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Primary school tobacco education: A needs assessment

Summary

The aim of the project was to investigate the views of primary six and seven teachers on the resource needs within the field of tobacco education with a view to informing HEBS on issues to be addressed when designing future resources.

The research was conducted in twenty-five schools, spread throughout four locations in Scotland. Data was collected through focus groups, paired interviews and single person interview.

An understanding of the 5-14 curriculum, and its implications for classroom practice is important for any resource design. Teachers need to justify all activities in terms of attainment targets, so teaching materials need to fit within this framework. This is particularly significant for cross-curricular activities.

Teachers reported that interactive activities were the most appropriate methods of teaching health related issues, and the main classroom activities were discussion and role play, with some schools making links with art, language, environmental studies.

Smoking was presented to pupils as a matter of personal choice, with teachers taking an impartial stance. However, this placed teachers in a contradictory position as they were actually promoting a non-smoking message.

Teachers are not well placed to access recent research findings about smoking, and most role-play activities were based on an outdated notion of peer pressure. Children enacted scenes of coercion where they devised short-term strategies to avoid accepting cigarettes without losing face

Delivering tobacco education to children whose parents were smokers was seen to be problematic for a number of reasons. Children could become alarmed about their parents’ health prospects. Problems could be created if children became critical of their parents. Teachers were anxious to avoid eliciting parental complaint. For these reasons teachers often diluted the health messages they gave to those children. A small number of schools looked in detail at reasons why people smoke, in order to help children make sense of the conflicting messages they received.

At this age pupils did not feel that the long term health implications of smoking were relevant to themselves, but related more easily to messages about social implications or sporting prowess. Some teachers reported a gendered response to health messages. It was widely felt that the pupils found the concept of addiction to be incomprehensible.

Teachers adapted their teaching to suit their pupils, and were not looking for highly prescriptive resource materials. They had no desire to be resource-led, but wanted materials that could act as stimuli to interactive classroom activities, the details of which they would devise themselves. Factual information was useful as a teacher resource.

Outside agencies were often used to deliver part of their tobacco education, and were seen as having high impact on the pupils. Police, nurses, drama groups and a mobile interactive classroom were all sited as very useful additions to the normal teacher input.

These issues all had implications for future resource design. There is a need for close communication between schools and health promoters to ensure resources are easily available to teachers, and that teachers have access to recent research findings in this field.

1. Introduction

1.1 Aims

The overall aim of the research was to investigate the views of primary six / seven teachers on the resource needs within the field of tobacco education with a view to informing HEBS on issues to be addressed when designing future resources.

In particular the research focused on:

• Gaps which currently exist in the field of smoking education
• The integration of tobacco resources into existing teaching focus and curriculum
• The range of issues that teachers recommend the resource should address in order to be helpful / complement their classroom activities

1.2 Teachers as health educators

Teachers play an essential role in the delivery of health education to children and young people, and it is important that their views should be heard in the debate on how to tackle these issues. However, most teachers are not in a position to be well informed on the latest research findings, and often their views do not concur with recent understandings of adolescent smoking. Consequently some ideas expressed in this report may appear dated or even inaccurate.

It is the role of health promoters to keep abreast of current developments and find ways of putting these into practical use. Teachers are the gatekeepers to health education in schools, and new resources will only be used in classrooms if teachers consider them appropriate to their needs. Therefore it essential that health promoters gain an understanding of current approaches to tobacco education in order to inform their thinking about future resource development.

1.3 Setting the scene: The Scottish Curriculum

In Scotland the primary curriculum and the first two years of the secondary curriculum, are dictated centrally by the 5-14 guidelines, and any attempts to enhance the curriculum with additional resources need to be set within this context.

Various curriculum areas are identified, including health, personal and social development (PSD), maths, language, environmental studies, and expressive arts. Each curriculum area consists of several strands, (essentially topics) and within each strand a learning pathway is outlined by identifying different levels of competence, through which the pupils progress (starting at level A and ending at level F). In order to achieve these levels pupils must meet the requirements of a number of attainment targets. Attainment targets provide an indication of what pupils should know or be able to do as a result of their learning activity.

When planning their lessons teachers are acutely aware of the specific details contained within the 5-14 guidelines. All activities must be justified in terms of meeting attainment targets, and account must be made of the different levels at which their pupils are working.

Schools operate their curriculum within a time budget, so teachers allocate a specific amount of time to each curriculum area. In some cases (e.g. maths) this would be allocated regularly on a daily or weekly basis, whereas other curriculum areas (e.g. health) may be concentrated into a term or even a week. 

Whilst the curriculum clearly defines separate subject areas, it also encourages cross curricular approaches:

Teachers need to plan for opportunities that will enable pupils to make connections across all curricular areas through application of knowledge and skills (Scottish Executive 2000 section 3.19

The teachers operate within a very structured framework, and progress through this is planned well in advance at school level. However the specifics of how the teaching is approached and the types of classroom activities involved are not prescriptive and this allows a good deal of freedom for the school and the classroom teacher to develop their methods. In this study the focus is on the classroom teacher and how (s)he delivers tobacco education within this setting, trying to identify how resources could be designed to work effectively within the existing learning environment.

1.4 Background

The popularity of smoking amongst young people, and the implications for their future health, are such a cause of concern amongst Scottish health professionals and politicians, that the Scottish Executive have issued a target to reduce smoking amongst 12 – 15 year olds from 14% to 11% by 2010 (Scottish Office 1999). The uptake of smoking increases through the teenage years, with relatively few regular smokers at age 12, so these figures mask the alarmingly high smoking rate amongst 15 year olds, particularly girls, 24% of whom are regular smokers. Boys of this age, on the other hand, are now smoking less frequently than in 1998, the figures having fallen dramatically from 24% to 16% (Currie et al 2002).

Many studies have pointed to factors which increase the likelihood of young people becoming smokers. Family background is important in a number of ways. Socio-economic status is strongly associated with smoking; tobacco use being most common amongst young people from workless families, and least common amongst middle class children (Griesbach et al 2001).  Parental smoking patterns and attitudes are significant; as the number of smoking parents increases so does the likelihood of the child becoming a smoker. Perceived parental disapproval of smoking is a significant disincentive, although most effective if the parent is a non-smoker themself (Anderson et al 2002). Having an elder sibling who smokes also increases the likelihood of a child becoming a smoker, this effect being even more significant than parental smoking patterns (Goddard and Higgins 1999). Adolescents living with a step-parent are also more likely to become smokers than those living in intact families, regardless of parental smoking patterns (Griesbach et al 2003)

However, it would be a mistake to think that these factors predispose adolescents to smoking, and that the young people themselves are passively living out their destiny. Such a belief would render school-based health interventions pointless. There is much evidence to suggest that young people actively make choices about their health-related behaviours, and their decisions are made within a complex social context. At a basic level the statistics demonstrate that adolescents are more likely to smoke if their friends do (Griesbach et al 2001). Denscombe (2001) found that smoking was found to have a symbolic significance both in terms of presentation of self to others and in terms of reflexive construction of self. Smoking was seen as a passport to a fun loving, outgoing, non-conformist lifestyle (Lucas and Lloyd 1999a), Smokers, particularly male smokers desribe themselves as aspiring to images of “tough” “druggy”, “tarty” (Amos et al 1997l) and “hard”, “big” and “cool”(Rugkasa et al 2001).

Not only does smoking project an image of the individual, it also acts as an identifier of social groups. A remarkably consistent picture emerges from studies in Scotland (Mitchell 1997, West and Sweeting 1997) and New Zealand (Plumridge 2002), in which smoking is associated with both the top and the bottom of the social hierarchy. Young people display a high level of agreement about their perceptions of the social groupings, their relative status and their membership. Smokers are most likely to be members of what Mitchell would call the “top” group (rebellious, cool, disaffected with school), the “low status pupils” (on fringes of other groups, socially and academically unsuccessful) and  “trouble makers” (aggressive, regularly in trouble, involved in a wide range of dangerous behaviours). Non smokers were more likely to be in the “middle” group, academic achievers, describing themselves as “quiet and sensible”, but described by others as “sad”.  

This understanding of the lifestyle choices that young people make, calls in to question some of the more traditional notions surrounding tobacco use. The concept of “peer pressure” in which adolescents are bullied into risk behaviours against their will does not appear to apply generally. Conscious and deliberate decisions are made whether or not to smoke, in the light of the wider social context of youth culture. Denscombe (2001) reported adolescents feeling more in control of their lives as a result of smoking and commented:

Time and time again the young people in the research argued that “‘It’s my choice – no-one forces me to smoke. I know the risks and I’ll take my chances. For now, smoking works for me” p174 

The exception to this can be seen in the group of “low status” pupils. These marginalised young people were often keen to improve their popularity however they could, and were more vulnerable to coercion. If agreeing to participate in risk behaviours was seen as a route to greater popularity then they would take part (Mitchell 1997).

