Health Education Research Advance Access originally published online on April 13, 2005
Health Education Research 2005 20(6):645-655; doi:10.1093/her/cyh027
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‘Stop it, it's bad for you and me’: experiences of and views on passive smoking among primary-school children in Liverpool
1 Institute for Health, Liverpool John Moores University, Liverpool L3 2AB, 2 Institute of Public Health Research and Policy, University of Salford, Salford M5 4QA and 3 School of Community, Health Sciences and Social Care, University of Salford, Salford M6 6PU, UK
4 Correspondence to: S. E. Woods; E-mail: s.e.woods{at}livjm.ac.uk
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Abstract |
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This article looks at how children between the ages of 4 and 8 years report they feel when they are exposed to passive smoking and how they react in these situations. Data were collected annually from a cohort of 250 primary school children, which was tracked from their Reception Classes to Year 3 across six Liverpool schools. Quantitative and qualitative methods were employed—including a survey, the Draw and Write investigative technique and semi-structured interviews. Findings showed that children had some understanding of the health problems that passive smoking posed to both themselves and the smoker. Between the ages of 4 and 7 the majority of children held negative feelings about being exposed to smoke, but at the age of 8 there is a clear decline in negative expressions. Most of the children were prepared verbally to confront a smoker, usually a parent, in order to get them to stop, but rarely took direct action and left the room themselves. Results suggest that children would be receptive to information on the dangers of smoking during the early years of primary school, while the dialogue between children and their parents suggests that the latter have a key role to play in strategies to tackle passive smoking in the home.
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Introduction |
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In the last 10–15 years a growing body of research exploring the risks to children through passive smoking has developed and its consequences on children's health is now extensively documented (Weitzman et al., 1990; Chilmonczyk et al., 1993
; Strachan and Cook, 1997; Dybing and Sanner, 1999; WHO, 1999; ASH, 2002b). It is estimated that 17 000 children under the age of 5 are admitted to hospital every year in the UK due to illnesses resulting from passive smoking (Royal College of Physicians, 2003). Moreover, a report from ASH suggested that in the UK between 1600 and 5400 new cases of child asthma occur every year due to exposure to parental smoking (ASH, 2000).
Studies within the UK show that over 90% of children are at some time exposed to tobacco smoke (Cancer Research UK, 2003), while 42% of British children actually live in a household where at least one person is a smoker (ASH, 2002a). As Public Health News states: ‘Nearly half the children in the UK inhale tobacco smoke pollution in their home. It is now the most common place for children to be exposed to tobacco smoke’ (Public Health News, October 2004, p. 8).
While the issue of children and environmental tobacco smoke (ETS) has been and continues to be rigorously examined from a range of perspectives, one aspect remains under-reported within existing literature: what children themselves think about passive smoking and how they react when they encounter it. Yet this is an important omission on a number of levels. Since the late 1980s a range of legislation has been introduced that aims to ensure children have the opportunity to contribute to decision making on issues that directly impact on or are relevant to them (Department of Health, 1989, 2004; Department of Education, 1993). At the same time the value of taking into account children's observations and reactions has been increasingly recognized by researchers. Indeed, some research argues that the views of children are of ultimate importance (Ruddock et al., 1996). Other work has focused on exploring and promoting the role and the rights of the child, specifically in health issues (Mayall, 1996, 1998), while the wider debate has seen the rise of a new theoretical tradition, the ‘sociology of childhood’, that identifies children as active social agents who make an important contribution to society (James and Prout, 1997; Corsaro, 1997; Christensen and James, 2000; Morrow, 2001; Milton, 2002). The tenets of such a theoretical perspective underpinned the development of the Liverpool Longitudinal Study on Smoking (LLSS), upon which this paper is based.
