in the last five years smoked. Again, these figures indicate the need to look at the social scenarios underpinning these findings.
Such an environment has a serious impact on young people. Not only is smoking going to be modelled in the community, but parental attitudes, values and low self esteem are likely to be transmitted to them. School alienation is also associated with smoking, leaving these young people in triple jeopardy. Again this points to the need to go below the surface and explore social issues. Health promotion programmes will need to address issues of equity, inequity and related factors.
Psychological Factors
Individual factors influencing smoking also need to be analysed
in a more sophisticated manner. We need to look beyond beliefs
and attitudes to the factors which lie behind them. Socialisation
is influenced by values like machismo, and the emphasis on slimness
in fashion. The notion that smoking makes you slim develops from
a broader attitude to gender, implying that health education may
need to include gender and sex education rather than purely smoking
education. As the Health Career model emphasises, transitions
are a key factor in smoking behaviour. Given that the key transition
for young people is adolescence, and it is here that we see a
spurt in smoking prevalence, we need to explore how and why young
people use smoking as an aid at this time of their lives.
Problem behaviour theory argues that smoking is a symptom of adolescence which would suggest that our health promotion programmes must deal with adolescence rather than specific behaviours like smoking. Hurrleman suggests that programmes should include individual and situational inputs. The former might include life skills, and assertiveness skills training, for example; the latter, policies to tackle factors like deprivation. If we do not take account of the latter, we are in danger of victim blaming. A combined programme of education and policy is therefore required.
An assumption is made that in order to prevent people smoking, young smokers must believe themselves to be susceptible to serious disease and death. In fact they know this and indeed it is part of the attraction. Risk-taking is part of the motivation for smoking and other activities, so if young people did not believe they were susceptible, they would not do it.
Implications for action
Primarily, the implication for health promotion is that we
need horizontal programmes, which look at the factors underlying
behaviours and diseases, as well as vertical programmes, where
smoking is addressed within education about cancer or heart disease,
for example. In part, this is to do with getting at the root causes
of smoking, but it is also to do with enhancing the quality and
effectiveness of programmes.
Health promotion is defined as health education combined with healthy public policy. Policy at a number of levels is essential: at national level to control the tobacco industry, but also at the miso level. For example, policies are required in schools to combat teachers smoking, and to improve relationships within schools so that the alienation from school felt by some young people can be addressed.
It is likely that schools which are struggling to meet national curriculum targets are running superficial health education programmes. We know from American experience that the quality of the results is dependent on the amount and quality of the input. General programmes looking at self esteem and personal skills may get better results. Empowering education is particularly important to give young people a sense of control and the ability to look critically at society including the tobacco industry. Alliances and collaboration, as well as education and policy, are essential, particularly as we have successfully tackled the 'soft targets' and must now tackle the more difficult groups.
Barriers - what are they and how can they be overcome?
Performing an audit is an essential starting point for developing
interventions. Assessments must be made of the following: funding
sources; knowledge of the population and its characteristics;
the extent of support in the community from, for example, the
press and the medical and research communities; the structures
within organisations and in the target group; and the effectiveness
of particular strategies.
In order to make reasonable choices which use resources efficiently and accountably, rational, pragmatic and logical choices have to be made. These must be based on current, up to date knowledge about the problem, the available resources and a cost-benefit analysis of the options available.
Programmes for young people
Young people who reach their twenties without becoming regular
smokers are likely to remain confirmed non-smokers, and will not
be susceptible to messages about the benefits of smoking. Adolescents
and pre-adolescents are receptive to messages about smoking, and
many of them start to smoke because they have not made a conscious
decision to be a non-smoker.
It is possible to re-enforce a 10 year old's decision not to smoke. However, preventive efforts are too sporadic and can be undermined by the tobacco industry. For programmes to be effective, they must be long term and develop progressively, maintaining their orientation towards the age and interests of the target group of young people. Active support from others is essential to create an environment that encourages non-smoking. Interventions aimed at young people must therefore occur within the context of preventive programmes directed at adult smoking. If the whole community is not engaged, interventions can be ineffective.
Therefore, in planning interventions the following questions must be asked: is the information available to support funding applications; how should applications be presented; is there support in the community; are the necessary staff, alliances and structures in place; does the programme have credibility with young people and those working with them; is there support from the press, the medical community, and the research community for the intervention? Finally, how can what is available be used to best effect?
Workshops were held to explore participants' experience, in their own work, of the barriers to effective prevention. Delegates were asked to consider the contribution of low knowledge levels, inadequate funding, lack of support, structural issues and unclear intervention strategies. Delegates then identified ways in which the European Network on Young People and Tobacco could help address these issues. The outcomes of the workshops are incorporated in the Executive Summary. Also in these groups, presentations were given on work being undertaken in different countries. See Part 3 for summaries of these.
The quality of programmes is dependent on the quality of planning. In planning interventions a stepwise approach to analysing the problem is suggested, where research is an integral part of this process. Analysing the problem is the first step, looking at the quality of life, the factors which influence this, and the contribution made by both the environment and individual behaviour to the identified problem. The next step is to define the target group and to analyse why the group does or does not engage in a risky behaviour. The final step is to undertake an access point analysis to explore how to make contact with this group.
Once the problem has been analysed, the programme can be designed. A clear statement of goals is essential, followed by a definition of the preferred approach, which could be educational, structural or both. Once an intervention has been developed, based on insights from theories, research and other projects, the programme can be pretested. To date, research has been concentrated in the development phase of programmes, with less research being done to test programmes using controlled studies or longitudinal studies. Research to enhance the continuation of interventions and their diffusion is also required. Successful diffusion requires intersectoral collaboration and specific strategies.
Types of research
Broadly, there are three types of research: formative evaluation
used to support programme development; process evaluation to inform
the implementation phase; and effectiveness evaluation to assess
programme impact.
The goal of formative evaluation is to reach an understanding of why a particular group engages in a particular behaviour. The determinants of the behaviour and the relationship of these to environmental factors, demographic factors, personality factors, and cognitive factors are explored. During needs assessment, which is an important part of formative evaluation, the needs of stakeholders (i.e. those who may now, or in the future, have some interest in becoming involved in the project) are analysed; interest in the project is aroused in order to raise money and support; the needs of intermediaries are analysed; and access points to each group of stakeholders are identified.
Programme evaluation involves analysing the quality of the programme. To do this the following are assessed: the quality of the materials, the methods, the programme providers, the dosage of the programme elements and the costs of delivering the programme. In assessing the effectiveness of the programme, behavioural changes are measured, as well as changes in attitudes, social norms, perceptions, skills and intentions.
Finally, the process by which programmes are sustained and diffused needs to be analysed. It is important in this respect to identify the stakeholders, the determinants of their participation, and their adoption of the programme. Structural problems have to be addressed. A solution to this may include developing health education interventions for government ministers and policy makers.