Similarly the widespread belief that smoking is causally related to low self-esteem does not appear to apply universally to teenage smokers. The “lost souls” who were neither academic achievers or successful socially could be seen to suffer from a poor self-image (Sweeting and West 1997).  However the rebellious risk takers were high in the pecking order, suggesting that these young people would have a positive self-image. The low self-esteem hypothesis possibly stems from teachers’ perceptions of these pupils, who are not generally high academic achievers, whereas for youngsters there are other sources of esteem outside of school. It is unclear whether it is the act of smoking, and other risk taking activities, that raised the youngsters’ self esteem, or whether it was their high self-esteem that led them to become involved in risk taking activities. Mitchell and Amos (1997) question the true level of confidence that leads a young person to take up smoking for reasons of social identity, and suggest that the concept of self-worth rather than self-esteem should be explored. Clearly the link between self-esteem and smoking is not a straightforward one, with high esteem being associated both with high status smokers and with non smokers; the “practical logic” involved in negotiating the complex social world of adolescents also involves other issues (Glendinning and Inglis 1999, Glendinning 2002).

In many ways adolescent smoking fulfils different functions from adult smoking. Young people view smoking as a profoundly social activity, but also associate it with fun, deriving pleasure from the paraphernalia of smoking, (such as using lighters and blowing smoke rings) and from the risks of being caught. (Lloyd and Lucas 1998). In contrast adult smoking is seen, by teenagers, as personal and is associated with loss of control, with addiction and neediness. Adults are seen to use cigarettes to help them cope with life, by alleviating stress, depression and nervousness (Rugsaka et al 2001). Young people do not always link the two, believing themselves to be in control, and consequently leave themselves open to addiction.

The role of stress in the initiation of smoking has received little attention, the emphasis being given over to concepts of social identity. Yet, not all adolescents in particular social groups do smoke, suggesting that personal factors must also have a role. A Californian study (Siquiera et al 2000) and a British study (Lucas and Lloyd 1999b) both showed higher levels of stress and greater use of negative coping methods in adolescent smokers than non-smokers or experimenters. Young people recognised that stress plays a major role in the initiation of the smoking habit. Smokers were more likely to use negative coping strategies of anger and helplessness and less likely to use the positive strategies of seeking parental support and cognitive coping.

Of considerable interest and concern to health promoters at the current time is the issue of gender, given the much higher smoking rate amongst young women. Patterns of smoking uptake differ between the sexes: boys experiment earlier than girls (Owen and Bolling 1995), and those boys who do smoke are heavier smokers than girls (Goddard and Higgins 1999). However girls are less likely to give up tobacco, a Spanish study showing 22% of male experimenters became regular smokers compared with 42% of females (Ariza-Cardenal 2002).

Both sexes use smoking as a way of creating identity, appearing “cool” and identifying with the top social groupings. But boys have other ways of creating a desirable image through sporting activities, and so have a socially acceptable reason to refuse cigarettes.  Girls’ social activities are more passive and do not offer a similar protection from the desirability of smoking. They are more locked into accoutrements and decoration as ways of presentation of self, and smoking is an integral part of that image. (Plumridge et al 2002) Girls who do not smoke have to accept the label of “average”, whereas boys have a let-out clause.

1.5 Methods

Research for this project was conducted in four areas of Scotland, which were chosen to give a diversity of settings. These were

• Cumbernauld: a “new town” on the outskirts of Glasgow, with a predominantly working class population.
• Stirling: A historic town with a very socially mixed population
• Aberdeen: A small city with a range from deprived inner city estates to affluent suburban areas
• Aberdeenshire: A large rural authority. Some schools are located in isolated settings; others in small market or fishing towns.

Within each area a sample of schools was selected to provide as wide a range as possible of social and geographical circumstances. Twenty-five schools were included in the sample, using the Scottish Area Deprivation Index, wherever possible, to guide selections. Further details of the schools are given in appendix A.

The field work consisted of seven paired interviews, fourteen single person interviews and four focus groups. The participants were teachers with experience of primary six and primary seven teaching.  For the most part they were unpromoted classroom teachers, but the sample also included some senior teachers, assistant heads, depute heads and head teachers (see appendix A).

The format of the interviews and focus groups was semi-structured. An interview schedule was drawn up (appendix B), to guide the discussions, but the respondents were able to raise other issues of importance to them. The duration was usually around 45 minutes, and could loosely be seen to fall into two parts.

Initially the interviews and focus groups would explore the place of smoking education in the curriculum, the teaching approaches used and the activities in which the children were involved. Teachers were asked how they managed their classrooms to ensure that the health messages were accessible to pupils of all abilities, social and ethnic backgrounds. The issues of parental smoking habits were discussed, and the problem of how to promote a non-smoking message to pupils who saw smoking as a normal adult activity.

Secondly, a range of resources were examined and discussed in the light of the classroom issues already raised. Teachers were asked their opinions of various resources in terms of their content, presentation, suitability for the age group, and effectiveness in delivering their message. They were also asked to describe how they would use that type of resource in their classrooms. The final question asked teachers, if they could draw up a list of resources they would like to see produced, what would be on that list.

The resources used were:

• “Jar of tar”; a jar which was approximately half full of a black viscous substance, which represented the volume of tar a 20-a-day smoker would inhale over one year.
• Three posters; one detailing the short term deleterious effects of cigarettes, such as bad breath and shortage of cash, one bearing the slogan “Butt head, fags are a drag”, and one depicting a dinosaur lying on its back, suggesting “maybe they all smoked”.
• “Project tobacco”; a four page informative leaflet, designed to support school based tobacco projects. It covered the chemical contents of smoke, the cost of smoking (and other attractive items that the same money could buy), the environmental impact of the tobacco industry, the history of tobacco, passive smoking, addiction and the health effects of smoking.
• “The Dragons Breath” a series of three books which offer creative ways of bringing smoking into the curriculum.  Book one “A Dragon’s tale” contains a story in which a dragon takes up smoking and suffers some unpleasant side effects. Book two contains activities such as songs, poems, jokes games and puzzles. Book three contains a mega quiz; fifteen rounds of smoking related multiple choice questions.
• “Drug Education”; a book of photocopiable resources, with teachers notes for each activity. Tobacco related worksheets included mathematical handling of smoking related data, the “smoking tug of war and resisting peer pressure.
• ”Smoke free for life”: a Canadian smoking prevention curriculum, which offered a closely prescribed course of lessons throughout the school. It included detailed teacher instructions on lesson timing and planning, as well as worksheets, overhead projector sheets and cross curricular links
• “Tobacco factsheets”: ten factsheets for teachers containing detailed up to date information on a wide range of smoking related issues.

Full details of these resources are in appendix C.

2. Findings

This chapter presents a range of issues that have implications for future resource design. Sections 2.1 to 2.6 explore the issues of importance to teachers when delivering tobacco education. Section 2.7 examines teachers’ responses to specific resources, with a view to informing future design.

Quotations are given with a reference number. These numbers can be used to identify the source of each quotation using appendix A. Individual schools are not named, but their general locality and brief information about the school is given.

2.1 The place of smoking in the primary curriculum

Smoking was primarily located within the curriculum area of health, within a drugs topic. Drug education, for most schools began in the early stages (P1 to P3) with discussions of medicines, and related safety aspects. The consideration of recreational drugs occurred in the upper stages, with tobacco being introduced as a legal drug. Most schools placed tobacco education in their P6 or P7 curriculum, although a few schools taught it as early as P5. Very small schools, with composite classes, sometimes covering P4 to P7 would have a three or four year rota, so tobacco education could be delivered to a wide range of ages.

Smoking was also seen as relevant to the PSD (personal and social development) curriculum. Issues such as peer pressure and bullying were thought to link closely with the initiation of smoking. Whilst the PSD curriculum does not specifically mention smoking, it clearly was an issue that was very often explored in this context. Some teachers deliberately designed PSD activities around smoking, whilst others claimed that the pupils themselves would always bring smoking into a peer pressure discussion.

In some schools the PSD aspect would be delivered at a different time from the health education curriculum whilst other schools felt they were so closely linked as to be almost indistinguishable, with one teacher commenting that “PSD is their emotional health” (school 5).

Smoking also was seen to have a relevance to the study of the human body, and teachers referred to the physical effects of smoking on the lungs. Not all teachers discussed tobacco use at this point in the curriculum although some made a deliberate point of so doing.