Building on the wealth of existing data, this article looks specifically at children's understanding and awareness of passive smoking, how they feel when they are exposed to it, and what, if any, strategies they both encounter and employ to deal with it. Given the prominence of children in the issue of ETS in the home, gaining their views on and experiences of passive smoking may well be an important step in better understanding the problem, while their input could influence the design of more appropriate reduction and prevention strategies in the future. Moreover, at the broader level it is crucial to recognize that it is from children's own accounts that we can gain real insight into the complex factors involved in the process of becoming an adolescent smoker.
An overview of the LLSS
The findings discussed in this paper are drawn from the LLSS, a larger on-going multi-method research project, which was set up to explore children's perceptions of and views on smoking, and their attitudes and behaviour towards it (Porcellato, 1998). The article draws only on data that was collected from the Early Years stage of the research, which focuses on the first 4 years of primary school. The project began in 1994, with the first round of data collection in 1995, when a cohort of 250 children entered Reception Class aged 4–5. These children were then tracked annually as they moved up through the participating schools, with the Early Years phase ending in 1998 when the cohort was aged 7–8. (The LLSS continued to follow the children through primary school, with the years 1999–2001 forming the Pre-adolescence phase. At the end of this time the children dispersed into 31 secondary schools across the city. The study has continued to track the cohort annually, with 210 of the original sample, now aged 13–14, taking part in the Adolescence phase of the research.)
The LLSS was specifically designed to collect both quantitative and qualitative data on children and their attitudes and beliefs about, and behaviour toward, smoking (Porcellato, 1998; Milton, 2002). A key to the strength and appropriateness of the methodology used during the LLSS was its adoption of a child-centred approach to the research. This ensured the direct participation of the children in the process, most importantly allowing them to voice their own thoughts, perceptions and views. Over the past decade there has been an increasing recognition of the importance of conducting participatory research with children (Boyden and Ennew, 1997; Morrow, 2001; Fraser, 2003). Within health-related research however, it still remains limited (Pridmore and Bendelow, 1995; Oakley et al., 1995; MacGregor et al., 1998; Pridmore and Stevens, 2000).
The study also implemented a triangulated approach to data collection, applying a range of techniques to what was essentially the same issue. The value of triangulation as an approach is that it ‘adds rigour, breadth and depth to any investigation’ [(Denzin and Lincoln, 1994), p. 2] and facilitated an extensive exploration of the topic. It enabled researchers to draw out findings that may otherwise have remained hidden and both established a thorough picture (Mays and Pope, 2000) whilst validating the findings through a comparison of results from the different methods used (Breitmeyer et al., 1993; Barbour, 2001).
Given the age of the participants in the study, a strict set of ethical guidelines was adhered to in order to protect the children and three layers of consent were sought. Initially permission was obtained from head teachers for the children to participate in the study. Then, letters were sent home to parents explaining the new research, together with a consent form. Parents were able to give positive consent or withhold permission for their child to take part in the research. On the advice of head teachers, the consent form included a non-response clause, which meant that children whose parents who did not return the form were automatically included in the study. The rationale for the use of this ‘opt-out’ mechanism was both to ensure a high level of participation, which is essential for school health-based research, and limit selection bias within the cohort. Lastly, the final decision on taking part in the research rested with the children themselves who were asked each year if they wanted to continue.
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Methods |
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All primary schools in Liverpool, UK were invited to participate in the research. Of those who responded, six urban primary schools were chosen to take part in the study. The selection was based on three indicators:
- Employment statistics from the 1991 census.
- Liverpool lung cancer Standard Mortality Ratios (Mooney, 1994).
- Index of well-being (variables included population change 1971–1991; percentage of households not owning cars; percentage of population with limiting long-term illness; percentage owner-occupied; percentage of lone parents; unemployment rates; youth unemployment) (Shepton, 1994).
; Porcellato et al., 2002). Researchers visited the schools annually for data collection. Each year all of the children in the cohort present on administration day took part in a self-completion questionnaire (Porcellato et al., 1999) and a ‘Draw and Write’ exercise (Wetton, 1990). Alongside this data collection, focus groups were conducted within each of the schools from Year 2 onward (Porcellato et al., 2002). Lastly, a number of case study children were selected within each school to participate in a one-to-one semi-structured interview and to complete psychometric tests exploring self-esteem (Harter, 1985). These children were randomly chosen by their class teachers in the first year of data collection and became the case-study sample for the following years of the study.