Benefits of research to programme managers
Information to inform interventions is provided at all these
levels of research. Programme managers gain extensive information
about the context of the intervention; the target group and its
sub groups; the environment; the relevance of the intervention;
the needs and perspectives of stakeholders; the consistency and
competence of those delivering the programme; the cost effectiveness
of the programme and its ability to achieve its goals. Collaboration
can also be monitored, and information gained as to why policies
or programmes are, or are not, implemented.
Traditionally, researchers and practitioners are involved separately at specific stages of the project. A new approach known as the linkage approach, developed in the U.S.A., brings representatives of identified stakeholder groups together at the start of a project. A project group is formed which includes, among others, representatives of the target group, financial experts and the workers who implement the programme. Even within a constrained timescale specific research questions can be explored and findings used in the implementation of the programme. Similarly in the course of their practice, workers can identify specific research questions. These can then be fed into the research programme. This approach has been found to be very productive in making researchers more attuned to the needs of practitioners.
Background to the study
In England, a prevention programme was established based on
research findings which showed that: 9/10 years old was the peak
age of experimenting with smoking; at 12/13 years regular smoking
was most prevalent; and at 15/16 years old, those who smoked wanted
to stop. As a result of the programme, the onset in boys was delayed
and fathers stopped smoking. For girls, however, onset was not
delayed and mothers' smoking did not decrease.
On the basis of these findings another programme was established for 12/13 year olds, where the risk factors for taking up smoking in the next few months were explored. At greatest risk of taking up smoking were young women who held positive beliefs about smoking, who had a smoking parent and a smoking best friend, who knew a cigarette brand and who did not give correct answers to any of the health questions posed. Least likely to take up smoking were boys whose parents did not smoke, whose best friend did not smoke, who could not name a cigarette brand and who gave correct information about the health effects of smoking.
Study methodology
To explore the relationship between self esteem and smoking,
a study of 11-15 year olds was carried out in two state schools
in England. 830 pupils completed a three-part questionnaire in
the classroom, which asked about the respondent's refusal skills
the smoking behaviour of the respondent and his/her family and
friends. The Harter Self Perception Scale for Children was used
to assess respondents' self esteem. Within this scale there are
6 domains: social acceptance; physical appearance; athletic competence;
behavioural conduct; global self worth and scholastic competence.
Findings and Discussion
Smoking prevalence among the young people was very similar
to national figures. However, significant differences in self
perception were found between boys and girls, with boys having
stronger and more positive perceptions of themselves than girls.
Only in one domain of the self perception scale, behavioural conduct,
did girls have higher scores than boys. Boys' perceptions of their
physical appearance were positive, whereas girls' scores fell
steadily and rapidly as they got older. Girls' scores for global
self worth started lower than boys and remained so, getting lower
as they grew older.
Low scores in scholastic competence and behavioural control were strongly related to smoking in both boys and girls. Smoking and self perception with regard to physical appearance, and global self perception were significantly related to smoking in girls only. The never-smokers in both boys and girls, but particularly in girls, were much more likely to have a higher self perception with regard to physical appearance and global self worth. Smoking was not significantly linked at all to high self perception scores with regard to athletic competence or with social acceptance, for boys or girls, although with older students it was associated with social acceptance. Importantly, the fall in self esteem preceded taking up smoking. In the year before taking up smoking self perception falls with regard to physical appearance and global self worth. It is during this year that they take up smoking.
Physical appearance and smoking have long been linked by the tobacco industry in its marketing campaigns aimed at women. The cigarette has also been presented as a fashion accessory which enhances physical attractiveness. Further qualitative research is planned to explore the findings from the quantitative research reported here and to consider how advertising influences the self perception of young women.
In 1986-7, baseline research was conducted into smoking prevalence among 13-14 year olds in Barcelona. The levels of smoking were about the same for boys and girls, with daily smokers constituting about 5% of the age group. The following characteristics were found more likely to be associated with smoking: living in an area of low socio-economic status, having more pocket money, having friends and siblings who smoked, having positive attitudes to smoking and an intention to smoke in the future.
A prevention programme was developed called PASE. It was based on the social influences model and aimed at 11-13 year olds in the pre-contemplation or experimental stages of smoking. The programme included a video and a set of classroom activities to be delivered by the teachers. School health professionals supported the programme and have since become important in the diffusion of the project, taking responsibility for promoting the PASE in schools.
After a quasi-experimental study to test the effectiveness of the programme, it was offered to the city primary schools through the educational council of the city. It is estimated that in the past year 125 schools, 40% of the schools in the city, have adopted the programme. By the second year of the programme, the variation in participation in the programme between school districts was striking. In some districts, half the schools were involved, while in others none were. Process evaluation was undertaken to explore this.
The socio-economic status of the school neighbourhood seemed to be a factor with higher participation observed in poorer areas. This might be explained partially by the fact that the school health teams put more effort into these areas. Public schools adopted the programme to a greater extent than other schools, as did those schools which had been involved in the pilot phase. The structure and staffing of school health teams were also considered. The adoption rate was greater in those teams with stability of personnel. Adoption was also greater where the District Educational Research Centre had been involved in promoting the programme to schools and where one person was responsible for it in the team. In all multivariate analyses, the involvement of the school health teams in the marketing of the programme was the variable with a higher association of school involvement, followed by school involvement in the pilot phase. Teachers attitude to the intervention may also be a factor and this is being tested through the on-going process evaluation.
In the course of this research, the team made several observations: they found a lack of available models for diffusion research at the organisational level; a lack of academic interest in this type of research; and a lack of political demand for this kind of research.
Background
The preliminary findings of the pilot year of a cross national
project, funded by Europe against Cancer, and involving the U.K.,
Spain and the Netherlands are presented here. In the main study
the pre-test and post-test behavioural and attitudinal data from
four groups will be compared: those who have experienced an in-school
intervention, those who have experienced an out-of-school intervention,
those who have had both, and a control group experiencing neither.
An essential feature of the intended project is to examine the
additional impact of out of school interventions. The target group
will be children aged 10/11 years and 13/14 years in the three
countries.
An examination of the literature indicates the need to develop and assess alternatives to school based interventions. Many smoking prevention programmes take place within schools and are delivered by teachers, but some young people are disaffected and alienated from school and therefore may reject health messages put forward by people seen as authority figures. Out of school interventions to complement the work in schools need to be explored.
Intervening in out of school settings is fraught with problems: where are the youngsters, what do they do, how can they be reached, how can the impact of the intervention be assessed? During the pilot year two questions have been explored: where could out of school interventions take place and what might such interventions involve? A survey has therefore been conducted into the out of school activities of the target groups in the three countries to gather information on possible venues for out of school interventions and to provide data on smoking and other behaviour.
Findings
Data was collected in June/July 1995 from approximately 6000
young people who were identified as at greater risk of smoking.