Over and above this, some schools used smoking as a basis for activities in expressive arts and language. These will be considered later as the various activities are explored in more detail.

2.2 Classroom activities

2.2.1 Discussion

There was universal agreement that whole class discussion was an important part of all aspects of health education, and many teachers also encouraged small group discussions. By approaching smoking from a discussion point of view, teachers were able to take a child-centred approach, focusing on existing knowledge and experience, and building on that. Issues of importance to the children could be explored in greater depth, with guidance from the teacher. Pupils’ own experiences and viewpoints were considered to be a valuable resource for the whole class.

Teachers saying it’s not cool has no effect because teachers aren’t cool, but that’s why the discussion is best, if it comes from them, from their pals, then they are more likely to take notice. The teacher would take a very backward role, she just directs the discussion and lets them… If the teacher starts to lecture, then they switch off (school 7).

Smoking was generally presented to the pupils as an issue of personal choice, and discussions would centre on matters of salience to that choice. Impartiality on the part of the teacher was seen to be of great importance when dealing with smoking.

Our approach is " I’m not saying what’s right and I'm not saying what’s wrong. All I'm saying is that you've got the choices, and whatever choices you make you have to live with the consequences that go with that choice" (school 18).

One reason for maintaining impartiality was to be non-judgemental of the pupils and of their families. It was felt that open debate could only occur if the children felt they were not under scrutiny. And secondly, teachers freely acknowledged that a strong negative message from figures of authority could offer a challenge to young people to do exactly the opposite.

  We try not to push it down their throats as a no-no as that doesn’t help, we tend to say it’s entirely your choice, but you are being given the facts (school 7).

However, the impartial approach put teachers in a difficult and contradictory position, as they were attempting to promote a non-smoking message.  Some teachers, would refer to the “right” choice or the “healthy” choice whilst still claiming neutrality.

You have to be very impartial, of course. You can’t be seen to have a personal stance as such. I tend to say “I’m not saying this is right or wrong, it is a free choice, but what we are trying to do is to educate you to make the right choices for your health. And we now know it is bad for your health.” So I’m trying to alert them to the risks, to the dangers, so they can make informed choices. But you do have to be careful to remain impartial. (school 1).

When discussing the relevant issues, the majority of teachers concentrated on the negative aspects of smoking, such as the effects on health, the financial implications, effects on image (such as smelly breath), and in some cases the problems of addiction. Teenage uptake of smoking was discussed in the context of peer pressure and the need to look “cool”. Teachers rarely looked at the pleasurable aspects of smoking or its role in stress relief. Consequently the “choice” which the pupils made as a result of their discussions was somewhat forced and generally a foregone conclusion.

In a minority of cases it was seen as important that the pupils were invited to discuss the reasons why people do smoke. For two of the schools it was the starting point of their discussions. In these cases, it was felt that smoking was such a common activity that children would not be able to make sense of messages that just pointed out the detrimental aspects of smoking, particularly if the children had came from homes where parents or siblings were smokers.

We really look at why people have a need to smoke. It’s a drug, we establish that it is a drug, but it’s a legal drug, and we then go on to say why do people have a need to smoke? (school 2).

A lot of young people start because its cool. They think they look grown up, but a lot of parents do it, a lot of adults do it because they feel better at the time they are doing it. That's definitely the way we do it. That’s why people use drugs, that’s why they use alcohol and its why they smoke. There's no doubt about it that at that moment they feel better. And that’s what we're saying (school 6).

In addition, one teacher (herself an ex smoker) felt that unless she told the children both sides of the story, they would in the future, be surprised by and unprepared for the pleasurable aspects of smoking.

That’s why I think it’s important to, not to lie about it being fun, and it being good and that people enjoy it, but that you can become addicted. So then if they try it they say “this is great, my teacher never said that, she just said tar in the lungs.” But if we say, that’s why people get addicted, because it is good and you probably will enjoy it. But think about the consequences before you start because it is hard to give up (school 10).

All teachers felt that at this age pupils held strong anti-smoking views, and that through their discussions the children would almost invariably favour the non-smoking choice. This was the case regardless of whether discussions had considered the reasons why people do smoke. However it was often suggested that the universality of the responses could be affected by the pupils’ perceptions of the teachers expectations (in spite of attempts to appear neutral). Additionally, the dominant opinion within the group was so strongly against tobacco that peer pressure could inhibit pupils with other views from speaking honestly.

2.2.2 Expressive arts and language

Role-play was very widely used to address the PSD aspects of drug use, including tobacco, and was felt to be an extremely valuable approach. In particular, it enabled the children to recognise situations in which they could feel pressurised to have a cigarette, and to develop avoidance strategies. This was seen mainly as a preparation for situations that they were likely to encounter in secondary school. Small groups would be given a scenario, and each child would have a role to enact. Often teachers would give different scenarios to different groups, then each group would present to the class, discussing the success or otherwise of the strategies, and other possible methods of handling the situation.

The scenarios generally focussed on situations where cigarettes were being offered round a group, and the children needed to find ways of avoiding joining in without losing face. Other scenarios were centred on more direct coercion such as name-calling.

The strategies devised by the pupils would be short-term methods of dealing with a one-off situation

Some of them have very good strategies to say “no”. They try to change the conversation: “what about the match?” or “do you want to come swimming with me on Saturday?” (school 2).

In drama classes of mine they have said things like, “I've really got to go because I've got to get home”, just make an excuse to get out of the situation. Or just point blank say, “No, I'm not doing that because it’s disgusting. You can do it if you like” (school 9).

The longer-term issue of maintaining status without becoming a smoker was generally not addressed.

For some schools tobacco education was seen as a vehicle through which to deliver other areas of the curriculum. Examples of this could be seen in creative writing, personal writing, poetry, debating, writing letters of persuasion (for example a letter to an MP wanting to ban smoking in public places) designing posters or leaflets, and presenting school assemblies.

But teachers were divided as to how far the 5-14 curriculum allowed them to do this.

In quite a number of cases they were extremely reluctant to use health issues across the curriculum.

Things are more compartmentalised now because of the 5-14, really it’s a drugs thing, and that where it should be (school 8).

In other cases a cross-curricular approach was embraced with enthusiasm, with teachers looking for ways of linking their various curricular themes. To a large extent this depended on the school strategy for tackling the 5-14. If it favoured a cross-curricular approach to everything, it would do so for smoking education, but if this was not the case, teachers had more difficulty in seeing how they could use tobacco education in other areas.

Teaching across the curriculum was fraught with administrative difficulty, and   required very careful forward planning, as teachers were obliged to justify all their lessons in terms of the 5-14 attainment targets.

The way it works, the learning outcome has to be something on health if you are doing a health lesson. And if it’s an art lesson, it has to be an art learning outcome rather than a health one. You can combine them but you have to be clear about what your learning outcome is (school 9).

The inspectors could come in, if you were doing topic work, and you gave them some research, they would be entitled to say, that’s language work you are doing. It’s extremely difficult. If they are coming in to see a health lesson, and we’re going to do some writing or some research, they say it’s no longer the topic, it’s language. So if I do role-play within a topic, I have to say ”I’m not teaching about cigarettes here, its drama”, and it has to go into that (school 11).

Other schools took a more optimistic view of fitting cross-curricular work into the 5-14 curriculum and saw it as a means to fulfil several criteria at the same time.

If the opportunity presents itself to teach in a cross-curricular way, we do. The Scottish curriculum now is so stuffed full, that if a thing doesn't fit into the curriculum and hit two or three targets, I would say forget it  (school 20).

What’s actually factual about the 5-14 curriculum in Scotland is that if you split everything into individual components there is no way you can fit it into the working week. One of the keys is to try and combine outcomes. So you might kill some of your drama outcomes at the same time as some of your health outcomes  (school 23).

2.2.3 Other practical activities

“Hands on” practical activities were seen to be effective methods of teaching and learning. A well-known, and much liked activity was the “smoking machine” where the air from a burning cigarette was sucked through cotton wool, leaving a visible orange stain. Unfortunately, it was not widely used, as most schools did not possess a purpose-designed kit, and teachers did not always have the time to collect and assemble the necessary washing-up liquid bottles and associated paraphernalia.

One school used an interesting practical activity to demonstrate the pros and cons of smoking. This involved physically balancing reasons for and against smoking to see which carried the greatest weight.

The main activity for smoking in P5 is actually one we got from Northamptonshire Science, it’s a very very good activity.  The activity that we found is a balance that has a scale of one to 10. And children work in groups with statements that say “smoking calms my nerves, smoking does this, smoking does that” so it’s the reasons why people smoke and the reasons why people shouldn’t smoke. And the balance, it’s got one to ten on each side. And each card’s got a hole in it and they’ve got to decide if it’s a reason for smoking, or a reason against smoking, and they’ve got to decide if it’s a one or it’s a ten. Now it always happens that the balance comes down against smoking, but they can see there are reasons why people do smoke (school 13).