This article draws on the findings of the Draw and Write exercise and the annual case-study children's interviews, as both of these looked specifically at the issue of passive smoking. Noreen Wetton pioneered the Draw and Write investigative technique in 1972. This method has been used in a wide range of research into children's health and was initially applied during a national study of primary-school children's changing perceptions of health (Williams et al., 1989). For the LLSS, the Draw and Write tool was adapted from another source (Somerset Health Education Authority and Somerset Education Consultants for the Best of Health Project, 1994), which investigated children's understanding of smokers and smoking.
The Draw and Write technique was administered to the whole class at the same time. The researcher read out a series of questions addressing a range of smoking-related issues, one of which was passive smoking. They then gave instructions to the children on how to complete the task, which involved producing drawings and writing comments on their pictures. The technique was administered on a sheet of A3 paper that was divided into four sections, the approach being designed to mimic the format of school tasks the children would already be familiar with. In the Early Years phase additional researchers were available to act as scribes for children who had difficulty writing. Data based only on what the children had written was then coded. Initially the majority of categories were taken from the original study, the Best of Health Project (Somerset Health Education Authority and Somerset Education Consultants for the Best of Health Project, 1994). However, during the process of analysis, it became apparent that these categories were too broad and further ones were devised to accommodate the range of information that emerged from the data. The newly formulated categories remained the same for the duration of the project, with a small number being reorganized to ensure consistency for longitudinal analysis. For the purpose of data management, data was quantified using frequency of response measurements and the statistics were analysed using Excel. As the Draw and Write is administered on a classroom basis with a view to gauging trends, statistical analysis was not conducted on an individual child basis, but rather by school, allowing only a basic comparison of socioeconomic status through school location.
As part of the data collection process, and the focus of this article, each year in the Draw and Write exercise the children were told to imagine that they were in a room full of smokers. To complete the task the children were asked to Draw and Write about:
- (1) How they felt in this situation?
- (2) What, if anything, they would say to the smokers?
- (2) What, if anything, they would say to the smokers?
Within the interview the children were given a number of opportunities to talk about being around smokers, but were specifically asked ‘if people are smoking near you how do you feel?’ and ‘can you tell me what term passive smoking means?’.
Table I presents the number of children that took part each year in the Draw and Write exercise and interviews. The increase in the cohort number in 1998 was due to the fact that the researcher undertaking the fieldwork that year was able to conduct repeat visits to the schools, which led to more children taking part in the study. In preceding years time constraints had significantly reduced the opportunity for re-visits.
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Results |
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As established, the children were asked over the course of the Early Years stage of the study what the term ‘passive smoking’ meant to them. Not surprisingly, across all 4 years of the research no child acknowledged an understanding of the actual term and only very rarely did anyone actually attempt to answer the question, even at age 7–8, as the quotes in Figure 1 illustrate.
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However, as the following discussion shows, at younger ages children do have strong feelings on the issue of being exposed to smoke, show concerns over its impact on their health and employ a range of ways to deter adults from smoking in front of them.
Feelings when exposed to ETS
Looking first at the issue of being around smokers, it is clear from the findings of the Draw and Write exercise that at ages 4–7 the children overwhelmingly had negative feelings when they were in the company of smokers. However, when the children reached Year 3, aged 7–8, there was a substantial drop in the number reporting negative feelings, suggesting that they were more receptive to smoking at an early age. On the whole, gender appears to have no effect on these views, with about the same percentage of boys and girls articulating similar responses. The only anomaly was when the children were aged 5–6 when significantly more girls appeared to have negative feelings about smoking than boys, 84% compared to 71%, but this evened out as they got older. Findings are presented in Table II.
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A cross-comparison of results by school showed that there was no significant difference in responses over time between the Low, Mid or High SES primary schools.