Youngsters were presented with a list of activities which they
might go out to do after school and were asked to indicate how
often they took part in these activities. Commonality across the
three countries was particularly striking with three-quarters
of the 10-11 year olds going shopping, going out with the family,
going to a friend's house or hanging about with their friends,
once a month or more often.
Some preliminary analysis by smoking status has been undertaken, looking at 'ever smokers' and 'never smokers'. In all three countries, more than the expected numbers of 'ever smokers' took part in hanging about with friends and going to discos.
In the older age group, again there are common features across the three countries, especially in the more popular activities - going to friends' houses, going shopping and hanging about the streets with friends. Differences in activity by smoking status were observed with more than the expected number of 'ever smokers' hanging about with friends, going to amusement arcades, youth clubs, pubs or discos. Arguably, this might indicate that the 'ever smokers' are more gregarious and sociable, and more likely to seek adult oriented activities.
Analysis by gender indicates that more boys than expected are involved in particular activities. Common to all three countries are: going to sports centres, watching sports, going to arcades and going to bars. More girls than expected were going shopping.
Implications of findings
The data for each country show a high degree of European commonality
in the activities pursued by both age groups. Although differences
on the basis of smoking status are shown, popular activities are
ranked highly by smokers and non-smokers alike.
The most popular activities have young people in very dispersed locations. Possible health education approaches might therefore be bill boards in shopping centres or leaflets to young people's homes which encourage discussion with friends. However, these have implications for a controlled study and in order to separate those groups receiving in-school interventions only, each intervention may have to be undertaken in a different geographical area.
Sports venues are frequented by large numbers of young people as both participants and spectators. Cinemas are also popular, indicating that multiple approaches to out of school interventions are to be recommended. Sports venues and cinemas could be settings for interventions. Finally, a considerable number of young people attend youth clubs, so opportunities to deliver interventions here could be explored.
The aim of the presentation is to summarise learning from 20 years of research on smoking prevention programmes in schools. Four types of programme can be identified: information programmes; social influences programmes; life skills training programmes; and affective approaches.
Social influence programmes
The North Karelia Youth Programme targeted 13 year olds, who
received 5-10 45 minute sessions on smoking during a two year
programme of education on smoking and heart health. A parental
programme was run in tandem. Role plays and videos on resistance
skills were included in the programme as well as information on
the influence of peers, parents and the mass media on the onset
smoking. Four schools received the programme. There were 2 control
schools with a total of 851 pupils taking part. Follow up studies
to assess the impact of the programme on smoking prevalence were
carried out in 1981, 1982, 1986 and 1993. Students were therefore
surveyed for the last time the age of 28, 15 years after they
first took part.
After the programme, there were one third fewer smokers in the programme schools than in the control schools. This effect was observed again two years and fours years after the programme. In the last survey, however, the prevalence was similar due to a decline in smoking in the control groups. In terms of how many cigarettes these children have smoked during their lifetimes, the boys in the programme schools smoked 38% fewer cigarettes than those in the control groups. For the girls results were less clear.
A comparable programme run about the same time in the United States observed similar results. Early studies included only a few schools, but later ones were larger, like the Midwest multi-community trials which involved 42 schools and 15,000 students. The results for large numbers of schools were similar to those from small samples.
One of the criticisms of these studies was that the schools were not randomised and that therefore the choice of school could explain the result. One of the first randomised trials done on social influence approach was the Waterloo School Smoking Prevention Trial. Some years after the programme was administered, at age 12-13, there is some effect, but at the last follow up in the twelfth grade, age 17, the effect was absent. Similarly in the Oslo Youth Study, the two year follow-up indicated that the smoking onset rate was less in the intervention schools, but by the 12 year follow up, there was no clear effect.
Lifeskill Programmes
In studies which compare the information giving approach with
the skills training approach, we find that those which include
skills training delay the onset of smoking. Information programmes
show an increase in knowledge among participants but no effects
on behaviour.
In the Minnesota Heart Health Programme study, some long term effects on smoking prevalence were observed in the intervention community compared to the reference community. The 'Know Your Body' programme indicated that results will be better if the health education programme is started early and if more topics are included.
In these programmes lifeskills training is added to education about the social influences of smoking. An example was the Life Skills Training curriculum run in New York State, U.S.A., which was tested in a large scale trial, over a three year period, involving 56 schools and over 4000 students.
The main conclusion from analysing the results of all the studies taken in this area, is that adding a lifeskills training aspect to a social influences based programme does not improve the effectiveness of the intervention. Also, to deliver social influences programmes, 10 to 15 hours are required over three years, while 20 to 50 hours are required for the lifeskills approach, making the former easier to integrate into school timetables.
Teenage smoking and its relationship to smoking in the community
Data from Finland indicates that friends smoking is very strongly
associated with young people's smoking. In future we need to understand
this relationship more fully. Mothers and fathers smoking is not
such a strong predictor. Smoking in adolescence is a strong predictor
of smoking in adulthood, with 60% of teenage smokers continuing
to smoke in adulthood. Of adults who smoke, 50% started in junior
high school and 50% started after junior high school. This finding
would seem to indicate the need for research and prevention programmes
targeting 16-20 year olds.
Two projects were undertaken, one aimed at technical/vocational schools and the other at high schools. This was the first project in Europe to undertake such work with high risk youngsters undertaking vocational training. Both projects were funded by the Dutch Cancer Society.
After formative evaluation was carried out, a peer-led programme was devised which was introduced on video, and included small group activities and home activities. Five sessions were devised including an introductory session, sessions exploring the short term effects of smoking, direct and indirect peer pressure and alternatives to smoking. Different effects were found in the two schools. In the vocational schools, the programme delayed the onset of regular smoking, while in the high schools the number of experimental smokers was significantly lower than in the control group.
A programme was then developed to reduce regular smoking among high school students using a social influences approach. The programme aimed to operationalise the 'linkage' idea, to test the effectiveness of booster sessions delivered after the main programme and to evaluate the feasibility of collaborating with health education districts. Sixteen districts were involved in disseminating the project, training and supporting teachers and carrying out process evaluation.
After 18 months, it was found that the social influence programme with booster sessions was the most effective method. In terms of the results of the diffusion study, most elements evaluated positively. One area in which improvement was required was in the time involved to distribute materials. The most successful implementation happened in high schools and where teachers had previous experience of health promotion.
The Dutch Cancer Society and the University of Limburg now recognise that there is a need to explore new ways of diffusing programmes and that programmes need to include different approaches for different target groups.
Three topics are covered in this presentation: some barriers to effective health education with young people, some principles of practice when working with young people and some practical examples of some work recently undertaken by Fast Forward in its work with young people on drugs issues, including alcohol and tobacco.
Barriers to effective education
Three barriers to working with young people on tobacco issues
have been identified by Fast Forward. Firstly, adult behaviour,
particularly when youth workers or teachers, who are smokers,
effectively tell young people "do as I say, not as I do".