2.2.4 Worksheets

Worksheets were used in some schools, but only very sparingly within this topic.

I think in Scotland we are coming to the point, we've arrived at the point where we are trying not to use so many worksheets, photocopiable written material with children. I think we've come through a period where we've used a lot more than we should have done, instead of the active learning through science experiments, investigations, surveys, discussions (school 23).

  It was widely held that that the best way to tackle health issues was by allowing the children to express themselves and to interact with others. It was felt that excessive use of worksheets would be boring for the pupils, would create barriers for those with literacy difficulties, and would not allow for exchange of ideas.

There's much less value in sitting by yourself doing a worksheet, even if you can manage the reading and writing involved, than there is in discussion. After all we are talking about smoking as a social issue, about the influences of other people on making these choices, so it is much more valuable to be discussing the issues with your peers than it is to be sitting quietly, by yourself, writing down your own ideas (school 3).

However, one teacher did point out that for a child who was very shy, or had a viewpoint contrary to the other pupils, a worksheet could allow the opportunity to say something that would otherwise remain unexpressed, and for that reason a well designed sheet could be useful.

Use of worksheets was limited to very specific activities, perhaps to start a lesson, to give children ideas to bring to a debate, or to tie the up points raised in discussion but never as the focus of a whole lesson.

2.3 Relevant health messages

Teachers were in a very strong position to understand which types of health messages were seen as relevant by the children. Owing to the interactive teaching methods, it was clear to the teachers which issues aroused most interest in the children and gave rise to most discussion. Children had difficulty relating longer-term health implications, such as lung disease, to themselves, but would relate them to their parents or grandparents.

The disadvantages of smoking that had more salience to their lives were the social issues such as stained teeth and bad breath. Also, teachers felt that the financial implications of smoking were relevant to some pupils, particularly if compared to the price of other socially desirable items.

The likes of the bad breath, stained teeth, these are the messages we are trying to get across to them. The social things, seem to have more effects. Things that affect their social life as teenagers seem to be more important to them than the health aspects (school  8).

They don't take on board the information about health issues until they are much older. They’re more likely to be worried about smelly clothes, or shortage of money. They're worried about their parents or their grandparents who are in that situation, but they don't relate that to themselves  (school 10).

Opinion was divided as to whether gender differences were apparent at this age. Some teachers felt that boys and girls were not yet very different in the way they responded to the health messages. But a number of teachers did detect gendered responses, and the perceived difference was consistent. Girls, they felt, were more interested in body image and its social implications, and so would identify more strongly with the messages about personal smell, and finger discolouration. Boys, on the other hand, were more interested in sport, and were worried about the effect of smoking on their physical performance.

Whether we like this or not, boys are more into active sports, at the primary, early secondary stage than girls are, and girls are more into socialising, rock music, pop music and all the rest of it  (school 23).

In order to ensure that the classroom activities targeted the interests of both sexes, teachers talked of covering as many aspects of smoking as possible, so that the pupils could draw on the material that was most relevant for them. Additionally, the types of activities that were used allowed pupils to develop the themes that interested them most:

To get round this I do a lot through role-play, because they are choosing their own images, which you can discuss afterwards. They have chosen the things that are most relevant to them. The other will be interested because it is their own peers acting that out (school 10).

The concept of addiction was seen as a crucial aspect of tobacco education but teachers felt it was difficult for pupils to understand. For obvious reasons, teachers were keen to impress upon pupils the likely consequences of taking up smoking in their teens, but they felt that at this age addiction was a very alien concept to the pupils, totally outside of their experience. They may have observed their parents’ dependence on cigarettes, but they could not relate that type of neediness to themselves.

I don't think children can understand the concept that things are not always within their control. I think they think they'll always be able to make the choices, and that they'll never reach a stage where they don't want to do something but they can't control it (school 5).

I think they're aware of the dangers, but I don't think they are aware of how addictive it is, and how hard it is to give up. But they've never experienced that. They think they can dabble, and then they'll give it up, but they don't realise that they can't dabble (school 10).

2.4 Inclusion

When asked about ensuring that the smoking message was accessible to all pupils regardless of social or ethnic background, and regardless of ability, the response was remarkably consistent. The need to include all the pupils was paramount and it underpinned the choice of classroom activities.

Activities have to be inclusive, to be accessible to everybody. It is everybody's health, and they all have a right to education (school 5).

The main activities especially discussion, drama, and art were highly pupil-centred, allowing all children to contribute what they felt was relevant. They offered a range of ways in which the pupils could express themselves, and the experiences of all could be shared. There was no barrier created by the need for literacy skills, nor, the teachers felt, by any child’s particular background.

Whole class is good for this kind of thing, its a good leveller. A child who is not good at reading or writing may be good at speaking out. You wouldn't hear what they had to say if you did it through written work (school 9).

Nobody felt the need to differentiate these activities, in terms of what was asked of the pupil, but the expression “differentiation by outcome” was often applied. This meant that pupils would respond differently to the tasks and produce different styles and qualities of work. Not all pupils would contribute equally to discussions, but the teachers did not see this as a problem, because they were still able to learn from the comments of the others.

The only work that the teachers would differentiate were any tasks that depended heavily on reading or writing, for example worksheets. As described above, their use of such material was limited, but they saw little difficulty in doing this where necessary, one teacher commenting “Our whole job is about differentiating” (school 7).

Teachers often avoided this situation by putting children in mixed ability groupings. For example if the scenario for a role play was written down, the teacher would ensure that each group contained sufficient pupils with the appropriate literacy skills to read the instructions.

2.6 Flexibility

Although repeated references were made to the restrictions that were created by the 5-14 curriculum, this could be seen to operate at a macro level of course design. Within the micro context of planning how to deliver the lesson in the classroom, teachers had a great deal of freedom. This was seen as a prerequisite to effective teaching; professional judgement had to be used to determine how best to approach the topic with any particular class.

Every class is different, so you always tackle things different ways (school 18).

What is suitable with one class isn't always going to work with another class, and you have to adapt, or make your own  (school 5).

Teachers emphatically did not design a course of lessons that could be re-run year after year. They had a range of tactics at their fingertips and would modify their methods and resources to meet the needs of their current charges.

For health education, in particular, they reacted within their lessons to the responses of the children to the issues raised. Often their plan would be modified as the discussion progressed, so to some extent the lessons were unpredictable.

A lot of the PSD that I would be doing is child-led. I know where I'm going, I have a careful plan, but sometimes I'll say, I'll cross that one off because they're nae heading in that direction (school 21).

  You often find that’s when you do your best teaching, when things just come up. If you're doing a good job, it should spiral out questions that bring up discussion and that’s how the arguments develop (school 1).

2.7 Resources

When shown the range of resources, teachers’ responses demonstrated the flexible and imaginative way that primary schools approach their teaching. It became very clear that teachers were not interested in being “resource-led”, in other words they were not looking for materials that removed from them the necessity to plan their lessons. Rather, they selected resources that enabled them to deliver their message effectively.

From a teachers’ point of view we don't want things to be resource-led. We have that structured programme, where we say “these are the concepts we want to teach", and we then look for the resources to meet that need, not the other way round   (school 5).

They were accustomed to changing and modifying materials to suit their own purposes.  

In this section, the teachers’ responses to the sample of resources are presented.

2.7.1 Jar of tar

This was a very visual resource, demonstrating the volume of tar a twenty-a-day smoker would inhale over the course of a year. There was general agreement that visual stimuli were very effective teaching tools for most pupils and that for some pupils they were essential

They’re very kinaesthetic. If they can visualise it they’ll  remember it, they’re more likely to take the message away with them (school 13).

Some children, visual learners, need to see something like that. You have to take account of different learning styles (school 1).

There was some debate as to whether it was appropriate to show such a shocking image to the pupils. Some teachers felt the more shocking, the greater the effectiveness of the message:

That would be great. Shock value. It’s so visual. The more shocking the image, the more impact it has (school 5).

An alternative view was that pupils were used to horrific images through the media, and that the revolting contents of the jar might actually be appealing to them

That is over-gruesomised. Children would love it. It almost attracts them rather than putting them off. It’s not a deterrent (school 21).

There were teachers who felt that the implied message from the jar of tar could be too disturbing for some children, particularly if they had family members who smoked heavily, or who were suffering from smoking-related illness.