Data collected during the annual round of interviews with the children supports these findings. When asked how they felt if they were ever in a smoky place, over 90% of them in each of the years gave a negative response. Analysis revealed that there were two broad categories of answer, the first relating to their emotions. Representative comments are shown in Figure 2.
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As the children moved up from Reception Class they started to volunteer a second category, which related to concerns about their own health, particularly citing difficulty in breathing and problems with coughing whilst in the company of smokers. As presented in Figures 3 and 4, findings from the Draw and Write exercise showed that although there were some fluctuations in the number of children concerned for their health, by the age of 7–8 over 32% referred to feeling anxious about this issue. The low response in Reception Class was understood to be due to the children not fully understanding the question being asked, although the reason for the fall between Years 1 and 2 is not clear. The dramatic increase in Year 3 may well be related to receiving, and being more receptive to, health education messages at home and in the classroom as the children grow up.
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Only in 1997 when the children were aged 6–7 did gender appear to make a difference, with double the amount of respondents raising specific health concerns being girls, 15 compared to 7% boys. In other years, gender was not an important factor. Exploring the findings by school showed that, in all years, children attending the school in the area with most preferable socioeconomic conditions were least likely to cite a specific concern for their health in each year of the study. Up until Year 2 figures were similar across schools from Low and Med SES schools, however, by the time children were aged 7–8 those attending the Low SES schools were by far the most likely to report health concerns. Such a pattern may well be related to the levels of smoking in the children are exposed to in their homes. Results are shown in Table III.
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Again, the results from the Draw and Write are supported by findings from the interviews over time in which there are frequent incidences where the children specifically mention feeling a certain health-related problem when in a smoky place. Examples of their responses are shown in Figure 5.
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References to their health occurred across all of the years data was collected, although as expected explanations increased in breadth and depth as the children got older.
Actions when exposed to ETS
Findings from the Draw and Write exercise, shown in Figure 6, illustrate that from Reception age upwards when in a smoky room children were vocal in asking or even demanding that the person who was smoking either stopped or left the room, as is highlighted in the title of this paper.
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This action is also reflected within some of the children's drawings, as presented in Figure 7.
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The total number of children acting in this way peaked at Year 1 when the children were aged 5–6 and then declined by 23% over the next couple of years. Between Reception and Year 2 gender did not appear to be a significant influence, with very similar amounts of boys and girls being vocal towards a smoker. In Year 3, however, considerably more boys than girls asked a person to stop, 69.1 compared to 53.2%. Variation with regard to primary school was minimal over the period. The overall reduction in this type of response to smokers may be explained by a rise in other actions from the children as they move up primary school. The Draw and Write exercise found that, most notably in Years 2 and 3, children started talking about health problems with the smoking adult, providing a type of health advice, with 11 and 31.3% of the cohort, respectively, offering this. Examples are shown in Figure 8.
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As the children progressed through school gender did appear to be a factor here, with 39.4% of those offering such advice being girls in Year 3 compared to just 21.8% being boys. Less extreme was the variation between schools, with 38% of those children attending the Mid SES schools most likely to act in this way, followed by 34 and 28% in the High and Low SES schools, respectively.
There was also an increase in the percentage of children in these years questioning the smokers as to why they engage in the habit, from 1.7% in Reception Class to 7% in Years 2 and 3. Again, as the children got older gender bias could be seen, with nearly twice as many girls as boys questioning the smoker in Year 3. Furthermore, over the period the children attending the Low SES schools were always least likely to act in this way, most notably in Year 3, with less than 10% of the responses coming from this group.
While the children appeared unafraid to talk to the smoker during their early years, only a very small percentage stated that they would take action such as leaving the room, amounting to around 1.5–2% of the group. Only in 1997 when the children were aged 6–7 was a gender variation evident, with no girls taking action at all. Interestingly, in all years it was only children attending the Mid and High SES schools that gave this response. However, within the interviews about 3% of children each year did cite examples of the smoker, usually a parent, going somewhere else to smoke, either elsewhere in the house or in the garden, rather than stay in their child's presence. The children in question uniformly welcomed such a response. Another action described by a small number of children, less than 5% across the Early Years study, was where the parent removed themselves from a room specifically to move away from a new baby, and again the children who saw this acknowledged it as important and positive adult behaviour.