Secondly, unlike the harm minimisation messages included in educating
young people about other drugs, the only message about smoking
is "don't do it"; there is no safe way to smoke, or
safe amount to smoke. This adds some difficulty to interacting
with young people. Thirdly, there is an assumption prevalent among
adults that information is all that is required to prevent young
people taking drugs or smoking.
Examples of the work of Fast Forward
Four key principles are applied by Fast Forward in its work.
It is important that young people are listened to, challenged,
informed and involved in the education process. Several years
ago, Fast Forward ran a conference called "From Bogart to
Bon Jovi" where popular art forms like video, puppetry, sculpture
and dance were used as media through which young people could
express their views on smoking.
Roadshows have been used to concentrate work in particular geographical areas, where staff and volunteers work intensively in a particular area for a limited time. Young people from the area are challenged to become active in the organisation's work by becoming peer educators themselves. They are trained and recruited in advance to deliver educational sessions in schools and youth clubs, using small group work and other techniques.
An example of a Fast Forward project which informed young people involved a group young volunteers travelling to Europe and researching drug issues in Rotterdam, Amsterdam and Munich. Their findings were then developed into a radio programme which was broadcast live on Radio Forth, the commercial radio station covering the east of Scotland.
A recent piece of work involved the development of a booklet called "Bolt Ya Radge". A group of young volunteers researched the drugs information needs of young people in Lothian and developed a booklet to meet the needs that emerged. Young people were integral to the whole process of needs assessment, writing the text for the booklet, deciding on the cartoon style of the booklet, right through to leading the press launch. As a resource for young people, the booklet seeks to provoke discussion among young people and to get them thinking about drugs issues.
Eight key principles of creative work with young people
There are several key strategies underpinning Fast Forward's
creative approach to working with young people: get young people
involved and working alongside staff; use imaginative techniques
and make unusual connections; uncover young people's skills; ask
for outside help; take risks; plan carefully but exploit the unexpected
and enjoy yourself in the process.
Background
Theatre and Co. specialise in a form of theatre called Forum
Theatre, developed in Latin America by Augusto Boal. The technique
emerged during a period of political oppression when a military
dictatorship was in control of his country. Boal realised that
drama could be used as a tool to encourage the people to look
critically at what was happening around them. Firstly, a group
of actors stage a piece which reflects the problem to be discussed,
then the audience are invited to make suggestions as to how the
problem could be tackled. The actors integrate the suggestions
by improvising a response, in character, while continuing to encourage
more ideas from the audience. Instructions from the audience continue
until an outcome is reached.
The value of this technique is that it challenges individual viewpoints and glib solutions. It makes the audience really think through the issue. They become involved in its intricacies and refine their opinions in the process. Tobacco prevention has been dominated by information giving - people know the issues around tobacco and can give all the 'right' responses. This is particularly true of children in school, where they are a captive audience and trained to give the 'correct' responses.
Forum Theatre
There are two key elements to this technique: the play itself
which can be of any length, and the leader who works with the
audience. The role of the leader is to warn the audience that
they will be expected to take on the role of the actor and drive
the situation in the play. When the audience is asked to become
involved in defining the action they tend to listen to the play
more carefully, and the result of participating is that they become
less aloof from the problem being considered. They realise that
saying something should be done and actually doing it are two
very different things. Actors may respond to audience suggestions
in unexpected ways and take on the role of 'devil's advocate',
confronting the audience's point of view. Drama is a good way
of accessing the emotions which surround a problem and going beyond
the intellectualisation of the problem. The approach has been
used successfully in a play which explored heroin use and could
equally be applied to the tobacco issue.
Evaluation
Much of the work undertaken by the company is commissioned
by other organisations, like health promotion bodies, and they
want to know if the approach is successful. Drama is an expensive
medium; plays need to be rehearsed and actors paid. It is also
very difficult to evaluate, as it is not possible to access what
is going on in the audience's heads during the performance, or
the long term effects of being involved.
As a way of expanding the repertoire of tools used in preventing people starting to smoke and to help smokers stop smoking, the Paris Association against Tobacco has designed an interactive CD programme. A variety of people were involved in the project including scientists and expert members of the association. The CD includes data about smoking, cartoons for young people, quizzes for adults, video clips, interviews with celebrities and medical imagery. Material can be drawn out of the CD to create programmes suitable for any groups.
The CD has been piloted, over one year, in La Rochelle and Caen, where terminals were set up in shops, public buildings and schools. It attracted a lot of interest. Unfortunately, few people filled in the evaluation questionnaire after they had used the programme, making their reactions difficult to assess. It will also been set up and will be evaluated within the Epidaure Centre in Montpellier. Three questions will be evaluated: does it work?; are the contents of the CD understood fully by the users?; and does it change the behaviour of smokers?
Young people in a Paris school found the CD interesting. It was set up in their school for eight days and pupils could use it to check their health status. The machine encouraged the young people to talk to the workers who found that many of the pupils were heavy smokers and generally unhealthy. Workers were then able to give the young people advice about stopping smoking. The effect of this advice and the success of the young people at stopping smoking will be evaluated by visiting the school again.
Rationale for the new 'hard-hitting' campaign
A harder tone has been adopted for the Foundation's most recent
media campaign aimed at young people. Images of coffins, mortuaries
and black lungs have replaced lifestyle images. The rationale
for this change is based, firstly, on the observation that smoking
prevention messages are being lost in the plethora of sophisticated
advertising and information aimed at young people. Industry messages
promoting smoking are particularly intense, and deliberately reflect
young people's attitude to smoking. The message: 'together we
can solve the smoking situation - it's no big deal' is an example
of this. Mass media has therefore lost some of its effectiveness
as a method of communicating the non-smoking message to young
people.
Secondly, the need to tackle smoking levels among the young has become ever more urgent. Figures from 1995 indicate that the 10-12 year old group are smoking at twice the level observed in 1992, an increase from 2% of the age group to 4%. Similarly, the level in 12-14 year olds has increased from 20%, a constant level over the last few years, to 25% in 1995.
Objectives of the campaign
It is hoped that the 'hard-hitting' approach will return smoking
and health to young people's agendas. "Roken. Dood- en doodzonde"
is the campaign slogan which in English translates to something
like "Smoking. Dead and a dead shame". The message about
the health risks of smoking is direct and aims to underline government
health warnings on cigarette packets and tobacco adverts.
Television advertising, bill board adverts and youth magazines are the mass media used. The television commercial shows a young woman standing in front of a mirror lighting a cigarette who suddenly transforms into a coughing old woman. A second T.V. advert, shown in the government forum for television messages, is aimed at parents and teachers. Bill board posters have various images including a young woman lying in state in a coffin shaped like a cigarette pack, and a grave which has been dug in the shape of a cigarette packet. Written materials include a brochure available at libraries and post offices, and a magazine for young people. Leaflets on smokefree schools are also distributed to teachers.