2.7.2 Posters

The teachers’ attitudes towards posters demonstrated their very flexible thinking about resources. Nobody suggested that it would be appropriate to simply put the poster on the wall as a source of information for the pupils. Quite a number of teachers only displayed pupils’ work, and would not use up valuable wall space with printed posters. Of those who thought posters could be displayed, it would be in the context of a specific teaching purpose.

Having said that, the teachers all liked to use posters in their classes, and found the short sharp slogans to be a useful way of conveying ideas to pupils. Again, the visual aspect of learning could be addressed by using posters.

The posters were always seen as a stimulus to a pupil activity, rather than simply a means of delivering a message. So, for example they could be the starting point of a class discussion on the health aspects of smoking.

I think posters are good for discussion work. They're a good visual starting point. You wouldn't have them up all the time as they lose their impact (school 23).

In quite a number of schools pupils designed their own posters, leaflets or slogans to encourage people not to smoke. The published posters were seen as an excellent entrée to this. By discussing their layout, design and language, pupils could develop their own ideas of how to effectively present information in that format.

Teachers also saw possibilities of using posters as a starting point for various types of writing.

Smoking fits in well with functional writing, persuasive writing. This could give you the stimulus, the ideas for the creative writing. The less able might tell me, or use a scribe (school 2).

Of the three posters used, the most popular consisted of a series of brightly coloured slogans such as “bad breath”, “stained teeth,” “always broke”. These were the issues that teachers felt were most relevant to their pupils, especially to girls. The format was eye-catching and generally appealing.

Less popular was a poster with a large image of a cigarette end and the slogan “Butt head, fags are a drag”. In this case, quite a number of teachers didn’t approve of the use of slang, and many felt that it didn’t convey any specific information to the pupils. However, some teachers did like it particularly because of the language, feeling that it would appeal to the pupils. Others appreciated its artistic design. Disliking the poster was not always seen to be a reason not to use it, as it could still be the basis of useful discussion, examining the poster and analysing its message, and exploring the pupils’ opinions of the design.

A third poster, in black and white bore a picture of a dinosaur lying on its back (presumably dead), and underneath it was the slogan “maybe they all smoked”. There was universal dislike of the visual aspects of the poster (no colour) and mixed opinions of the joke. While some teachers felt that their pupils would enjoy the joke, quite a number thought the humour was too sophisticated for this age group.

2.7.3 Project tobacco

The purpose of this four page leaflet was to present children with information on a range of tobacco related issues, which they could develop into individual projects.  The immediate impact was light-hearted; a magazine style layout interspersed with cartoons. Within this was a great deal of information, broken into small chunks and arranged irregularly throughout the pages. Subsections included: health effects of smoking, passive smoking, the history of tobacco, environmental reasons not to smoke, tobacco and the law, the contents of tobacco smoke and the costs of smoking.

There were opposing reactions to the suitability of a humorous approach, exemplified by this teachers’ mixed response:

The funny quirky imagery might teach against the serious message you're trying to present, but there again, this is going to draw their attention They'd want to look at it because it is imagery that is interesting to them, because it’s funny, rude whatever. Pre-teenage they quite like this, the vomiting over everything (school 23).

Although the written content was well received by the teachers, they felt that the magazine format, with the crowded page was difficult for children to manage. For the most part they felt that whilst the language was appropriate, the page layout was too confusing.

Ever resourceful, several teachers suggested ways that they could modify the leaflet for their own use.

If I was working with this, these would be separated out onto cards, and this would be the discussion for one group, and this would be the discussion for another group and so on (school 7)

I could use this a series of three or four lessons of language time where tobacco use was the context, and the teaching was the language, and we'd look at the layout of that and what worked and what didn't. Or why it didn't work. And while we did this we'd keep parts and decide where they would go on the new one that we'd do. In the meantime we'd be having the messages (school 6)

Nobody suggested that they would use the leaflet as it had been intended, as the basis of a project.

As a teacher resource, “Project Tobacco” was deemed to be extremely useful.  From an adult perspective a lot of information was presented quite simply in a small space; ideal for the busy teacher to use as reference.

2.7.4 The DragonÂ’s Breath

This was a pack of three books, together with audio tapes, described by its author as “a creative approach to smoking issues for ages 7 - 13”.

“The Dragon’s Story” was told in the first book, and was universally rejected as being aimed at much younger children than P6 and P7.  However, the concept of using novels or short stories was seen as an exciting possibility by some teachers, although a problem was seen in terms of finding the time, within the already crowded curriculum.

I think using story for anything would work really well. I'd read it with the children. Read round the group. People who wanted to read could read, people who didn't, wouldn't. And I would stop after every page or two and discuss what its about (school 6).

  For a story to deliver an effective health message, it would need to be located in the real world, as experienced by primary school children

They love stories, especially if you read it to them. If you had a story about young people that they could relate to it could be effective. Someone who was cool and trendy, in a band maybe, who had chosen not to smoke (school 3).

However, caution was advised when using adults to write for children, trying to recreate their social world.

But if somebody was going to do that my advice would be: speak to lots of children first, not to the likes of us telling what we think might be cool (school 3).

It was also pointed out that publishers nowadays use a range of techniques to make story books easier to use as a whole class teaching resource, such as large flip chart books, with cellophane sheets that have speech bubbles on which the children can write their ideas.

The second book in the “Dragon’s Breath” pack was geared towards a range of activities and contained jokes, poems, songs and puzzles. The most interest was generated by the poems, and some songs. Again, the main purpose seen for these was as a stimulus for the children to go on and create their own poems and songs.

I like the idea of the poems. I've never thought about that before. Certainly having a model to work from would be quite good, and you could use it as a stimulus for the children to write poems (school 16).

They would enjoy the poems and the songs, but after we had looked at some of these there is no reason why they couldn’t put together a song or a rap of their own. They love performing. Its something they find fun and enjoyable, but they don't realise its learning (school 3).

The jokes were less well received, although some of the teachers thought their pupils might enjoy the occasional joke, many felt that the subject was too serious for light humour, and there was certainly no call for quite such a large selection of jokes.

The use of puzzles did not generate a great deal of enthusiasm, except two cases where the teachers felt many of their pupils struggled with literacy. Well designed puzzles could be appealing to the eye, and could stimulate a lot of thought by pupils, but might only require them to fill in a few words, or even to draw lines to connect related concepts.

The final book in the Dragon’s breath series consisted of a “mega quiz”; fifteen rounds of multiple choice questions. Whilst nobody required quite such an extensive quiz, the use of quizzes as a means of summing up was very popular.

My class love quizzes. If there was a quiz on smoking, my class would love it. We have quizzes at the end of the day. When you answer a question you can put your chair up and be ready to leave when the bell goes, so there's their incentive (school 16).

Quizzes, which were designed to identify different levels within the 5-14 curriculum, had potential as formal instruments of assessment.

We would use quizzes probably at the end as a summing up. The big thing is assessing, you could use it as assessment. Especially if the  5-14 levels were on it. Marking up level C and D and E questions (school 2).

2.7.5 Drug Education, including tobacco and alcohol

Throughout the discussions, teachers repeatedly rejected teaching methods that involved the children sitting individually, working through worksheets, as a totally inappropriate approach to health education. However, this did not preclude them from finding this to be a very useful resource. A book of this nature would be used extremely selectively, information and ideas would be taken and modified for use by their children.

For example, a number of the sheets provided statistical information followed by questions requiring pupils to interpret the data in some way. This type of exercise, as it was presented, did not give a very direct health message, and was seen as too dry, boring, and difficult. But the teachers could immediately see ways that they could adapt it to bring parts of it into their discussion.

This sheet, showing how smoking goes up as they get older, I might copy that onto an overhead, and I might say, “What can you see happening here? Why do you think that happens?”. And that could lead us into a whole discussion about peer pressure, and why teenagers smoke (school 25).

More popular were the types of worksheet that asked pupils for their opinions and ideas. But again, the method of presentation would be more interactive, perhaps organising pupils into small groups to share ideas. For whole class work the worksheet would be projected on an interactive blackboard, or overhead projector, so that the children could write their ideas down and share them with the whole group.

2.7.6 Smoke-free for life

This was a Canadian programme of study which began in grade one and progressed to grade nine. It was a fully comprehensive course with all lessons planned. Advice was given on the necessary preparation, and all the materials were supplied, whether they were worksheets, diagrams, or overhead projector transparencies. Teachers were clearly informed of the lessons’ objectives. Work was differentiated for all abilities, and even timing within the lessons was suggested.

The highly prescriptive format of the course generated a certain amount of mirth amongst the Scottish teachers, and even a little indignation.

I think this is a bit spoon feeding quite honestly, I mean, you spend 15 minutes on this and 15 minutes on that. Personally, as a professional I find it a bit insulting, I can decide myself how to do it” (school 15).