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Discussion |
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What the LLSS has shown is that whilst the children cannot define what passive smoking is, from the age of 4–5 upwards they are very aware of its occurrence. Their reports show that they are able to articulately describe how they feel when faced with a smoky environment. Over time they are also increasingly aware of how their own health, and that of the smoker, is being affected by inhaling the smoke, their responses around these issues becoming more sophisticated as they move up primary school. Interestingly, when the children reach age 7–8 it is those attending schools in areas with the least preferable socioeconomic conditions that most frequently cite specific problems with their health. However, these children are least likely to question a smoker about their actions or offer health advice, which perhaps suggests that while they may be the group most exposed to passive smoking, they progressively become used to people smoking around them and are more accepting of the behaviour. As such, while children's understanding of health issues is clearly related to the academic progress of the children and their increased exposure to public health messages, it is likely that their views and actions are also shaped by the environment that they live in; the context within which they go about their day-to-day lives. Where and how they live has an impact on how they make sense of the world around them as they grow up, and it is important to acknowledge that the attitudes that they form towards smoking are grounded in their actual experiences.
Our research with the Early Years children found that the majority of children in Reception Class to Year 2, aged 4–7, hold negative views on smoking. However, this pattern changes in Year 3, ages 7–8, when there was a considerable fall-off in negative expressions. This appears to indicate that it is the youngest children who are most conscious of smoking around them and as they get older they simply get more used to it; for these children it has already become integrated into their daily lives. Taking this point further, it is not unreasonable to surmise that they have begun to be more accepting of smoking as they try to rationalize why their parents and other key figures in their lives engage in a practice that the children know is so damaging. This perhaps shows that during the first few years at primary school children would be receptive to information on smoking, rather than treat it as a taboo subject with such a young age group as is often the case today. As such, our research highlights the need for supplementary programmes to be designed for children under the age of 7, with initial intervention occurring during the early years of primary school.
As previously discussed in this paper, existing research provides evidence of how children's health is being affected by passive smoking, but this study shows in addition that children themselves are at some level aware of the problem. Yet whilst they express such dislike and concern over the issue during their early years, they are very reluctant to take direct action and remove themselves from the situation. Instead they rely on the actions of their parents to protect them from ETS. In our study of 4–8 year olds we found that while this does happen, it appears to be only in a minority of households. This supports existing research that proposes interventions to protect children from passive smoking need to focus on addressing parents' knowledge and behaviour (ASH, 2002; Slish and Cabana, 2004). Thus, while there have been health promotion interventions that tackle the problem, e.g. through parental education programmes in primary care, our findings prompt the question whether additional, or more targeted, schemes focussing on approaches which involve both children and parents are required to address the issue more effectively. Certainly, to date, school-based intervention programmes have not been particularly successful in preventing the uptake of smoking by adolescents (Charlton, 1999; Thomas, 2004). However, the evidence from the LLSS has demonstrated that from an early age children are aware of, and have started to develop views on, smoking and the dangers it poses to their own and other people's health. It may be that school-based interventions may have greater success if they were implemented from an earlier age in primary school.
It is vital to acknowledge that the children's thoughts about and attitudes towards smoking are grounded in their actual experiences, and there is a wide range of factors exerting an influence on them. Existing literature, in conjunction with the findings from the LLSS, emphasize the influence of the parents (de Vries, et al., 2003). The willingness of many of the children in this study to raise the issue of passive smoking with their mothers and fathers shows that they actively want to talk about the negative impact smoking is having, and that they have expectations that their parents should – and they often do – respond positively to reduce this. Building on this reciprocity may well be a valuable way forward when looking at new prevention strategies, bringing a dialogical approach to addressing ETS in the home.