The Health Minister and the State Secretary for Education launched the campaign jointly and this generated lots of free publicity. Some publications have, however, refused to place the adverts because they have found the imagery too challenging.
Future plan to develop the campaign
The campaign will continue in 1996 on radio, television and
in youth magazines. Further teaching material will be developed
for use in secondary schools with 12-16 year olds, and a magazine
will be developed for children aged 10-12 years. An animated film
is scheduled for production and further research is planned, in
conjunction with the University of Limburg, into new ways to promote
SmokeFree policies in schools.
'Kids Advise the Senate' was set up in 1991 by the then Minister for Youth, Mr Thomas Kruger. The group aims to give young people input into the political debate on issues that affect their lives. To date the group have developed good relationships with the media, members of Berlin senate, and the Social Democratic candidate for the office of Mayor of Berlin. Currently, ten young men and ten young women, aged 11 to 18 years are involved in the group. Other young people can communicate their views to the group via a telephone hotline into their office.
Young people's views on smoking, their reasons for smoking and its meaning to them are not adequately understood by adults. Young people smoke to promote their public image, to cope with stress, as a way of being accepted in a group and to defy their parents Once it is part of their life, it is difficult to stop. Smoking is a way of saying 'we are no longer children' and of stating independence, especially from their parents.
One of the most important factors influencing young people to smoke is the way it is presented in films and advertising. In the film 'Basic Instinct', the heroine defies authority by smoking, and heroes of 'Western' films, are incomplete without a cigarette. Tobacco adverts depict men as tough and women as sexy. These images are absorbed by young people, who start smoking to feel, and appear, tough and sexy. However, this is the 'clean' side of smoking, the other side depicts the smoker as the 'loser'. Rock bands, for example, regard smoking and other drugs as a way of making "this fucking life better". Some young people take up smoking purely to say "Look at me, I'm a loser."
Two main mistakes have been made in anti-smoking campaigns. Firstly, giving information about diseases caused by smoking has little effect, as nobody at age 16 is thinking about how they will feel when they are 60. Instead, the high cost of smoking should be stressed and young people's self esteem should be strengthened to prevent them looking for confidence in a cigarette. Secondly, the adverts produced for anti-smoking campaigns do not show the people who really smoke, but rather the 'ideal teenager' who does not seem to have any problems. Most young people do not accept the messages of these adverts as they do not identify themselves with the young people acting in them.
Possible future strategies might include tackling tobacco advertising and de-criminalising the use of tobacco, as this makes it more attractive. Parents should also be encouraged to take more responsibility for setting a positive example; and rewarding non-smokers is a better strategy than punishing smokers. Prohibiting smoking in public places is important but so is making non-smoking attractive, for example, by offering cheaper health insurance to non-smokers. Otherwise, for smokers who are not interested in their health and who have enough money, there is no attraction in giving up.
To be successful in deterring young people from smoking, smoking must be made unattractive, unnecessary and useless. This view must be supported by people who are young people's idols from show business, like rock bands and film stars. To be successful, it is essential to make it clear to young people that they can be accepted as valuable members of society without smoking.
The main responsibility of the National Development Officer for Youth for the National Smoking Education Campaign is to develop a strategy for working in informal youth work settings. These include youth clubs, leisure services and voluntary uniformed groups, like the Scouts and Guides.
The Smoke Signals Project
A central part of the HEA's programme of work in youth work
setting is the Smoke Signals project, developed as a result of
requests from youth workers for more training and support in undertaking
smoking education with young people. The project aims to bring
youth work specialists and health promotion specialists together
to plan and deliver smoking education interventions; to increase
the number and quality of interventions in youth work settings;
and to promote a positive, participative and radical approach
to smoking education which locates smoking in the context of young
people's lives, their issues and interests. A training guide for
the work was developed jointly by youth workers and health promotion
specialists. Workers were introduced to the guide through a programme
of 'training the trainer' days.
One of the key achievements of this project has been to shift perceptions of smoking education in both fields particularly in two areas: the process of developing training for youth workers; and the building of alliances between health promotion and youth service agencies.
Participative Training
Experience in the field, established good practice and published
sources were all drawn on in the course of developing the training
guide. Within the training programme, youth workers, both smokers
and non-smokers, were encouraged to explore their own attitudes
and to question their own viewpoints. Having experienced this
process for themselves, they were encouraged to bring a climate
of awareness and supportive understanding to their work on smoking
with young people.
The training programme also includes practical activity-based sessions for workers to try out resources and have the opportunity to plan educational work. Workers' main requirements were new ideas for activities that would stimulate discussion with young people and tackle smoking positively rather than lecture them about their health.
Building Alliances
Healthy Alliances have been promoted recently as an effective
method of health education and have been prominent in youth work
practice for a considerable time. One of the main aims of the
youth service is to empower young people through their participation
in shaping the youth work environment. Through this alliance this
idea has been brought into health promotion work with young people.
On-going support of workers was identified as key to ensuring that the initial impact of the training would not be lost and that youth workers would continue with smoking education. Local health promotion workers, specialising in smoking, were ideally placed to offer this.
Young people are involved voluntarily in youth work, and are encouraged to take responsibility for their own learning. The skills and expertise of youth workers in building relationships with young people enables them to locate smoking education within the interests, needs and realities of young people's lives. These relationships and the informal nature of the youth work environment, enable young people to articulate their views.
Learning for the future
Differences in viewpoints emerged early in the project; youth
workers felt that smoking education should be addressed within
a holistic framework, while health education workers with a brief
to tackle smoking thought it should be tackled as a separate topic.
Young people themselves will be involved in the training programmes
more in the future; those who have already taken part in programmes
generated by the first phase of the project will be involved in
future training initiatives
Health education is still on the margins of mainstream youth work practice, but given that the main focus of the youth service is the personal and social development of young people, the service is ideally placed to take this work forward. The National Youth Agency (NYA) has included health issues as a key part of its youth work curriculum. Health is one of a number of areas of work delineated in the curriculum: personal identity, relationships, community and environment, power, justice and equality, education, employment and training, health, housing, money, sport, leisure and travel.
Smoking is a sensitive area for youth workers as many of them smoke themselves. Youth workers' personal views on smoking tend to determine the stance taken on smoking within the youth club. They either ban smoking from the club or allow young people to smoke. Neither of which really address the issue.
Health education in clubs is one way of tackling smoking, especially if young people are involved in developing the programmes. Programmes should include input on the facts about smoking; discussion on the cultural, economic and social influences that affect young people's choices; the opportunity to develop social and interpersonal skills; and input on reducing the risk of harm.