Again, the teachers saw a use for this book in their teaching, but not as intended by the authors. In the main it was seen as a useful teacher resource, as it was rich in factual information, but teachers would be happier to impart that information to the children themselves.

Its important for teachers to have real information at their fingertips and its important that what they’re telling children is the truth. This is very useful for a teacher, and some of the resources are useful. What I’m trying to say is that there should be a pack of material that give teachers real facts, a tobacco pack for teachers that they can use if they want to, but the kinds of activities that you are promoting for children are more the kinaesthetic, imaginative (school 13).

A serious drawback of this book, even as a teacher resource was its sheer size. Teachers were always short of time, and were put off by resources which required extensive reading. There was a distinct preference for materials which were more concise.

2.7.7 Teacher factsheets

The  ten factsheets were shown to the teachers in draft form, with no colour or illustrations, just plain typing. Yet they were widely approved for being both concise and informative.

I think it’s important that teachers get the correct information because we are.. Primary teachers at any rate are generalists, we’re not specialists, so to be given this sort of thing.. I like that because its very useful to be sure that you’re imparting the right information to children” (school 2).

I would like this. I like dropping facts like that into things. There's a bit here about child labour and tobacco. Would they be less likely to smoke if they knew that children were living in poverty, and having to work in the factories? Whats the morality in that? Yes, I would enjoy this. Especially as you teach up the school they are looking for facts, particularly the more quirky ones  (school 21).

2.7.8 Perceived needs for future resources

There was a wide range of opinion as to the quality and abundance of current resources, and consequently the need for newer materials, as exemplified by these two statements:

There are a lot of resources, sometimes I think we're on resource overload (school 5).

We really need resources. We have nothing in school (school 24).

This raises the question of how health promoters ensure their materials reach schools, and are made freely available to staff within the school.

2.7.9 Other types of resources

In addition to discussing the resources presented to them, teachers were invited to suggest other types of material that they would like to see produced.

Videos were often suggested as an excellent starting point to discussions, although it was acknowledged that they date quickly. It was seen as essential that any video material used actors of their own age or slightly older, and related the issues directly to young people. Frequent reference was made to an existing health education advertisement, produced by HEBS in which three young girls reduce their attractiveness to boys by smoking, and this was thought to be exactly the right type of approach to delivering health messages.  Additionally, it was thought that the use of teenage icons, either pop or sports personalities would be effective in this context.

Who delivers message is as important as the actual message, so other young people are more influential than teachers. Football stars and pop stars (school 24).

Videos could also be useful for role play, although in this context they would need to set a social scene, again one that carried relevance for young people, which then prompted the children to act out the possible consequences of that scene.

Since group work was seen to be so important both for discussion and role-play, a number of teachers suggested that sets of discussion cards could be useful, that could be issued to pupils to initiate their activities

Discussion cards, scenario cards that could be used in drama. Activities that would take a child 10-15 minutes to complete at the very most, that involved them in the whole process of decision making as well, so the acts are there to help them make the right choice (school 13).

Information on different aspects on index cards or postcards. So like a workshop approach, so within each folder the ideas and information and discussion points would be there. And then you could use it for role play, or discussion but the information for the different groups would be there (school 7).

Great emphasis was placed on “hands on” practical activities as effective teaching strategies, but most teachers felt they had very little to offer in this area, and would appreciate advice on how to deliver this type of lesson. Suggestions of some kind of kit which contained materials and instructions were common, and which enabled practical activities to be organised without too much inconvenience to the teachers.

I would like any kind of experiments to come  in a pack, with all the things you need, I don't want to have to start looking for things (school 24).

As IT becomes more embedded in the school curriculum, the demand for interactive CD roms and websites will increase. The current response was mixed, with some schools being well resourced with computers, good internet access and teachers who were confident with the type of classroom management required. The staff from these schools were keen to develop IT resources for health education. There was recognition that for some pupils this was a very effective method of learning. It could also offer an alternative avenue for pupils who were not very socially confident, who perhaps contributed little to class discussions.

Other schools were more cautious, either because they were not yet well resourced, or because they did not feel confident in using the computers in the classroom.

2.7.10 Gaps in current information

Although teachers were able to identify the types of resources that they would like to see in the future, they were less forthcoming on new issues that they would like to see addressed in any future materials. The only major gap in the resources, in terms of content was identified by one of the teachers who made a point of examining honestly the reasons why people do smoke.

Some guidance about putting it into choices for life, that kind of approach, making good choices for life. Getting teachers to be really aware of why people do it and telling the children why people do make the bad choices  (school 6).

Up to date statistics were reported as being difficult to access, and useful for stimulating discussion.

Some teachers identified their own lack of knowledge about current thinking on the effectiveness of health education approaches, and made a request for this type of information to be circulated to schools.

It would be nice to get some feedback from HEBS about the effectiveness of health education. If they talk to high school children, to find out what works, what stops them from smoking (school 11).

2.2.5 Visits by outside agencies

Grampian police employ twelve full time community police officers whose entire job consists of working with schools. These officers were regular visitors to the schools in Aberdeen and Aberdeenshire, where they delivered an educational package entitled “Learning for Life” which began in the early stages and continued up through the school. Tobacco was discussed in the context of drug taking, and social issues such as bullying and peer pressure were also part of this course. The “Police Box” which contained the resources used by these officers was widely used by teachers throughout Scotland.

Two other schools used nurses to deliver part of their health education. The teachers spoke highly of this input to their curriculum and felt the children paid more attention when the message was presented by other professionals.

When teachers say don't, x number of kids will go straight away and do it. It’s much better when someone different comes in, and they're more interested in them. They know much more about it than we do. And the kids see us all day every day, it’s more memorable from someone different  (school 24).

Only one school relied entirely on the police to deliver their smoking education. For most schools this was just one resource, which was built upon in class after the professional had visited.

Another health education initiative, which was spoken of extremely highly by the two schools in the sample who had used it was a travelling roadshow:

One of the things that is really brilliant in Aberdeenshire is the ALEC (Aberdeenshire Life Education Centre), the travelling roadshow that goes round. It’s a joint funded project between Aberdeenshire council and the Rotary Club. They purchased a large, mobile classroom, I suppose you would call it and it goes round schools in Aberdeenshire and Moray, and we use it as part of our health programme (school 23).

One school had experience of a visiting drama company, which had dealt with health issues, and again, this had considerable impact upon the pupils:

We were also involved in something called “ A Puff a Sniff and a Swallow”. It’s a drama by Livewire Productions. It’s a drug education production, but smoking was involved as well, and I think if children take part in drama and physically work through issues I think that’s really important. The drama people come round and they engage the children in little scenarios. It’s a role play type thing, which I think is very useful, I think you get far, far more from a group of children if they’ve watched a performance and been part of it. You can then take that back and get an awful lot from it (school 13).

2.5 Children of smoking parents

Children who come from homes where one or more adults smoked are the most likely to become smokers themselves, so their education is of particular importance. Questioning in this area revealed a series of issues that presented difficulties to teachers.

The main problems were:

• children could become very alarmed about their parents’ health prospects when presented with details of lung disease and cardiovascular dysfunction
• children could become very critical of their parents
• smoking education could occasionally elicit parental complaint, if the parents felt the teaching had  implied criticism of themselves
• it was difficult to effectively promote a non-smoking message to pupils who saw smoking as a normal adult activity.

The strategies for dealing with these issues varied between schools and between teachers. In a minority of cases the teachers felt that home and school were completely separate. These teachers felt that to discuss smoking at home would be prying into areas that were not their concern, and that all pupils needed to be presented with the facts.

You can't skirt around it. You have to say that everyone who smokes knows about these dangers, that grown ups know about it, that the families know about it….. But they have to know the facts, you can't just say, they'll be all right (school 18).

Most teachers reported treading very carefully when presenting the data about the long-term health implications to the pupils.

We have had one or two children who become quite distressed when they were thinking about their parents and people at home smoking. So you have to be very sensitive, and be very aware (school 4).

In these cases teachers often diluted the messages about severe health problems, believing it to be in the best interests of the child(ren) concerned.

I think you can see if children are really worried, and you do gauge your response, and you know them quite well. If there is a child who is going to become seriously upset about this then you would tone it down a lot. Well smoking affects different people in different ways. I suppose I have said things like, “my grandfather was ninety four when he died, he smoked a lot” (school 23).

One teacher pointed out that it was counter to the pupils’ own good health if they were excessively worried about their parents:

It’s not very healthy for the child to have the burden of worrying about their parents. It’s all very well trying to persuade them not to smoke, but is not very fair if you’re suggesting that their parents are going to die early (school 2).