To conclude, it is evident is that with 42% of British children living in a house with at least one smoker, exposure to ETS remains a big problem. The present study makes it clear that young children themselves are significantly aware of the issue and have real concerns about the impact of passive smoking on their health.
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Acknowledgments |
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The authors gratefully acknowledge the invaluable assistance of the head-teachers and staff from the six participating primary schools during the course of the Study. Also, we would like to thank the parents and the children for their co-operation and involvement in the project. This research has been made possible by the support of the Roy Castle Lung Cancer Foundation, which has provided the funding to carry out the LLSS since 1994.
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References |
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ASH (2002) Fact Sheet 8: Passive Smoking: A Summary of the Evidence. ASH, London. Available: www.ash.org.uk/html/factsheets/html/fact08.html.
ASH (2002a) Passive Smoking: The Impact on Children. ASH, London. Available: www.ash.org.uk/html/passive/html/kidsbrief.html.
ASH (2003) Fact Sheet 14: Smoking in Public Places. ASH, London. Available: www.ash.org.uk/html/passive.
Barbour, R. (2001) Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? British Medical Journal, 322, 1115–1117.
Boyden, J. and Ennew, J. (eds) (1997) Children in Focus – A Manual for Participatory Research with Children. Swedish Save the Children, Stockholm.
Breitmeyer, B.J., Ayres, L. and Knafl, K.A. (1993) Triangulation in qualitative research: evaluation and completeness and confirmation purposes. IMAGE Journal of Nursing Scholarship, 25, 237–243.
Cancer Research UK (2003) Children Widely Exposed to Passive Smoking. Cancer Research UK, London. Available: www.healthypages.net/index-news.asp?newsid=3290.
Cancer Research UK (2004) Passive Smoking and Smoking in Public Places. Cancer Research UK, London. Available: info.cancerresearchuk.org/publicpolicy/briefings/prevention/tobaccocontrol/smoke.
Charlton, A. (1999) School based youth centred smoking intervention programmes: to be or not to be? Paper presented at the WHO Conference on Tobacco and Youth, Singapore.
Chilmonczyk, B., Salmun, L.M., Megalithlin, K.N., Neveux, L.M., Palomaki, G.E., Knight, G.J., Pulkkinen, A.J. and Haddow, J.E. (1993) Association between exposure to ETS and exacerbations of asthma in children. New England Journal of Medicine, 328, 1665–1669.
Christensen, P. and James, A. (2000) Research with Children: Perspectives and Practices. Falmer Press, London.
Corsaro, W. (1997) The Sociology of Childhood. Pine Forge Press, Thousand Oaks, CA.
De Vries, H., Engels, R., Kremers, S. Wetzels, J. and Mudde, A. (2003) Parents' and friends' smoking status as predictors of smoking onset. Health Education Research, 18, 627–636.
Denzin, N.K. and Lincoln, Y.S. (1994) Handbook of Qualitative Research. Sage, London.
Department of Education (1993) The Education Act. HMSO, Norwich.
Department of Health (1989) The Children Act. HMSO, Norwich.
Department of Health (2004) The Children Act. HMSO, Norwich.
Dybing, E. and Sanner, T. (1999) Passive smoking and sudden infant death syndrome (SIDS) and childhood infections. Human Experimental Toxicology, 18, 202–205.
Fraser, S., Lewis, V., Ding, S., Kellett, M. and Robinson, C. (eds) (2003) Doing Research With Children and Young People. Sage, London.
HMG Worldwide (2003) Children widely exposed to tobacco smoking. HMG Worldwide, New York. Available: www.healthypages.net/news.asp.
Harter, S. (1985) Manual for the Self-Perception Profile for Children. University of Denver, Denver, CO.
James, A. and Prout, A. (eds) (1997) Constructing and Reconstructing Childhood, 2nd edn. Falmer Press, London.