The NYA recommends four strategies for getting smoking on the club agenda. Firstly, youth workers can keep up to date and informed about the issue, challenge young people's attitudes and correct misinformation. Secondly, youth workers can encourage discussion by using posters and other stimuli to raise questions about smoking. Thirdly, young people can be encouraged to seek solutions, and to look for additional information and assistance. In facilitating this, the worker's role is to act as a sounding board and an access point to interagency networks. Lastly, young people can plan action for change and, with workers' assistance, organise activities that consolidate previous learning. Workers should support young people and acknowledge their achievements.
Youth workers are not health experts so they need help from those who are. Relationships between youth workers and health personnel need to be developed locally so that skills and experience can be shared. Joint training events and inter-agency forums support this process.
David, Vicky and Ian were invited to respond to the presentations. They supported the view, put forward by Becky Saunders, that young people tend to listen more to other young people and youth workers than teachers. On being asked if they had any advice for people trying to educate young people about smoking, Ian responded that workers should listen to what young people have got to say rather than just saying don't do it. David and Vicky emphasised the need to educate parents and teachers about the role models they present as smokers, and to get them to stop smoking.
Henk Stegeman asked the young people for their views on smoking education being undertaken in youth clubs. Ian responded by describing how the issue is dealt with in Edinburgh Youth Cafe, where issues like smoking can be discussed with the staff who listen and offer information. Smoking education is therefore not introduced by staff but rather staff take the lead from the young people, offering support and education when requested. On being asked their view of the imagery being used by the Dutch, they responded positively, saying that the Dutch presentation was thought provoking. Vicky, who is blind, suggested that this type of information did not reach visually impaired people and that some should be specifically designed for them. David said that the shock-treatment approach 'hit the spot', but pointed out that people won't stop unless they really want to.
Siri Kohl seconded this view saying that, as a smoker, she was touched by the adverts but not shocked enough to give up smoking. She felt that young people today see so much cruelty and death that it doesn't make an impression, and advocated the use of drama as a way of enhancing self esteem.
Conference continued to discuss the effectiveness of using 'hard hitting' advertising. Henk Stegeman argued that the Dutch campaign techniques were being used exclusively to get smoking back on the agenda as a health threatening issue, rather than to get people to stop smoking. In research done in Ireland, described by a delegate from Ireland, young people were split down the middle, half advocating positive 'cool' messages, the other half arguing for macabre, shocking images. They were a mixed group of smokers and non-smokers, so it would seem that a mixture of both approaches is required, as some young people will be attracted to some images and not others.
The aim of A Non Smoking Generation is to create a whole generation of children who are growing up tobacco free. Educational visits to school classes are the most important activity undertaken by the organisation. Fieldworkers called 'Inspirers' carry out these visits after special training from the Non Smoking Generation.
'Inspirers' have to fulfil certain criteria: they have to be young (under 25 years old), educated to high school level and non-smoking. Personal qualities desired include being able to act on his/her own initiative, to be outgoing with a personality and lifestyle which appeals to school pupils. 'Inspirers' often work alone in their own area of the country, so they have to be able to act independently and to deal with the local media.
Most 'Inspirers' are recruited through government training schemes for unemployed young people. They receive an intensive course of training which includes input on group work, tobacco and its harmful effects, information technology and advertising.
'Inspirers' methods are directed at young people's emotions, attitudes and values, since approaches appealing to common sense have been shown not to work. Discussion focuses on reinforcing non-smoking as a natural behaviour, as well as considering why people start smoking and issues of self confidence and group pressure. 'Inspirers' are closer in age and experience to young people in schools than their teachers, so the message is not tainted with adult judgements and lecturing. 'Inspirers' are seen by the young people as slightly older classmates and as a result their message is heeded.
School children and their teachers have reacted in an overwhelmingly positive way to 'Inspirers' inputs. Classroom visits normally last for about 80 minutes. 12 year olds receive two sessions with a gap of two weeks between them. 13 year olds only get one visit. Teachers receive a folder, developed by A Non Smoking Generation, containing ideas and suggestions for how education on tobacco might be continued. Finally, A Non Smoking Generation runs an annual competition for schools in which each class competes individually. A condition for entering is a promise to remain smoke free for the following year.
Campaigns are a second part of the organisation's work. These have been launched against particular brands of cigarettes and provoked considerable reaction. Marlboro was targeted in 1994, being the most popular brand smoked by young people in Sweden. The second most popular brand, Prince, was targeted in 1995. In attacking Marlboro, the aim was to stimulate awareness of subliminal advertising and as a result of the support generated, a ban on indirect advertising is being considered by the Swedish parliament. The 'Prince' campaign was also successful, with legislation now being considered on restricting the sale of cigarettes to young people below a certain age.
In order to clarify the confusion that exists between the terms coalition and association, definitions of these terms will be offered. The different definitions and roles of each must be understood if participants are going to act in the most productive ways and take advantage of funding opportunities,
A coalition brings together different organisations while respecting the specific remit of each member. While this can be difficult, as competition can exist between different groups, a successful coalition can multiply the efficiency and impact of each of the organisations involved. Coalitions therefore aim to create synergy between associations. A critical balance is required for success.
Associations of varying sizes concerned with different issues, for example health promotion, cancer and consumer rights can work together towards a common goal while each remains focused on its specific remit. A coalition in this case provides a forum which amplifies and increases the efficiency of the associations.
There are a number of coalitions working in the tobacco control field at several levels. The UK, for example, has a national coalition - the National Tobacco Alliance. In Europe, a meeting to establish a European Alliance of European Community countries is planned. There is also the International Association of Non Governmental Organisations. Such a multiplicity of coalitions is characteristic of a sector that is struggling financially.
It is important to avoid multiplying the number of associations and coalitions. The intervention level of these different coalitions is different; this must be clear. A lack of understanding of this can result in mistakes being made in both the activities undertaken and the funding applications made.
The supra governmental organisations, such as the World Health Organisation or the European Commission, can only act at the governmental level, through governments and essentially through Health Ministries. Non Governmental Organisations (NGO) at international or national level have much more room to manoeuvre. They act on public opinion. Influencing public opinion on health problems and on measures to be taken to reduce the health hazards of tobacco, is our best ally. Pressure from public opinion determines the action taken by governments and elected members.
Political lobbying should not be done. For example, since the Maastricht Treaty any action at European Commission level, like the adoption of the directive forbidding tobacco advertising, is doomed to fail. Political lobbying inside the European Commission is not tolerated anymore. It is, however, still possible within networks of associations.
We should not make the mistake of not knowing where we are placed. If associations ask for funding from the Europe against Cancer programme, it should be for funding the implementation of co-ordinated actions/programmes which have a European dimension. The programmes should be of high quality and evaluated scientifically so that results can be used to influence public opinion and government policy. If this is clearly understood mistakes, or knocking on the wrong door when requesting funding, will be avoided.