One of the reasons why teachers were so careful to be non-judgemental, was to avoid being seen to be critical of parents.

You can't flag up "well, this is a very wrong thing that your mum and dad are doing", you can't say that, we just say it’s all down to personal choice (school 3).

In some schools, the level of parental support was very high, and the schools felt they had no problem in delivering a strong health message, even to those children whose parents did smoke. But in other cases, there were considerable concerns about parental response, both towards the school and towards the children. One teacher was very concerned about the health of one of her pupils who lived in a very heavy smoking household. On the subject of passive smoking she said:

You would mention it but you would have to be very careful. I think I would find if one of the children mentioned that issue of smelly clothes, I would find myself trying to avoid it, because of the problems it might cause for this child and possibly the problems it might cause from the parents coming down to school to complain (school 16).

A common approach to the problem was to try and foster a spirit of tolerance of smokers whilst at the same time trying to encourage the children not to start.

You also stress as well how very difficult it is for their parents to give up. I say to them your parents aren't smoking because they want to. It’s very difficult to stop once they start, and they have to be supportive (school 5).

From a religious point of view, the concept of forgiveness was important:

I don’t think you can be looking down your nose at it. It’s not a crime, its not a sin, coming from the Catholic aspect, and I’m always very careful to say that to the children, that your parents are not doing something that is wrong, …..they do see their parents who smoke and who don’t want to smoke and who can’t give it up. You can’t be very judgmental. This is part of it for us. If your mum and dad want to smoke they may have good reasons for it, but it’s better not to start (school 11).

It was not unusual for teachers to have a “set response” which they could use to explain away adult smoking, in a non-judgemental way, which they hoped would then free the child from the need to follow in his/her parents footsteps. For example:

It’s quite simple. You can ask them to ask their parents “Would they start smoking now?” And its almost always “no”. It’s very much “do as I say, not as I do”. So we discuss that (school 10).

You can certainly point out, when they say “my mum smokes” you can say "well, your mums and dads are a different generation from you and it’s only very recently that the real illness side linked to tobacco is coming up. When your mum and dad were younger the dangers weren't quite so well known, so it seemed like quite a safe choice. Now you are making your choices given the fact that you now have all that information” (school 3).

However, it was acknowledged by some schools that pupils whose family smoked found it more difficult to believe the dangers associated with smoking:

If your mum does it, how bad can it be? Your mum wouldn't be doing it if it was wrong or bad. They see a drug addict as being young and outside the law, whereas they're granny's not a drug addict  (school 5).

In this sample there were three schools who felt it was vital that in order to make an informed choice these pupils needed to understand what motivated their parents to smoke, in terms of stress relief, coping, addiction and pleasure (see pages8-9). Two of these were schools in areas of deprivation, which had high levels of parental smoking. They had found that pupils were unable to comprehend the anti smoking message if only the negatives were discussed.

We found that if you go down the road of smoking being completely bad, then the pupils come back and say “why does my mum smoke?”  (school 13).

3. Conclusions and recommendations

The data gathered from teachers in this survey can be seen to have significant implications for future resource material. The main points to be drawn are outlined below.

Resources should be linked to the Scottish 5-14 curriculum.

• Pupils’ activities must be justifiable in terms of the prescribed learning outcomes. Teachers are much more likely to choose to resources which are clearly marked with the attainment targets and the achievement levels
• The main curricular areas are health education, and PSD. With careful reference to the 5-14 guidelines, resources could also be linked in to drama, language, art, and science.
• Most schools teach tobacco education as part of a drugs package. Issues relating to smoking are also of relevance to other drugs, and resources should recognise this link.
• Drug education begins in the early stages of primary school, and it has been suggested that children would benefit from their first tobacco education between the ages of four and eight (Porcellato et al 1999). There may be some benefit in designing materials that could be used as the children progress through the school.

Resources should not be highly prescriptive

• Teachers design their lessons to suit the pupils in their class, and will vary their approaches with different groups of children. They select the resources that meet their needs for that particular class, and readily modify materials for their own purposes. A prescriptive lesson or series of lessons would not meet the varying requirements of pupils, and although teachers may take ideas from such materials, they would not often follow them closely.
• This flexible approach to teaching would be best served by a range of different resources which address different learning styles, and which give rise to a variety of activities.

The purpose of class resources is to stimulate activity.

• Teachers were constantly looking for materials that could stimulate interactive or creative activities, particularly discussion and role-play, but also experiments, creative writing, functional writing and art. Resources needed to be visually exciting, and convey their message in a concise and direct way. Pupils would be put off by too much written information, or by worksheet style activities. Instead teachers preferred posters, discussion cards, videos, practical demonstrations or other ways of delivering direct messages.
• Teachers did not require the resources to direct the activities, although they appreciated suggestions, teachers preferred to use their own professional judgement regarding classroom management.

Health messages must be relevant to the children’s view of the world.

• De Meyrick (2001) pointed out that health messages to young people must be concrete, verifiable and in their own time frame. This was borne out by teachers who considered that their pupils could not identify with long-term health warnings about smoking (such as cancer risks).  Issues of social relevance were thought to be of greater interest to primary pupils, or the immediate impact of smoking on their sporting prowess. It is important to present a wide range of health messages to children, to allow for their differential responses. In particular, there may be a gendered response to the social and sport related issues.
• Of particular concern, both to academics (De Meyrick 2001, Halpern et al 2003) and to teachers is the childrens’ vulnerability to tobacco addiction as a result of social smoking. Primary teachers felt that their pupils did not easily relate the concept of addiction to themselves. Any resources which could address this issue, in a child-centred way, would be welcomed by the schools.
• Not only the content, but the presentation of educational materials must relate to the children’s experiences and interests. Teachers repeatedly suggested the use of other children, or teenagers to present the messages, in a context which related to their social world. Pop stars, media personalities and sports celebrities would also create interest amongst children, and could be influential in their decision making.

Role-play scenarios should be grounded in teenage reality

• Role-play was commonly used as a means of preparing children for social situations involving tobacco use. Most teachers thought up their own ideas on which to base their role-play, although some used videos as a starting point.  In most cases the types of scenario were based on the rather outdated notion that young people start to smoke reluctantly, as a result of peer pressure or coercion, in order to avoid losing face in a situation over which they have little control. There was little evidence of teachers understanding the active choices that young people make when they decide to become smoke (Mitchell 1997). Consequently the type of strategies that young people were developing were of use only in the short term, to evade a tricky situation (for example “ I’d love a cigarette, but I’ve got to be getting home for my tea”). They did not address longer-term issues of maintaining status by other means, whilst remaining a non-smoker.
• Health promoters have a role to play in filling this gap, by the production of drama materials that relate more closely to the recent research findings in the fields of smoking initiation, together with explanatory teachers notes.

To make an informed choice, children need to see both sides of the case

• The paradoxes at the centre of tobacco education can only serve to confuse children. On the one hand teachers are expected to be impartial, and on the other hand it is their duty to deliver an anti-smoking message. Children are told that it’s their own choice whether or not they become smokers, and then in most cases are bombarded with anti-smoking information. Children can only make a balanced choice if they are supplied with all of the information, which would include a recognition of the reasons why people do choose to smoke. Most teachers did not know of any resources suitable for primary school pupils that looked realistically at the pros and cons of smoking; the one exception being the practical activity (using a balance) described by a teacher in school 13. There is clearly a gap here that could be filled by some thoughtfully designed materials.

Teaching should take account of the smoking patterns of significant adults.

• Children who live with parents or siblings who smoke are statistically more at risk of becoming smokers than children from non-smoking homes. Yet teachers often dilute the health messages they give to these children. This is done for the best of intentions; so the children are not frightened by their parents health prospects, so that they do not become critical of their parents, and to avoid any conflict between home and school. But for these children, to whom adult smoking is the norm, tobacco education must be confusing. The task facing a teacher wishing to impart a healthy lifestyle message is particularly difficult, and requires more, not less education.
• Existing resources offer teachers no assistance in handling this dilemma, and this is an issue which could usefully be addressed. This links in strongly with the need to examine the reasons why their parents smoke, but also raises wider questions.   

Teachers need resources too

• Teachers make a clear distinction between resources for pupil use, and resources for their own use, although they can presented as part of the same package. Like pupils, teachers find large quantities of script off-putting, and do not have time for reading lengthy tomes. Booklets for teachers must be concise and informative.
• Primary teachers like to have up-to-date facts and figures at their fingertips, and were particularly keen on the “teacher factsheets” used in the discussions.
• In addition, teachers need to be updated on most recent research findings that could be relevant to their teaching. Rarely do teachers have the opportunity or inclination to read recent health promotion publications, so resource packages should attempt to offer updates.