Jarvis, M.J., Goddard, E., Higgins, V., Feyerabend, C., Bryant, A. and Cook, D.G. (2000) Children's exposure to passive smoking in England since the 1980s: cotinine evidence from population surveys. British Medical Journal, 321, 343–345.
MacGregor, A., Currie, C. and Wetton, N. (1998) Eliciting the views of children about health in schools through the use of the draw and write technique. Health Promotion International, 13, 307–318.
Mayall, B. (1996) Children, Health and the Social Order. Open University Press, Buckingham.
Mayall, B. (1998) Towards a sociology of child health. Sociology of Health and Illness, 20, 269–288.[CrossRef]
Mays, N. and Pope C. (2000) Assessing quality in qualitative research. British Medical Journal, 320, 50–52.
Milton, B. (2002) A longitudinal study of Liverpool schoolchildren's experiences of smoking aged 9–11. PhD Thesis. Liverpool John Moores University.
Morrow, V. (2001) "It's cool,... ‘cos you can't give us detention and things, can you?!": reflections on research with children. In Carolin, B. and Milner, P. (eds), Time to Listen to Children: A Handbook for Students, Professionals and Parents. Routledge, London, pp. 203–215.
Oakley, A., Bendelow, G., Barnes, J., Buchanan, M. and Husain, N. (1995) Health and cancer prevention: knowledge and beliefs of children and young people. British Medical Journal, 310, 1029–1033.
Porcellato, L. (1998) Perspectives on smoking of Liverpool primary schoolchildren in their early years. PhD Thesis. Liverpool John Moores University
Porcellato, L., Dugdill, L., Springett, J. and Sanderson, F. (1999) Primary schoolchildren's perceptions of smoking: implications for health education. Health Education Research, 14, 71–83.
Porcellato, L., Dugdill, L. and Springett, J. (2002) Using focus groups to explore children's perceptions of smoking: reflections on practice. Health Education Research, 102, 310–320.[CrossRef]
Pridmore, P. and Bendelow, G. (1995) Images of health: exploring the beliefs of children using the ‘draw and write’ technique. Health Education Journal, 54, 473–488.
Pridmore, P. and Stephens, D. (2000) Children as Partners for Health: A Critical Review of the Child-to-Child Approach. Zed Books, New York.
Public Health News (2004) October 7th. Chadwick House Publishing. p. 8.
Royal College of Physicians (2003) Tobacco Smoke Pollution: The Hard Facts. RCP, London.
Ruddock, J., Chaplain, R. and Wallace, G. (1996) School Improvement: What Can Pupils Tell Us? David Fulton, London.
Slish, K. and Cabana, M. (2004) PACE Project. Department of Pediatrics, University of Michigan, Ann Arbor, MI. Available: www.news-medical.net/?d=1205.
Somerset Health Education Authority and Somerset Education Consultants with the Best of Health Project (1994) The Draw and Write Investigative Technique for the Primary School into Children's Changing Perceptions of Cigarette Smoke, Cigarette Smokers and Cigarette Smoking. Health Education Unit, School of Education, University of Southampton, Southampton.
Strachan, D.P. and Cook, D.G. (1997) Parental smoking and lower respiratory illness in infancy and early childhood. Thorax, 52, 905–914.[Abstract]
Thomas, R. (2004) School-based Programmes for Preventing Smoking (Cochrane Review). Cochrane Library 2. Wiley, Chichester.
Weitzman, M., Gortmaker, S., Walker, D.K. and Sobal, A. (1999) Maternal smoking and asthma. Paediatrics, 85, 505–511.
Wetton, N. (1999) Draw and Write Technique. Southampton, Health Education Unit, School of Education, University of Southampton.
Williams, T., Wetton, N. and Moon, A. (1989) A Picture of Health: What do you do that makes you healthy and keeps you healthy? Health Education Authority, London.
WHO (1999) International Consultation on ETS and Child Health WHO/NCD/TFI. WHO, Geneva.
Received on July 22, 2004; accepted on December 29, 2004
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