The European Alliance mentioned above should be formed on the 23rd October 1995. This alliance aims to partially fund co-ordinated European actions. Partially, because it is a community rule that there should always be 20% of funding from another party, such as a government. Any actions must correspond to the main guidelines of the Third Action Plan of Europe against Cancer for the period 1996-2000.
The associations which should be participating in the creation of the European Alliance are: members of the executive staff of European anti-tobacco associations, and of Cancer leagues (2 or 3 representatives per country), representatives of Networks which exist already for example GP's Network, Young People and Tobacco , tobacco free cities and hospitals and members of the General Directorate.
The aims of the Alliance will be discussed further at the meeting. However, one goal should be to create a secretariat which supports different members of the Networks to put forward co-ordinated requests. The Alliance will put people in contact with each other, offer methodological guidance and help them to define the aims of their project and how it will be evaluated. The selection of projects for funding will not be made by the Alliance as, by the provisions of the Treaty, this can only be done at European or national government level.
Finally, the International Coalition, created after the Paris conference in 1994. This coalition aims to implement the global anti-tobacco policy, devised at the Paris conference, which includes everything from taxation to banning advertising. It is a coalition of non-governmental organisations. Two organisations have, to date, pledged money to this coalition - the International Union against Cancer and the International Union Against Respiratory Diseases and Tuberculosis. Currently staffing is a half-time person, so it is highly recommended that other associations join this coalition and support its development.
Background to the Belgian Alliance
The Belgian Coalition Against Tobacco was established to implement
the International Strategy for Tobacco Prevention in Belgium.
Representatives of anti-tobacco organisations, heart associations,
cancer leagues and lung associations, from both the Flemish and
the French communities are involved in the coalition. Each organisation
chairs the coalition for one year and two spokesmen for the coalition
are elected annually to represent the coalition at national, European
and international level. The spokesmen represent both communities
and cannot be from the same organisation. Coalition organisations
meet at least twice a year.
At European level, the coalition's priorities are: to achieve a total ban on tobacco advertising; to increase the taxation on hand rolling tobacco to the same level as cigarettes; and to bring labelling on tobacco products up to 25% of the surface of the pack. Nationally, the coalition prioritises the introduction of legislation banning smoking in public, especially on public transport.
Community level coalitions
Since 1980, when Belgium was divided into two communities,
responsibility for legislation has remained at national level,
while responsibility for prevention is in the hands of the two
communities. In the Flemish Community, the Advisory Commission
for Cancer Prevention is a broad platform of organisations involved
in tobacco control. The main activities of its sub committee on
tobacco are: to introduce measures to reduce the consumption of
tobacco products; to support a total ban on advertising; to support
legislation on smoking restrictions; to support labelling measures;
and measures specifying the tar and nicotine content of cigarettes.
A second structure at community level, more active in delivering
preventive programmes, is the Flemish Institute for Health Promotion.
Advantages and disadvantages of collaboration
There are different degrees of collaboration, ranging from
independence, at one end of the scale to merger at the other,
with co-operation, co-ordination and collaboration coming in between.
Organisations need to be motivated to collaborate and may do so
for different reasons. Any of the following may be important:
being part of the debate on a current topic; making a contribution
as experts in the field; commitment to a particular outcome; a
desire to see the problem solved; or similarity of vision. Working
together may increase the credibility of the various organisations
and enhance resources. It is easier to collaborate if the benefits
are visible, if senior staff are supportive, if organisations
are prepared to share in the outcome, and there is agreement on
the agenda to be pursued.
Problems can arise in coalitions. These include conflict between persons and organisations, apathy and non-participation from some members, inadequate decision making, and lack of administrative support, without which they cannot function.
'Smokefree Cities' aim to create an environment where smoking is socially unacceptable. The objectives are to help smokers who want to stop, to defend the rights of non-smokers, to raise awareness of health issues and to prevent people starting to smoke. Activities to achieve these include creating smoke free places in the city, organising information campaigns, delivering education in schools, offering cessation groups and developing a programme with G.P.s to help their patients give up smoking.
The programme 'Your G.P. is your friend' is central to the project, as the G.P. is the only person who has one to one, long term contact with the population. G.Ps are given counselling to enable them to do this work.
In order to gather information on smokers, their gender, when they started smoking, and how much they know of the health risks, questionnaires were sent to all patients over age 14 who were registered with a G.P. Patients were invited to visit their G.P. and offered help to stop, which included referral to a cessation programme. Further questionnaires are circulated at intervals to assess the effectiveness of the programme.
Following the Empoli experience, fourteen other towns in Italy have joined the Smokefree Cities project. Casale Montferrato, a city in Northern Italy, for example, has a poor, post-industrial environment and many people suffering from respiratory diseases and lung cancer. The Smokefree Cities action was started on the initiative of a group of G.P.s with funding from the municipal authority and the local health service.
Fourteen G.P.s started the 'Your G.P. is your friend' and set up a counselling service to help people stop smoking. After 6 months, 54% of the smokers contacted had responded and received counselling. 37% of them had stopped smoking and 23% had reduced their consumption. A two year follow up survey is underway. The Institute of Epidemiology at the University of Turin has recommended that the programme be expanded.
Partnerships have now been set up with other European cities which wish to adopt the Smokefree Cities programme. By 'twinning', the cities aim to support and co-ordinate their programmes, to exchange information, to involve other organisations in Europe and to generate national and international support for the project. .
'When Education Goes Up In Smoke' is a three part collaboration between the Danish Cancer Society, the Danish Council on Smoking and Health and the Danish Heart Foundation.
In Denmark, young people normally attend the same school from age 6 to age 16 years. The school system is decentralised with the local authorities having the power to design their own curriculum and school boards having responsibility for the everyday running of the school. Within this system the school board is responsible for smoking policies. Pupils at lower secondary school level are allowed to smoke in school, and schools take a very liberal attitude to smoking.
In 1992, the coalition conducted a survey to assess the problem, sending questionnaires to headmasters and school boards. 80% of the questionnaires were returned.. In 88% of the schools pupils were allowed to smoke and about 10% of the 14-16 year olds were smokers, 38% of schools demanded permission from parents for pupils to smoke, and in nearly half of the schools, teachers smoked in front of the pupils.
In response to the survey, the coalition devised the project - 'When Education Goes Up in Smoke'. The objectives are: the school must support the pupils to stay smoke free; the school must not be a place where pupils learn to smoke; schools must be aware that the problem is their problem and be responsible for finding a solution; and teachers should be aware of their position as role models and not smoke in front of pupils. The goal was not to prohibit smoking, but rather to make it difficult for pupils to smoke.
Information was aimed at key decision makers in the schools with the press being used to create cross pressure on the decision makers. Evaluation was done at every stage of the process through small scale surveys and telephone interviews. Each school, on the basis of the results of the questionnaire, was given a grade. Schools responded to this, as did the press.