Outside agencies are a useful human resource

• A large number of the schools in the sample invited visitors to the school to deliver aspects of the health curriculum. These included police, nurses, drama workshops and a mobile interactive classroom. The expertise of these groups was widely appreciated by teachers, who felt that the messages had a greater impact on the pupils. Schools should be encouraged to take advantage of these opportunities. The funding of some of these organisations was a concern to teachers who felt that their financial support was well worth while.

Good communication links are needed between schools and health promoters

• An important part of health promotion in schools is encouraging teachers to use the resources produced. Schools vary enormously in their awareness of available resources, with some teachers claiming to be over-resourced for smoking, and some apparently having none at all. Their attention must be drawn to new resources, with subsequent reminders. E-mails with links to a website could be a possible means of achieving this.
• There is a real need for in-service training of teachers in this area, and this could perhaps be linked to launching any new materials. Teachers’ interest would also be enhanced if they could be involved in the design or piloting before publication. Such an exercise would raise awareness of the materials in production, it would ensure their suitability for classroom use, and it would increase teachers’ confidence to buy and use them.

4. References

Amos A, Gray, D, Currie C and Elton R  (1997) Healthy or druggy? Self image, ideal image and smoking behaviour among young people  Social Sciences and Medicine. 45 (6)  847-858

Anderson, M R Leroux, B G Marek, M S     Peterson, A V Kealey, K A Bricker, M S and Sarason I G (2002) Mothers attitudes and Concerns about their children smoking: Do they influence their kids. Preventative Medicine 34 198 - 206

Ariza-Cardenal, C and Nebot- Adel (2002) Factors associated with smoking progression among Spanish adolescents. Health Education Research 17 (6) 750 – 760

Currie C, Fairgrieve, J Currie, D and Atkar, P (2002) Scottish Schools Adolescent Lifestyle and Substance Use. Interim report. CAHRU. Edinburgh

Denscombe M. (2001) Uncertain identities and health risking behaviour: The case of young people and smoking in late modernity. British Journal of Sociology 52 (1) 157-177

Glendenning A (2002)  Self esteem and smoking in youth – muddying the waters?

Joural of Adolescence 25 415-425

Glendenning, A and Inglis, D ( 1999) Smoking behaviour in youth: the problem of low self-esteem? Journal of Adolescence 22 673 – 682

Goddard E and Higgins V (1999) Smoking, drinking and drug use among  young teenagers in 1998. Vol 2: Scotland. London: The Stationery Office

Griesbach D and Currie C (2001) Health behaviours of Scottish schoolchildren: Report 7: Control of adolescent smoking in Scotland. CAHRO: Edinburgh

Griesbach, D, Amos A and Currie C (2003) Adolescent smoking and family structure in Europe Social Science and Medicine 56 (1) 41 –52

Lloyd B and Lucas, K (1998) Smoking in Adolescence:Images and Identities. Sussex: Routledge

Lucas¸K and Lloyd B (1999a) Starting Smoking:Girl’s explanations of the influence of peer. Journal of adolescence 22 647-655

Lucas K, Lloyd, B (1999b)  Adolescent smoking: the control of mood and body image concerns  Health Education 99 (1) 17 – 26

Mitchell L (1997) Loud sad or bad: Young peoples perceptions of peer groups and smoking Health education research 12 (1) 1-14

Mitchell L and Amos A (1997) Girls, Pecking Order and Smoking Social  Sciences and Medicine 44 (12) 1861-1869

Owen L and Bolling K (1995) Tracking teenage smoking. Health Education Authority: London

Plumridge, E Fitzgerald L and Abel G (2002) Performing coolness: Smoking refusal and adolescent identities. Health education Research 17 (2) 167-179

Rugkasa, J Kennedy, O Barton, M, Abuanza P.S. Treacy M.P. and Knox B. (2001) Smoking and symbolism: Children, communication and cigarettes. Health Education Research, 16 (2) 131-142

Scottish Executive (2000) The Structure and Balance of the Curriculum. 5-14 National Guidelines. Learning and Teaching Scotland

Siquiera,L Diab, M Bodian, C and Rolnitzky, L (2000)  Adolescents becoming Smokers: the roles of stress and coping methods Journal of Adolescent Health 27 (6) 399 – 408

The Scottish Office (1999): Towards a Healthier Scotland. A White paper. The Stationery Office: Edinburgh

West, P and Sweeting H (1997) “Lost souls” and Rebels”: a challenge to the assumption that low self esteem and unhealthy life styles are related. Health Education 97 161-167

Appendix A Schools involved in this project

Number	Location	Brief description	Staff interviewed
1	Stirling	Town centre, mixed social intake	P7 teacher
2	Stirling	Outside town. Largely middle class intake	Two P7 teachers
3	Stirling	In area of social deprivation	One p6 and one p7 teacher
4	Stirling	Catholic school, located in council estate, but with intake from throughout town	Depute head teacher
5	Stirling	Mainly working class intake	Focus group of five teachers
6	Stirling	Tiny school (2 classes) in area of social deprivation	Head teacher (also upper stages class teacher)
7	Cumbernauld	Located in new middle class housing area, with mixed social intake	Head teacher
8	Cumbernauld	Mainly working class intake	Two primary seven teachers
9	Cumbernauld	Located just outside town, mixed social intake	Primary six teacher
10	Cumbernauld	Mainly working class intake	Focus group of two P6 and two P7 teachers
11	Cumbernauld	Catholic school. Located in working class area, with intake from throughout area	P6 and P7 teacher
12	Cumbernauld	Mainly working class intake	P6 and P7 teacher
13	Aberdeen	Area of social deprivation	Depute head, health co-ordinator
14	Aberdeen	Area of social deprivation	P7 teacher
15	Aberdeen	Middle class suburb	P7 teacher
16	Aberdeen	Area of social deprivation	P6/7 teacher
17	Aberdeen	Middle class area in city centre	P7 teacher
18	Aberdeen	Area of social deprivation	P6, P6/7 and P7 teacher
19	Aberdeen	Middle class suburb	Focus group of six teachers
20	Aberdeenshire	Small rural school (3 classes), mixed social intake	Head teacher (Also upper stages class teacher)
21	Aberdeenshire	Located in market town, mixed social intake	P7 teacher
22	Aberdeenshire	Small rural school (2 classes), mixed social intake	Upper stages teacher
23	Aberdeenshire	Market town. Mixed social  intake.	P7 teacher and head teacher
24	Aberdeenshire	Fishing town. Area of deprivation.	Two P7 teachers
25	Aberdeenshire	Small rural school (2 classes). Mixed  social intake	Upper stages teacher

Appendix B Interview schedule

1. How is smoking best fitted into the learning framework of P 6/7 pupils?

• Part of broader package of  health and fitness?
• Science of the heart and lungs?
• Social education e.g. friendship, peer pressure, self esteem, bullying?

2. What types of activities are most effective in helping young people develop negative attitudes towards smoking?

• Creative writing, art and drama?
• Data interpretation?
• Is group work or individual work more effective?
• Can circle time discussions be helpful?
• Games quizzes and other activities?

3. How do teachers ensure the health messages are equally accessible to all their pupils regardless of ability, racial and social background?

4. How do teachers deal with the wider family issues, when pupils see smoking as a normal adolescent and adult activity in a family of smokers?

5. Discussion of resources (link this with what teachers would like to see produced)

a. Content

• Appropriate range of issues?
• Any gaps?
• Relevant and useful info?
• Appropriate level of detail?

b .Language

• Appropriate level for age group?
• Does it need differentiating?

c. Design

• What is the immediate impact?
• Acceptable format?
• How is imagery used?

d. Classroom organisation?

• How would you use these resources in the classroom?
• Would they be the main focus of a lesson, or form part of a wider theme?
• Do they lend themselves to individual / group or whole class work?

e. Suggestion for future resources

• If you could draw up a list of resources you would like to see produced, what would you put on that list?

Appendix C Resources used for discussion in interviews and focus groups

1. Health Edco. A year’s worth of tar. Visual resource

2. Health Education Board for Scotland.  Maybe they all smoked.   Poster

3. British Heart Foundation (2002) Symptoms. Poster

4. British Heart Foundation (2002) Butt Head.  Poster

5. ASH Scotland (1998) Project tobacco. Leaflet

6. Schools health Education Unit (2000) Drugs Education, including tobacco and alcohol.  KCP : Hemel Hempstead.

7. Ward C (1991) The dragon’s breath Birmingham City Council, Education Department

8. Nova Scotia Department of Health (1996) Smoke free for life Nova Scotia Department of Supply and Services.

9. Health Education Board for Scotland (2003)  Tobacco factsheets  Draft