A range of methods were used over four years to achieve these goals. After the survey and the grading of the schools, guidelines were devised for school boards and a newsletter distributed. In 1994, a second newsletter was distributed and signage on smoking distributed to Youth Clubs. Two manuals were devised in 1995, containing guidelines for teachers, recommendations for good practice and teaching materials.
Qualitative and quantitative evaluation has been undertaken to test the impact of the programme. The preliminary results of the 1995 survey showed that 43% of schools had changed rules or policy within the last three years and 40% of these claimed that the changes had reduced pupils' smoking. In 60% of schools smoking had been on the agenda within the last year, in 82% of all schools, some pupils were allowed to smoke and in 82% of the schools smoking was fully integrated into the teaching plan.
A lot was learned while undertaking this work. It was found that three organisations working together has a greater impact, although it can be difficult and takes a lot of resources. A process-consultant worked with the group throughout and this eased the communication process. Research and evaluation were crucial to understanding the target group and keeping the process on the right track. Making alliances with key gatekeepers like head teachers and nurturing relationships with them was an important strategy. Timing - knowing when to introduce the materials was also important as was making time to develop spin-off ideas that emerged. Finally, giving grades to schools was an excellent way to communicate with them - it is a method that they understand!
This research project was supported by the Network of Health Promoting Schools, which is a collaborative partnership between the European Office of the World Health Organisation, the Commission of the European Union and the Council of Europe (see below). In Greece , this work is co-ordinated by the Institute of Child Health which is sponsored by the Ministry of Health. Greece has participated in the project since 1992 with 26 schools from different geographical areas.. The project aims to develop the skills of young people to make choices which promote their own health and that of their environment. Principles like promoting self esteem, empowerment and democratic ways of working underpin the Greek and other projects. A major feature of the project is the joint participation of the teachers, parents and the community.
In Greece, the project has been focused on training teachers to empower their pupils and enhance their self esteem. Most of the work has been focused on training teachers using an holistic approach and emphasising mental and emotional health.
After hearing Dr Anne Charlton speak on young people and smoking, the project sought to promote smoking cessation in schools. As a starting point, a questionnaire on smoking was circulated which sparked interest from both teachers and pupils who wanted to know how to promote cessation and how to develop smoking policies in their schools. As a result of discussions with teachers and pupils, it was realised that more needed to be known about the knowledge and attitudes of teachers towards smoking and smoking prevention. A questionnaire asking about knowledge, attitudes, behaviour and the policies operating in the school was developed and circulated. In one school, where a lot of pupils smoked, the questionnaire was also circulated to pupils who had just graduated. They have since formed a 'healthy team' to do health promotion work in the school and the community.
15 teachers and 10 parents responded to the questionnaire. In terms of knowledge levels - more than 90% of the respondents answered wrongly. Most of those who responded agreed with the proposition that if the school was offered money from a tobacco company it should accept. Findings like this indicate the amount of work still to be done.
Target 14 of the World Health Organisation's 'Health for All' targets was the basis for the formation of the European Network of Health Promoting Schools. It states that by the year 2000, all settings of social life and activity such as the city, the school, the workplace, neighbourhood and home should provide greater opportunities for promoting health. Also underpinning the work of the European Network of Health Promoting Schools is the WHO definition of health promotion - health promotion is the process of enabling people to increase control over and improve their health. The network was formally established in 1992, although pilot work had already been going on in four countries, Currently, 34 countries are involved in the network.
Countries are recruited to the network if they fulfil the following criteria:
The aim of the work is to demonstrate the concept of the health promoting school, not to recruit schools who are 'ahead' in their health promotion work. In the U.K., for example, schools with a variety of experience and expertise were targeted. Over the last few years, 470 pilot schools have been recruited to the network, and because other schools want to take part, each country has developed its own innovative ideas to involve about 2000 non-pilot schools.
The whole project was started by a collaborative agreement between WHO Europe, the Council of Europe, and the European Commission who were all converted to the ideas behind the health promoting school. This has meant that they can pool their commitment to school health promotion. These three organisations form the international planning committee, and their individual representatives report to their organisations on the direction of project. Committee members can link with influential committees both within and outside their agencies; and the network's activities are well supported, have long term funding attributed to them and are embedded in the work of the three organisations.
The health promoting school aims to enable pupils, staff and the community served by the school to take action for a healthier life, community and society. A holistic approach to health promotion is adopted, including not just curriculum work, or work on the environment of the home and the school, but all three. It is not just about pupils but also teachers and communities, and takes into account and tries to demonstrate the whole health promotion definition. Appropriate methodologies for the development of skills are developed and included in the curriculum. Curriculum approaches cannot be effective if the physical and emotional environment of the school is not addressed which means that schools have to look at the way pupils and staff are managed to ensure that teachers and pupils are reaching maximum potential. Both the management and the ethos of the school can impact on the way pupils, their families and the community are involved in the school. Hierarchical decision making structures may have to become democratic and transparent, and non- discriminatory policies developed for involving the community.
Research is important in smoking prevention as it supports the contention that smoking prevention is a science rather than a religion. Standards for research practice, the theme for this session, can be considered from various perspectives, at macro and micro levels. At the micro level in evaluation, the focus is on evaluating questionnaires and formulating specific items, while at the macro level, the issue can be examined through a planning model. By using a planning model and working through its specific steps, research can be integrated into the work of programme planners. Various stakeholders can be involved using the linkage approach, where representatives from research bodies, target groups, funding bodies and so on are involved.
Presently in the field of health education there is consensus that working with planning models, working intersectorally and integrating research with programme planning are all good practice. The ABC Planning Model was discussed in session 4 and while this is not necessarily the definitive model, it is important that an appropriate planning model is identified and used in designing interventions. In the group discussions, the steps of the planning model will be followed. Each group will consider whether, in their country, programmes are run by intersectoral project teams; whether target groups are analysed and differentiated adequately; whether programmes are evaluated adequately; and whether programmes are diffused using an explicit marketing strategy.
After this opening presentation, delegates were divided into groups according to country and asked to consider:
The conclusions of the workshop groups are outlined in the Executive Summary.
Dr Anne Charlton chaired this session which explored how conference delegates saw the future development of the European Network on Young People and Tobacco. Dr Charlton introduced the deliberations by reviewing the key lessons of the conference and outlining several key questions for consideration in workshop groups.
The conclusions reached on these questions are discussed in the Executive Summary.
A number of manuals were presented to conference during this session. Dr Annie Sequier outlined a co-production between France and Portugal. Dr Carla Arciti presented a bi-lingual guide for teachers produced in English and Italian. A group of Smokebuster club co-ordinators introduced a collaborative project being undertaken by four national clubs, under the leadership of the Ligue National contre le Cancer, France, to develop a practical guide to smoking prevention with children. These are described in part 3 of this report.
A series of formal recommendations (see Executive Summary) were derived from the conclusions reached by delegates in session 9. These were put to conference and accepted as the way forward for the European Network on Young People and Tobacco.